Private Practice, Research, Academia? Career Tips for Rheumatology Fellows

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As rheumatology fellows approach the end of what for many is 25th grade, it’s time to focus on what you want to do for the rest of your life. For most rheumatology fellows it will be some form of clinical practice, although enormous opportunities exist throughout the medical field for you to apply your talents. Some of you will find remaining in academia holds allure, and others will focus on finding a position in government, industry or technology.

Clinical Practice Option

In this article I lay out the clinical practice option: how to find and assess a position. I also review the fundamentals of applying for a job, including tips on the interview, and some essentials of evaluating a contract.

The majority of fellows will enter the workforce with debt—debt that has been incurred with the promise of earning a reasonable income as a fully hatched professional leaving the training eggshell.¹ Paying off that debt typically coincides with other economic pressures that may influence your quest for gainful and career-long employment, including buying a home and, for many, meeting the needs of a growing family, saving for your children’s education and, finally, starting the lifelong process of saving for your eventual retire­ment. Thus, economics may play a role in how you assess employment oppor­tunities and job selection.

Let me be clear: Private practice, contrary to many recent reports of its demise, is thriving, and rheumatology private practice is viable. To illustrate, the most recent ACR Workforce Study of Rheumatology Specialists in the U.S. indicated that by 2025 almost 7,500 full-time rheumatologists will be needed nationwide, but after accounting for retiring and part-time rheuma­tologists, the U.S. will have only 3,645 practitioners.² What does that mean for you? Simply, the workforce has a place for you, and you will be very busy.

Despite this very high demand, rheumatologists’ mean income, according to reports published annually in Medscape, is low relative to other medical and surgical subspecialties.³ This is due to a bending of the supply and demand curve caused by low reimbursements for cognitive services and the ability of large insurers, insensitive to the costs of conducting a practice, to dictate payment terms to providers.

Nonetheless, rheumatologists do have the ability to push back and improve payment terms with private insurers, and many have done so successfully. This is a topic I hope to explore in a subsequent article. Suffice it to say that many larger groups and some smaller entities in regions of the U.S. with very few rheumatologists have found economic success that significantly exceeds the Medscape income data.

Setting Considerations

Let’s assume that your plan is to work in a pure clinical setting. What are your options?

• Hospital or health system employment;
• Solo practice;
• Multispecialty group practice; or
• Single-specialty group practice.

Your options may be influenced by where you plan to work. In some regions areas, clinical rheumatology positions are locked up by large hospital systems that have purchased local practices or recruited physician employees. If you want to be in such an area, your only option—other than opening your own practice—is to apply to that system.

Hospital Systems

Many organizations have detailed the growing percentage of the physician workforce employed by hospital systems and private equity firms.⁴ This trend is stronger in some parts of the country and in some specialties more than others, and won’t necessarily continue. Surveys have shown that using institutional valuation methodologies, hospitals may lose money on rheumatologists by not crediting them with downstream revenues (e.g., income derived from laboratory tests, imaging studies, infusions and surgical referrals).

The Medscape 2018 physician compensation report showed that self-employed physicians—although not specifically rheumatologists—may earn as much as 50% more on average than those who are employed.

As Medicare attempts to gain control over costs, the traditional site-of-service revenue differential that hospitals receive for outpatient services provided by acquired specialists, relative to independent entities, may disappear.⁵ Should this occur, I believe we may see some acquired practices cut loose from the systems that purchased them. Additionally, the rate of hiring has been slowing over the past few years, and many have questioned whether hospital acquisitions of outpatient medical practices will be sustainable.

Further, the impact of the pandemic on practice acquisition trends is unclear.

Private Practice

If private practice is your preference and the region you want to work in is not locked up, then your choices will be between solo practice or single- and multispecialty groups. The groups you investigate for employment can be further divided into smaller and larger entities.

Solo Practice

Few physicians entering practice today choose to open up their own solo practice. Going solo has lots of barriers, both economic and regulatory. If solo practice is what you want, a Google search will provide you with a considerable amount of literature that can offer a map to help get you started. The American Medical Association, the American College of Physicians and others have resources that may be helpful.

Solo practice has its pros and cons. The major advantage is that you have complete autonomy. Unfortunately, being solo means you carry all the risks, pay all the office expenses (e.g., rent, staff salaries, insurance) and must figure out what to do when you are out for vacation, are ill or are on maternity leave. Solo practitioners have little leverage in negotiating contracts with insurers and are vulnerable to competition. Single practitioners may find it difficult to support the infrastructure necessary to deliver and derive revenue from ancillary services.

Multispecialty Group Practice

Multispecialty group practice may provide a rheumatologist with an in-house referral source, but that may dissuade physicians not in the group from referring patients to you. Income division may favor physicians in some specialties over others, typically rewarding procedural over cognitive services. Also, the attribution of income from ancillary services may not favor the rheuma­tologist who generates this work due to the Stark laws, which prohibit physicians from profiting financially from a self-referral.⁶

Group investments and purchases in some groups may serve the needs of some specialists over that of the rheumatologist—for example, the pur­chase of endoscopes vs. that of dual X-ray absorptiometry or ultrasound units.

Finally, coverage in a multispecialty group can be challenging for the rheumatologist covering for other members of the group and vice versa. Think about cardiologists, pulmonologists or gastroenterologists covering for you or you covering for them.

Single-Specialty Group Practice

My bias, of course, is the single-specialty group because that is the environment in which I have toiled for more than 40 years. The single-specialty group’s investments in ancillary services and staffing typically favor all of its members. Coverage of your colleagues is much more straightforward than in the multispecialty group.

It also doesn’t hurt that most surveys I have seen over the years indicate income for the rheumatologist tends to be more robust in this setting. Interestingly, the Medscape 2018 physician compensation report showed that self-employed physicians—although not specifically rheumatologists—may earn as much as 50% more on average than those who are employees.⁷

Looking for Employment

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Your search for a position can begin in many ways. To start, focus on where you want to live and look at opportunities in those areas. Finding the right position will require a multipronged approach.

Classified advertisements, such as those carried in the ACR Career Connection section of the ACR website, may give you initial leads, but Doximity, classified advertisements in Arthritis & Rheumatology, the New England Journal of Medicine, LinkedIn and even Facebook may also prove useful.

Talk to your program director and other members of your faculty because they often have colleagues and connections to people who may be looking to hire. Networking with your friends and colleagues, particularly those who entered practice a year or two before you, is frequently worthwhile.

Contact the local medical society in the area where you want to focus your search. It may keep a list of who in the community is looking to add a rheumatologist.

Many graduating fellows have found positions by making cold calls to practices in the city or town of interest. These calls may lead to an interview or advice to contact a colleague in a neighboring area. We have hired new physicians after such a call even when we were not actively looking to hire. As the leader of my group and its physician recruiter for many years, I have always welcomed such calls and, if not hiring, made it a point to engage with job-seeking physicians and tried to offer useful advice, pointing the caller to a practice looking to expand or away from one I felt should be avoided.

Remember that timing is everything, and sometimes you may be the perfect candidate but a day late or a year early. Nonethe­less, it is worthwhile establishing contact and fostering a relationship with practices that are attractive to you, even if they are not hiring. These interactions sometimes pay off with an unexpected job offer, a valuable new lead or a friendship with a colleague in the area where you eventually settle.

Private practice, contrary to many recent reports of its demise, is thriving, & rheumatology private practice is viable.

Working with a headhunter may seem attractive to you but may not be for a potential employer who would be responsible for paying a fee equal to your first three or four months of salary. In the end, a recruiter gets paid by your employer and their incentive may not fully align with your needs. For these reasons, be careful if you choose to use such a service.

Medscape published an article a few years ago titled “The Seven Job Search Mistakes of New Physicians.”⁸ Those mistakes are summarized below:

1. Refusing to cast a wider net;
2. Not allowing enough time—start planning a year or more ahead;
3. Gravitating toward big metropolitan areas—competition is more fierce, and pay is lower;
4. Not understanding the pros and cons of employment at a hospital;
5. Putting too much faith in recruiters. For all that recruiters can do to help you polish your curriculum vitae (CV) and introduce you and your family to a community, they’re not much help with negotiating employment contracts due to their loyalty to their client, who is, after all, paying the bill. “Recruiters can usually answer basic questions about the contract, but their incentive is to get the deal signed,” says Ericka Adler, an attorney in Lincolnwood, Ill., who specializes in physician contracts;
6. Rushing to accept the first good offer; and
7. Failing to be a tough negotiator—see my discussion of contract negotiations below.

The Interview & Other Aspects

At some point you will contact a practice, and an interview will be arranged. Prior to COVID-19, that would be in person at the practice or at a national meeting, such as the ACR’s annual meeting. Now, it may occur via Zoom. Expect the usual back and forth: You will learn about the practice, and a member or members of the practice will learn about you.

When that ends, whether the discussion was encouraging or not, write a thank you note.

Remember, you are meeting someone to determine if you want to spend the rest of your professional life with them and vice versa. At this point, your interactions will be as much about relationship building as they will be about your career, and your hopes and dreams.

If you like what you learned about the practice and the practice is interested in you, the next step is usually a second interview. This tends to involve a more intensive process. Typically, you would visit the practice, meet all of its members and its key administrative staff, and you would tour their office or offices. They will want to get to know you, and you will get a better sense of the facilities and the people you would be working with. Often, this second in-person visit will be at the practice’s expense, whereas the first visit will be at yours.

Once you have returned home, write a thank you note.

Thank you notes play an important role in applying for any job, whether in medicine or not. A perspective published on the LinkedIn website stated the following: “Thank you notes might seem old-fashioned, but there’s plenty of value to be found in the tradition. According to a study by Accountemps, just 24% of job applicants send thank you notes after interviews—but 80% of hiring managers who receive them say they are useful in evaluating the potential of applicants. Pro­ponents of thank you notes say they are an inexpensive way to strengthen a relationship and show the applicant cares about the job.”⁹

In a Medical Economics article in 2013 concerning thank you notes, an executive at Merritt Hawkins, a major healthcare recruiting firm, indicated that sending a simple thank you note to an employer can set you apart from other applicants because “so many of the hiring decisions are based upon personality type-issues. … For any given job, there are [scores of physicians] that are medically qualified. … But … clients are more willing to hire the candidate that fits in with their culture and their vision for their practice.”¹⁰

The article then sets out suggestions to:

• Be specific—reference specific people you met and information you gathered;
• Reference the next step—sound positive and forward thinking in the letter:
  • “I look forward to working with you,” or
  • “I look forward to receiving your offer letter.”
  • If the position requires a second interview: “I look forward to meeting again soon”;
• Check your grammar and spelling; and
• Keep the letter short, and use station­ery with an attractive letterhead.

Keep in mind that you have specific reasons for wanting to enter a particular practice situation. These reasons typically vary from person to person. Be in touch with your reasons. Some may be driven solely by a desire for the fulfillment that work as a clinician can bring; others may place high value on the personality fit or the income earning potential. Some of you are looking for a challenge, a position that allows you to do clinical research or an adjunct teaching opportunity. Some want a chance to innovate or build a practice, and others value the security of a job.

If you want to work full time now but part time later, be in touch with that and look for positions that allow it. Others may have a desire for part-time work only—in which case, don’t look at full-time-only jobs.

Some of you are simply looking for a good practice.

A Good Practice

What is a good practice? What are the clues? Typically, you will know it when you see it. Are the surroundings pleasant and kept up? Is the staff friendly, and do they greet you when you walk in? If you are in the waiting room, are the patients treated with kindness by the staff? Do you sense good vibes from the people you meet? What is the location like? The group’s reputation in the community? Do new doctors come and stay, or does the practice have a revolving door?

Does the practice provide support to voluntary patient-centered groups, such as the Lupus Foundation of America, Sjögren’s Foundation or Arthritis Foundation, and are members involved in the ACR or the local rheumatology society? What relationships does the practice have with nearby medical schools? Is the group forward thinking and acquisitive with respect to ancillary services and practice growth, or is it defensive? Are the doctors respectful of one another, or do you witness backbiting among the members of group? What is their prior history with new physicians?

Solo practice has its pros & cons. The major advantage is that you have complete autonomy. Unfortunately, being solo means you carry all the risks, pay all the office expenses & must figure out what to do when you are out …

Additional questions and concerns may be categorized as practical. Will there be space for you, how quickly will you be busy, how competitive is the marketplace, how do the physicians feel about their information technology platform? Are they open to new ideas—your ideas?

An obvious, but not always considered, issue if you have a spouse or significant other, is to be certain that both of you are willing to go where this good practice is situated. If not, don’t find that out after you have the offer. I have seen candidates who went all the way through the interviewing process with us to learn after the offer was made that the spouse or significant other was not on board. This can be embarrassing for you, for sure, but it also wastes the time of everyone involved in recruiting you.

Of course, the interviewing activity is a two-way undertaking. You are just one-half of the equation. What you want is, of course, important. But what does the practice that is interviewing want? Is the practice seeking someone who will be on a path to partnership or just an employee? Will you be replacing a doctor who is leaving or retiring, or will you be working to expand into a new office or into new space? Do they want you because of a special skill? This should become apparent as you move through a series of conversations with the members of the group.

Remember to do your homework when you go to meet members of a practice for your interviews. Homework tips are outlined below, some of which were summarized in a Medical Economics article:¹¹

• Take time to reflect on what kind of impression you want to make;
• Every practice has a website—thoroughly explore it before you interview;
• Prepare pertinent questions stimulated by that exploration;
• Practices are looking for the best cultural fit—this has nothing to do with race or ethnicity and everything to do with philosophy of how you practice and relate to one another; keep that in mind;
• Practices are looking for candidates who will be constructive members of the group—it helps to demonstrate:
  • Accountability,
  • Leadership skills and sensitivities,
  • A team player or collaborative mentality, and
  • Thoughtfulness;
• Be on time and dress appropriately.

The Contract

You have been offered an employment con­tract. It will typically be for a predetermined period that may vary from one to three years or more. Now what do you do? The simple answer is to read it closely, take notes, and hire an attorney to review it with you. I don’t profess to have legal training, but I have been on both sides of this type of transaction and would recommend you look for:

• Defined length of employment and termination provisions;
• Time to anticipated partnership—typically contingent on how you do during the trial period;
• Salary specifications—this usually increases in the second year;
• Incentive, if offered;
• Statement of coverage for moving expenses, dues, books, meeting fees and journal expenses;
• Vacation and professional allowances; and
• Call schedule.

Partnership is not guaranteed with each practice arrangement. Many practices do offer partnership, but such offers are typically made after a predetermined period as a salaried employee and are not detailed in an employment contract. If the intention is for you to become a partner, you do want to know when to expect that will happen. If the group has more than two or three members, it likely has a tested process to bring new physicians to partnership status. This should be explained to you during the interview process.

Physicians joining private practices typically start with lower salaries than those joining hospital systems and other large entities. Earning potential, however, is much higher in the private setting after just a few years. When given your offer, get a sense of what income growth to expect.

Do not expect a signing bonus if joining a private practice. Conversely, if a headhunter is involved in your recruitment, it will likely reduce your first year’s income.

In truth, only a few things are really negotiable in an employment contract. If you are the second or third to join a group, you may have more leeway in focusing on salary, vacation, term, bonus arrangements and the like. If you are joining a larger group, you will have less impact on mod­ifying the terms because those who came before you were subjected to almost identical arrangements and to make big changes may threaten group harmony.

In assessing your practice opportunities and, subsequently, your first contract, remember that for most young rheuma­tologists the initial term is a means to an end. The decision to join a group should be driven by the rewards you can expect as a full partner, living in a community that appeals to you with people you like. Focus on the endgame, partnership, and keep your eye on the prize.

Getting Ready to Begin Your New Life

Once you have agreed to contract terms and before the ink has dried, you have a new task. You must get licensed in the state where you will be practicing. That license is a necessary condition before you can get malpractice coverage. Malpractice coverage must be in place before health insurers will allow you on their panels and before hospitals will give you privileges.

Gathering the documents—which sometimes include your kindergarten report card—may be difficult and time consuming. It takes a good three to four months to get this all in order. Nothing is worse than reporting to work and not being able to see patients because these steps were not taken or these organizations were slow to process your application(s).

A well-organized practice will have a formal onboarding process. Days before you begin seeing patients, you will need to learn the new electronic medical record system. Staff will teach you the workings of medical insurance. Many members of the staff, such as medical assistants, schedulers, business office personnel and infusion staff, will want to get to know you and give you their perspectives. The practice will likely have a compliance plan with such matters as HIPAA (Health Insurance Portability and Accountability Act of 1996) and Medicare rules.

You will need to learn details of your malpractice, health and life insurance through the practice manager. The staff may also have a marketing plan to help you get started and may need a biography to post on the practice’s website and/or print on announcements sent to physicians in the community to alert them to your arrival. This is an exciting time in the medical careers of most of us.

There is a lot to learn and a lifetime to do it in. You have graduated from 25th grade and matriculated into the real world. Welcome!

Herbert S.B. Baraf, MD, FACP, MACR, is a clinical professor of medicine at George Washington University, Washington, D.C., and a founding partner of Arthritis and Rheumatism Associates, Washington, D.C., and Wheaton, Md.

References

1. American Association of Medical Colleges. Medical student education: Debt, costs, and loan repayment fact card for the class of 2021. 2021.
2. 2015 Workforce study of rheumatology specialists in the United States. Academy for Academic Leadership and the ACR.
3. Kane L. Physician compensation report: The recovery begins. Slide #3. Medscape. 2021.
   
4. Avalere Health. COVID-19’s impact on acquisitions of physician practices and physician employment 2019–2020. Physicians Advocacy Institute. 2021 Jun.
5. Report 4 of the Council on Medical Service (I-18). The site-of-service differential. Centers for Medicare & Medicaid Services. 2018.
   
6. List of CPT/HCPCS codes. Centers for Medicare & Medicaid Services. 
7. Kane L. Medscape physician compensation report 2018. Medscape. 2018 Apr 11. 
8. Page L. Seven job-search mistakes of new physicians. Medscape. 2015 Apr 7.
   
9. Shirayanagi K. The power of a thank-you note. LinkedIn.
   
10. How physicians can write the perfect job interview thank you note. Medical Economics. 2013 Sep 5.
11. Tips for nailing a job interview at a practice or hospital. Medical Economics. 2013 May 6.