The Realities of the First Year of Practice
December 2003
Editor’s Note: “Making the transition from trainee to practicing physician requires careful planning and support. While expertly equipped to handle the rigors of clinical diagnostic and treatment decision making, newly minted physicians often have been sheltered from the harsh realities of business management and credentialing issues, as well as the issue of skyrocketing malpractice premiums. With substantial debt load and work/family balance a priority, seeking support from local specialty and medical societies can provide essential peer assistance — especially from colleagues who have successfully negotiated this important stage in professional development.”
— John A. Fromson, M.D., Chairman of the Department of Psychiatry at MetroWest Medical Center
The first years of practice can be exhilarating but trying. The key to survival is ensuring access to appropriate resources and tapping available support systems.
Soon after she started her first practice position, Jennifer Shu, M.D., realized that she might have been better off taking more time to evaluate her options, or perhaps working locum tenens, before signing the contract. But, like many physicians fresh out of residency, this San Diego pediatrician did what she thought made sense: She accepted the “best” position she could find in terms of salary and benefits. She did not, however, look at the bigger picture of whether the position was a good fit for her from a professional and personal perspective.
Within a few years, she moved from that small group practice to her current job with Sharp Rees-Stealy Medical Group, a 20-physician group in San Diego, Calif.
Looking back, Dr. Shu says that residents, in their understandable excitement about starting the next chapter of their lives, often make decisions either too quickly or without enough information about the situation they’re about to enter. As the current chair of the American Medical Association’s Young Physicians Section and immediate past chair of American Academy of Pediatrics’ Section on Young Physicians, Dr. Shu had heard numerous “if I knew now what I didn’t know then” stories.
“When you first go from residency to practice, you don’t know how much you can negotiate or what’s not reasonable — in a schedule, productivity, or call duty,” Dr. Shu says. “And a lot of people, anecdotally, get themselves in situations that they never would have accepted if they knew how bad it would be — for instance, having to take call the first day they show up.” In other cases, newly hired physicians may face unrealistic demands regarding patient volumes or administrative duties.
“I think residency prepares you well from a knowledge standpoint, but it doesn’t necessarily prepare you for all the business aspects of medical practice and that can be difficult at first,” Dr. Shu says.
Although outright horror stories of bad practice situations are fortunately the exception, they do illustrate the point that the first year or two of practice can be a real eye-opener. After spending several years focused solely on learning how to take care of patients and gaining expertise in the medical field, such realities as protracted credentialing processes, insurer contracting complexities, and the sheer magnitude of economic and business issues physicians encounter can be overwhelming. In addition, there is another reality of practice life that may require a substantial adjustment: the recognition that you are now charged with making patient-care decisions and are ultimately responsible for those decisions.
“On the good side, residents find that their lives are more predictable, and they have more control over their schedules when they get into practice. On the flip side of that is the new level of responsibility, both qualitatively and quantitatively,” says Michael Ennis, M.D., an associate professor of family medicine and community health at the University of Massachusetts in Worcester who has been teaching residents for 17 years. “You’re the person with whom the buck stops — the one who is medically and legally responsible. That can be scary.”
It may be nearly impossible to fully prepare for this transition, Dr. Ennis says. But residents can help ease their adjustment into practice life by assuming incrementally more duties during residency, tapping the expertise of advisors in their midst, and becoming adept at obtaining clinical information electronically.
“That’s very important now, and it’s a big help when you’re new in practice and have to make decisions quickly about treatment or other matters,” he says.
Dr. Ennis also urges physicians who are moving to a new locale to obtain a grasp of the cultural profile of their prospective or actual patient base. It doesn’t mean spending countless hours boning up on six or more cultural or ethnic groups who might be represented in their new area, he says. But doctors in a new practice environment would be well advised to at least acquire a basic cultural awareness of the ethnic groups in the area: their views about obtaining (or declining) health care and their beliefs and rituals surrounding birth, death, and the pursuit of treatment. “It’s not so much an issue of becoming fully educated on all the cultures you might encounter, but rather of becoming culturally competent on those populations you will be working with,” he says. The primary objective is to be sensitive to patients’ cultural differences by asking questions that will encourage patients and their family members to discuss their wishes regarding medical care and treatment options.
For many physicians new to practice, however, it’s the business issues — coding and claims, for example, or payer contracts — that can prove most overwhelming initially, mostly because they’re foreign. Still, it’s possible, and ultimately wiser, to take the time to get a “jump start” on those, says Gordon Moore, M.D., a Rochester, N.Y., solo-practice family physician who also serves on the faculty of the Institute for Healthcare Improvement in Boston, Mass.
“It’s a good idea to take time to learn about the rather Byzantine architecture of ICD-9 and CPT-4 coding. It’s painful — and we have to live with it — but it’s important to keep in mind that all good billing comes from the brain of the physician,” Dr. Moore says. “Everyone else is just second guessing.” He recommends, in particular, taking classes on Medicare Evaluation & Management Coding and buying or borrowing an ICD-9 book to “learn how to code down to the fifth digit. The more you can learn about that in the beginning, the better off you’ll be in the long run.”
Dr. Moore also advises starting with a slower patient volume while learning the intricacies of billing and coding and insurer contracting, and he suggests taking advantage of the myriad clinical decision-support tools — such as ePocrates and other electronic prescribing aids and online databases — now readily available. “There are many good products out there, and they’re worth the money,” he says.
The extent to which payer contract issues will affect physicians starting out in practice depends, of course, on the practice setting. Someone practicing in the academic environment might be only minimally exposed, initially, to the machinations of case-rate negotiations and visit fee schedules. The physician in a small group practice will, of necessity, have a crash course in such issues.
That’s what Gregory Hood, M.D., an internist with a six-physician group in Lexington, Ky., found. Dr. Hood, who started out in the Southern California Permanente Medical Group six years ago and later went back to his hometown to practice, recalls vividly the challenge of evaluating payer contracts. “One of the best realizations I came to in those first years was that there are bad contracts out there — both in terms of medical practices and insurance companies,” says Dr. Hood, who is now business savvy and a member of the editorial board of Medical Economics.
“In a small practice, or when you’re just starting out, there can be a tendency to jump at any contract that comes your way,” says Dr. Hood. “But if you sign a contract that pays you $10 for a visit and it costs $15 to deliver the service, you’ll be plenty busy but won’t be making any money. You have to know what it costs to deliver the care to decide whether or not to take a contract from Insurance Company X.” To that end, both he and Dr. Shu recommend taking practice management courses early on and spending time reading the medical-business journals and local publications to get a sense of both the big picture and regional market forces. In addition, medical professional organizations (the AMA and other specialty groups) also offer excellent resources for young physicians, Dr. Shu notes, and he adds that “few residents take the time to explore what’s available online through their organizations.”
On a less practical level, networking can be invaluable to the newly practicing physician. Dr. Hood said he realized early on that networking can provide a true boost for the physician who is new to practice or new to town, and there are effective and ineffective ways to go about letting other physicians know you’re in town. He eschews the concept of sending out the traditional notice card, and instead he urges physicians to make the effort to arrange social encounters — even if it’s only 15 minutes — in the local hospital’s doctors lounge to introduce themselves and get to know other local physicians. “That does a lot more than sending an announcement or engaging in ‘cold calling,’ ” he says.
Following are other tips for easing the transition from residency to practice:
Don’t underestimate or “under-prepare” for the credentialing process. These days, health plans and insurers face so many regulatory and reporting issues that they must ensure all providers on their panels possess the appropriate credentials. And becoming properly credentialed can take several months, says Deborah Milburn, CMPE, manager of Dublin Primary Care in Colorado Springs, Colo. For this reason, physicians should ensure they have all license and training documentation close at hand, and they should become intimately involved in the credentialing effort to ensure the process proceeds as smoothly as possible. “Even if you have staff at the new practice to help you with credentialing, it takes a lot of diligence on the part of the physician to make sure it’s done right,” Milburn says.
“The credentialing process tends to blindside new doctors, but they must remember that getting credentialed with insurers is critical. If you don’t do it, you don’t get paid,” she says.
Strive for work-personal life balance, even in the difficult first years, and seek support among peers and community physicians. Residents who think they’ll be “home free” when they get into practice are often dismayed to discover that stresses of a new sort attend this new chapter of their medical career. They may face productivity pressures, interrelationship issues with new colleagues, or difficulties adjusting to a new cultural environment. Ensuring a balanced life is critical to coping with these new stressors, says Dr. Shu. “When you’re new to practice, you face all kinds of pressures: patient-care decisions, financial pressures, and pressures to see enough patients or pay off student loans,” she says. “All of these things can make it hard to keep your life in balance, but it’s important to ensure that you have time for yourself and your family. I recommend that physicians seek help from mentors or join support networks, if necessary. It’s very important not to isolate yourself when you’re starting out.”
State and local medical societies can be a valuable resource and also a source of support for newly practicing physicians and their significant others.
Ensure an adequate financial plan is in place. In tandem with the excitement of starting the first “real” practice position and receiving a good income comes another reality: the start of education loan repayment. With average medical school debt now topping six figures, loan payments are likely to account for a large portion of the household budget. For this reason, it’s imperative to ensure your personal finances are in order — and ideally that a formal financial plan is in place to help physicians manage the early transition years.
NOTE: The author, Bonnie Darves, is an independent health care writer based in Lake Oswego, Oregon.
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