Career decisions: Should you start, buy or join a practice?

It’s not just new physicians fresh out of residency or fellowship that face career decisions. It can happen to anyone, anytime.

Some are fresh out of training. Some are early-career physicians who decide they made a mistake in choosing an employer, choosing a location in which to practice, or found that the position they were planning on evaporated. Some always planned to work for someone else until they were more comfortable with their clinical and business skills before setting out on their own.

Related: How to survive in an independent practice

Some are mid-career doctors whose groups break up or are acquired by bigger groups with whom they find disagreement. Even senior physicians sometimes find themselves in a situation where they have to make a choice just a few years before retirement.

Joining a practice

Decide where you would like to practice, do a little research on community need, then look around for available options and support resources.

Taking employment by joining a practice is certainly the simplest solution, if a job is available. There is a flood of physicians taking this route now in response to the Affordable Care Act and with the increasing burdens of administration. On the other hand, I assist a regular stream of physicians that have become unhappy with their employer and who are eager strike out on their own or be able to control their own work environment.

Buying a practice

Buying a practice is an excellent alternative to starting one, if the purchase is at a fair price.

It is less expensive to buy a practice at or below fair market value (FMV) than to start your own, but it is less expensive to start a practice from scratch than to over-pay for a purchase. These scenarios compete with each other and balance each other out financially, which is what keeps FMV “fair”.

Related: What physicians need to know about acquiring other practices

Buying a practice eliminates much of the hassle and expense of a startup, provides a foundation of patients upon which to build, produces quicker cash-flow and reduces marketing needs. In some competitive markets, the only way in is to buy your way in.

Drawbacks can include inheriting antiquated systems in need of replacement, a dysfunctional staff, and perhaps a poor clinical reputation. Sometimes the seller’s spouse was the office manager, and management walks out the door with the seller. (Sometimes that’s a good thing.)

NEXT: When to take a risk

Location, location

As faculty on the topic for a number of medical associations, I’m commonly asked by attendees, “where in the country should I practice?”-as if there is some magic location that will ensure success.

My answer often is not what they expect. The best place to practice is where you want to spend the rest of your life outside of practice. In other words, when you leave the office at the end of your day you should be where you want to live.

Even those locations that might be considered grossly over-doctored will probably have a niche community opportunity within less than an hour’s drive. All the research says that money only buys happiness up to around $50,000 per year –enough to cover basic necessities–then it has no further impact. So look beyond the potential practice income in selecting a career situation.

Related:When should primary care physicians consult a career development coach?

When to take a risk

That’s not to say that I suggest radical untested change in seeking happiness. If you grew up in Florida and have always had an interest in Alaska, take employment for a year before investing in a startup, just in case you didn’t realize what minus 22 degrees and 20 hours of darkness day-after-day for months really feels like. On the other hand, if you want to specialize in Seasonal Affective Disorder, Alaska in winter might be the perfect location for you.

There are many creative ways to have a professional career. I had a client who, for over a decade, alternated practice every two weeks between rural New York State and a Caribbean island, and was quite happy with it until a hurricane eliminated the southern office. He sold the northern practice to a buyer wanting to be nearby aging parents.

I’ve known several physicians who fly to work, either on commercial airlines or in their own airplanes.

If you want more tangible evidence to support your choice of locale, it is easy–and more accurate– to do your own research of community needs rather than buying a demographic survey.

Pose as needing a simple evaluation in your specialty for a teenager or parent, and call around to the majority of medical offices in your specialty to find out the wait for a new appointment. Patients like to be seen within a week of calling for an appointment. For every two weeks of wait, there is room for approximately one additional physician.

If the only physician in town has a two-week wait, then adding one would theoretically result in two physicians having a one week wait, both still being full. If all three physicians in a community each have a four-week wait, then there is room for six to nine additional physicians. Your wait times will probably equal the others’ within weeks or months.

With a little bit of thought and planning you can hardly avoid being successful. Private consultants, most of whom are members of the National Society of Certified Healthcare Business Consultants, can also offer personalized guidance and support to your endeavor.

Keith Borglum, CHBC, is a practice management consultant, appraiser, and broker in Santa Rosa, California. Send your practice management questions to medec@advanstar.com.com

NEXT: What to consider when evaluating an employment offer:

What to consider when evaluating an employment offer:

• Compatibility: First and foremost is compatibility between you and the people and environment you will work in-the physicians, the staff, and management. Does it feel like a comfortable environment to you? Visit the workplace for at least a full day.

• Check references: Interview physicians with your prospective employer. Call another physician who left employment there and ask about his or her experience. 

• Income, financial and legal issues: The best approach is to have an independent medical consultant (available at NSCHBC.org or MGMA.org ) review the offer and tell you if it is a good opportunity. A consultant can find many hidden problems that an inexperienced person might miss.

• Security and risk: What’s your “Plan B” if things don’t work out? If you decide after a few months that the job is not for you, can you walk away without major obligations? Always plan your exit strategy going in.

• Government and management: Who is in charge of the physicians? Is there a senior doctor, or a lay president? If there are disagreements in the way the practice is run, how are they handled? Is there a protocol for arbitration?

• Staff considerations: Do employees have clear job descriptions? Do the doctors handle the employees professionally, or are they at risk for a lawsuit? Do the physicians treat the staff with respect and professionalism?