More and more rheumatologists are finding it advantageous to work in a practice with multiple partners. With growing costs and the need to provide more and more specialty services, working for a large practice with other rheumatologists or physicians of other specialties may be necessary.
Herbert S. B. Baraf, MD, FACP, MACR, is one of those rheumatologists who found the expansion of his practice to be helpful and, at times, necessary, and is now one of 16 partners at Arthritis and Rheumatism Associates PC (ARAPC), with offices in four different locations in Washington, D.C., and Maryland.
“It does make a group’s demands—read that as survival—much easier, because smaller groups are finding themselves at a disadvantage,” says Dr. Baraf. “Whereas hospitals are buying up primary care, oncology and other practices, what I would call services that are central to their mission, rheumatology is not a high priority for hospital networks.”
Other rheumatologists find working in larger groups advantageous because of the protection it provides against economic forces, as well as the convenience of having the support of other doctors on a regular basis.
“I’ve always found it far more comfortable to practice medicine surrounded by other smart people,” says Douglas White, MD, who works as a rheumatologist in the Gundersen Health System, a multispecialty group consisting of 400–500 physicians, with locations in Wisconsin, Iowa and Minnesota. “I really like the safety net of having other people to talk to.”
Merging Practices
There are several scenarios that may put a rheumatologist in a position where they are looking for a professional partner—whether it be a rheumatologist looking to bring somebody on and make them a partner, two rheumatologists who are in different practices who decide to merge and create a partnership, or groups of rheumatologists who decide to merge and create a larger group.
For Dr. Baraf, all of these factors came into play. More than 30 years ago, he was one of two rheumatologists who were looking to expand, which resulted in a partnership with another rheumatologist in town whose practice of internists was breaking up.
“Both groups were trying to minimize risk and trying to get economies of scale by being larger,” says Dr. Baraf. “We had already committed to move into more space. This was somebody who would share the responsibility for that—and the rent—so that made us happy.”
Fourteen years later, they once again realized that expansion to more locations and a larger number of physicians was necessary to protect themselves from managed care, what Dr. Baraf refers to as “predatory pricing on services.” The practice then added three more offices and merged practices with yet another partner. This type of pattern continued until ARAPC had 16 partners.
“It may not necessarily be part of your design, but if your overall goal is to be large enough to be a force in the specialty in your region, then you [need to be] mentally prepared to work out such acquisitions, mergers or expansions because they serve that goal,” says Dr. Baraf.
Benefits of a Large Practice
Both Dr. Baraf and Dr. White have worked in large practices for several years and cite several advantages to being one of many physicians in a practice: the economic cushion, access to services and the opportunity to easily consult with fellow practitioners.
“I have easy access to colleagues in a number of fields. I have easier communication with them since we have a unified EHR [electronic health record], and being in a large group affords me advantages like being able to go to interdisciplinary conferences,” says Dr. White. “I think there’s a bit of a buffer, or you might call it a bit of insulation, between me and some of the economic forces, which are felt more directly by people who are in solo practice or practice in small groups.”
Many direct benefits also exist for a patient seeing a doctor who works in a large practice. The doctor can provide a better range of services in one location.
“A larger number of physicians can justify the presence of ancillary services, whereas a [practice with a] small number of physicians can’t, so that … makes delivering a fuller complement of services to the patient more economically feasible,” says Dr. Baraf.
This is, of course, also a benefit to the rheumatologists, who are better able to do their jobs when having access to these services, including on-site X-rays, laboratories and bone density testing.
“Our model of practice is we feel that rheumatologists provide the best service when they can provide most of the ancillary services themselves. So a rheumatologist should look at their own X-rays; they should have their own laboratory,” Dr. Baraf explains. “It sort of dilutes and degrades the nature of the service that we are able to provide if we don’t have our hands on, and our arms around, these services.”
Challenges to Bridging the Gap
The benefits of merging practices, however, should not obscure the difficulties and hard work it takes to make a smooth transition. The challenges that come along with bringing on a partner range from agreeing on a set of goals to working out compensation formulas.
“The challenges are building consensus, governance, reaching agreements, having a shared set of objectives,” says Dr. Baraf. “I think merging practices, if you have two practices of five doctors, bringing them together, there is a lot of work involved in that, getting everybody to row in the same boat, in the same direction in a coordinated way. You’re doing a little merging of cultures.”
It also may mean handing over a bit of control or sharing it with your colleagues.
‘Make sure that the people you bring on are of like mind, that they work well in a group, that there are no flamethrowers.’
Dr. BarafLesley M. Arnold, MD
“You don’t necessarily have quite as tight control over the day-to-day operations,” Dr. White explains. “In a very small practice, the physician tends to exert more influence and control over their local environment, and I have to share that power with my partners. I think sometimes we are unable to be as agile and as quick as we could if we were smaller.”
The challenges don’t necessarily end after the practices have successfully merged.
“A larger entity creates more management issues because you have more staff, and ostensibly, you’re providing a broader range of services and they all need to be managed,” Dr. Baraf adds.
The Right Fit
Often, the qualities you should look for when trying to find the right colleagues to practice medicine with are the same as when working in any other field.
“It’s just kind of the normal personality attributes that you look for when you want to work with somebody in any setting,” says Dr. White. “I think you want people that have good interpersonal skills and that enjoy what they do, and if you’re surrounded by smart, motivated people or good communicators, I think you’re going to be fine.”
However, when hiring or merging practitioners who will be working in a group with several other physicians, there are a few things to be wary of.
“First, you want to make sure that the people you bring on are of like mind, that they work well in a group, that there are no flamethrowers,” explains Dr. Baraf. “You want to make sure that they are actively involved in management. They’re not there to be employed. They’re there to contribute, not just to provide the patient care, but to do the problem solving that needs to be done every day in medical practices.”
Dr. White also cautions practitioners to be wary of the administration structure of the practice they are getting involved in to be sure that they will be able to maintain some individual freedom while practicing within a multispecialty group.
“Sometimes, groups come with an administrative structure, and that administrative structure, if you’re not careful, can be overbearing. The result of an overbearing administrative structure is a physician who loses autonomy. … What you’re looking for is a balance in the protection the group provides you without an overbearing administration that removes your autonomy. That’s a hard balance to find, but I think that’s the key.”
Candace Mitchell is an editorial intern for Wiley and a senior at Ramapo College of New Jersey, majoring in communication arts: journalism and literature.
