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Medical Practice Types
Whether you are an internal medicine resident completing training and not pursuing a fellowship, or if you have trained in a subspecialty and are ready to begin practice, you should consider what type of practice situation will best meet your personal preferences and career goals. Multiple practice options are available, each with certain advantages and disadvantages. Here is a summary of the most commonly available types of medical practice settings.
Solo practice is described by its name—a practice without partners or employment affiliations with other practice organizations. Although previously a common model, this type of medical practice is becoming less popular than in the past, although it is a strongly preferred by some internists.
Solo practices are usually characterized by a small staff and typically have a limited patient base. This smaller size and the autonomy of being the only physician gives the advantage of being able to design, grow, and develop the practice as you'd like relative to other practice settings. Plus, a smaller patient base provides the opportunity for you to develop close, personal relationships with your patients and staff and provide your own unique style of medical care. On the other hand, the entire burden of running the practice rests entirely on you. This includes the medical care (such as the need to manage or arrange for hospital care and weekend coverage for your patients) as well as the entire business enterprise. The work involved in developing agreements with insurers and the burden of documentation for compliance and other regulations is usually significant. Also, solo practices are often at substantial financial risk due to the costs of doing business (such as hiring staff and maintaining malpractice coverage), possible lack of referrals, the small patient base, shifting patient allegiances because of insurance issues, and lost income caused by illness or vacation. Another consideration includes the extent of your educational debt which may further increase financial risk.
The locale in which you wish to practice will sometimes determine the success of a solo practice. Suburban or rural areas are often better suited for solo practice because of significant medical need and less competition from other medical resources. Additionally, some local hospitals affiliate and support solo practices (financially or with other services, such as access to electronic medical records) to help maintain their own patient base.
Group practices are typically divided into single-specialty and multispecialty practices. The defining characteristic of single-specialty practice is the presence of two or more physicians providing patients with one specific type of care (i.e., primary care or a specific subspecialty practice), while multispecialty group practices are defined as offering various types of medical specialty care within one organization.
Some advantages of group practices are increased financial security and better control of lifestyle. Because of the larger number of physicians and increased size of the patient base, group practices are usually better able to accept and manage financial risk than solo practices. Group practices may also be able to provide more employee benefits than are feasible in a solo practice, although often less than what may be available in employed physician organizations. Group practices also usually have the resources to manage the administrative tasks associated with running a practice, relieving the individual provider from the need to do this alone. Additionally, the increased number of physicians in a group spreads the burden of covering clinical care in the hospital, at nights, and on weekends across a greater number of people, allowing more flexibility in scheduling relative to a solo practice.
Despite these advantages, autonomy and decision-making ability decrease with the size of any group, increasing the risk for conflict around significant practice issues. Larger practices may also tend to become more bureaucratic and policy driven, and this may be seen as a disadvantage.
Employed Physician Practices
Increasingly, physicians are being employed within one of several practice models. Some hospitals may purchase and manage existing solo or group practices, or may directly hire physicians to work in their inpatient facility or ambulatory clinics. Health care corporations may own and run clinics with employed physicians. And some physician-run groups are structured on an employment model, where a group practice is structured more like a corporation that employs clinicians instead of pursuing a more traditional partnership model.
An advantage of being an employed physician is that much of the administrative burden of running a practice is shifted to the employing entity, allowing clinicians to focus more on practicing medicine. Additionally, a baseline level of compensation is usually assured, although productivity demands and productivity-based incentives may be significant. Because the organizations employing physicians tend to be larger, they usually have more resources than solo or independent group practices. Clinically, this usually means reasonable coverage for clinical responsibilities and improved control of lifestyle. This larger size and increased resources may also translate into more robust support services and opportunities for further education and training.
The downside of being an employed physician is that physician autonomy may be substantially diminished relative to other practice models. Scheduling and productivity expectations may be beyond your control, and policies and procedures may be developed by others without your input. There may be less clinical flexibility due to limitations of referrals and facilities based on the employing organization. Additionally, there may be other expectations as an employed physician, such as serving on committees or participating in other organizational activities.
Other Types of Medical Practices
Direct Primary Care
Direct primary care is an alternative practice model based on a non-traditional payment system. In this model, patients are charged a flat membership fee on a monthly, quarterly or annual basis for a defined set of primary care services instead of submitting claims for primary care services to insurance companies. There are variable forms of direct primary care practice based on the number and types of services offered, and there are also hybrid models that involve a supplemental, high-deductible insurance plan to cover services that do not fall under the umbrella of primary care.
As patient panel sizes tend to be smaller, the direct primary care model typically allows greater access to physicians compared to traditional primary care practices. Other advantages include the elimination of insurance co-pays and third-party billing which greatly simplifies the administrative burden for both patients and physicians and makes the costs of care are more transparent and predictable. Additionally, access to primary care is not dependent on the ability to gain insurance coverage. Disadvantages include payment of a regular membership fee even if services are not utilized, and typically a lack of coverage for non-primary care services including specialty care, some procedures, and hospitalizations that may require additional insurance coverage.
Concierge medicine, also referred to as retainer medicine, is a variant of direct primary care. Although they are similar in that both models have a core membership fee paid by the patient, concierge practices may have smaller patient panels and typically offer enhanced access and services above and beyond what is considered traditional primary care. Different models of concierge medicine exist, with some continuing to bill a patient’s insurance company for covered services instead of relying primarily on membership fees to cover costs.
Some internists work in independent contractor relationships. In this model, the practice (either solo or a group practice) remains independent, but a facility and possibly clinical coverage is shared with other physicians or physician groups. This may spread the costs of running a practice across others and may provide some flexibility in clinical scheduling. The disadvantage to independent contracting is the loss of a degree of decision making as compared to a completely independent solo or small group practice.
Locum tenens is a Latin phrase that literally means "one who holds the place," and refers to a physician traditionally hired to carry on the practice of an absent colleague, although locum tenens positions are also used for temporary coverage of different clinical needs, such as for rapid expansion of clinical services pending hiring of permanent clinicians.
Locum tenens positions are usually contract-based and physicians are hired as independent contractors, often through a recruiting firm, to work at a given practice setting. They encompass all care settings, including hospital medicine, ambulatory primary care, or urgent care medicine in various clinical settings. Depending on the clinical practice setting, there is often a required minimum length of time for a given post; for example, outpatient primary care locum tenens can often be a minimum duration of 2-3 months for a full-time clinical position. For hospital medicine, there may be a minimum number of shifts of a given duration that must be done per quarter.
Locum tenens may be a desirable option for those who have not yet finalized their plans to enter practice or pursue further training. It can also provide an opportunity to experience different types of practices in various parts of the country without a long term commitment. Or, it may be a career alternative for those interested in a different practice model, including practice opportunities outside of the US.
Locum tenens positions frequently pay somewhat more than a comparable salaried position in a group practice. However, benefits are frequently lacking, and malpractice insurance coverage may also be a significant consideration as many locum tenens positions provide only claims-made malpractice insurance without tail coverage which may require the purchase of separate coverage.