Feb 2001 Table of Contents

14 Alternative Practice Styles

Perhaps the road less traveled is the right career path for you. Here are more than a dozen ideas to get you started.

Fam Pract Manag. 2001 Feb;8(2):33-38.

Nearly three quarters of family physicians say they would choose the same career if they had it to do over, according to a recent survey by the AAFP. But a noticeable minority, 29 percent, were either neutral about their career choice or said they would not choose it again.1 If you happen to identify with that latter category, fear not. The opportunities for family physicians are endless, meaning you don’t have to feel stuck in your current career path. Maybe it’s time to transition out of direct patient care and work on, say, public policy. Or perhaps you just need to add some variety to your practice. If so, consider an alternative practice style.

Here are more than a dozen ways to jazz up, fill out or just plain change the feel of your practice.

1. Resort doctor

Winters in Tahoe. Summers on the Caribbean. Could a career in medicine really be that idyllic? It could if you choose to be a resort doctor. The promise here is lifestyle. If you have a passion for skiing or travel and want your practice to promote your passion, then this might be the niche for you. Resort doctors come in two basic flavors: cruise ship doctors and ski or vacation resort doctors. Generally, pay is somewhat less than that of traditional practice, and many of these physicians add on locum tenens work to supplement pay during off-seasons. At one extreme, a resort doctor could have no ties to a particular location and simply tour a series of resort-oriented locums positions. Alternatively, a physician could spend each ski season working at the same practice in a resort town, for example, while spending the off-season in some combination of other alternative practice types.

You can find these positions by looking at advertisements in family practice journals for resort town practices or by calling cruise lines directly. The real plum cruise line jobs are often passed down from doctor to doctor, so if you meet a cruise line doctor, let him or her know you are interested in trying a cruise or two. Get your foot in the door.

2. Prison doctor

OK, so this isn’t the “Love Boat,” but there are actually many perks to working at a penitentiary, including regular hours, a decent salary and government employee benefits. Call requirements vary but are generally minimal. Patients with significant injuries and severe illnesses are usually transferred to public hospitals. And vacation and holiday time off is guaranteed. In other words, no one has ever died from the stress of being a prison doctor. If you work at a women’s correctional facility, you will need gynecological skills; obstetrical skills are a real plus but not essential.

3. Free-range physician

Imagine no office, very low overhead and nurses you don’t have to pay. How? Make your car (plus a laptop computer and a cell phone) your office. Sound crazy? No way. More and more doctors are turning to this practice style. You might not make quite as much as you could in traditional office practice, but the draw is being your own boss and not having to worry about employees or employers.

Here’s how it works: You see your patients in their home, the nursing home, assisted living center, hospice, other institution or the emergency room. All of these facilities (save home visits and assisted living centers) have their own nurses (free) and their own records (also free).

To embark on this kind of practice, first figure out how many patients you would need to see per week in order to make a reasonable income. Estimate it at approximately half the number of patients you see presently and round down (remember, there’s no overhead and no splitting the revenue with a health system). For the sake of argument, let’s say you need to see 10 patients per day, 50 per week, 200 per month. You could pick up these patients at, say, three nursing homes and a facility for handicapped children. Add in the medical directorship at these facilities for some seasoning (and extra income), and there you have it. If you have a large home-bound population in your area, it is even easier to generate the volume you need. [See “House Calls: Taking the Practice to the Patient,” FPM, June 2000, page 49.]

The phone will be your friend and your enemy in this type of practice. If you manage your time so you visit all the facilities you have patients in at least twice a month, the need to manage minor things over the phone all but disappears. The order for a laxative can probably wait until next Tuesday if they already know you’re coming.

KEY POINTS

  • Twenty-nine percent of family physicians are either neutral about their career choice or say they would not choose it again.

  • Family physicians who are looking for a new job or simply to revive their current position should not feel limited by the stereotype of what a family physician is supposed to do.

  • There are numerous nontraditional career paths for family physicians, ranging from resort doctor to politician to college professor.

4. Medical director

Being medical director for one or more institutions is a common way to add revenue to your practice (and some control over those operations). This practice additive is usually not sufficient to replace your practice altogether unless the institution is quite large and you are willing to assume administrative responsibilities. Being medical director is an easy way to exercise some new skills and add variety to your practice without moving or changing your current position. Nursing homes, hospices and home health agencies are some of the organizations in need of medical directors.

5. Locum tenens

Often used as a bridge between positions, locums work can also be made into a practice style for the long haul. Gross income is generally comparable to a modest traditional practice, but you must be in charge of your own retirement investments. You’ll not find 401(k)/403(b) matched savings accounts funded by temporary positions.

Locums firms can take care of the irritating details such as local licensure and travel arrangements. By using their services, you wind up working for the locums firm in a sense, but you retain the power to decide where you want to go and how long you want to stay.

Through locums positions you could, for example, work in Guam for four months and then Colorado for eight. You can use your time as an extended interview or as a way to see the country. You can take positions until you find a “permanent” job, or look at locums as your permanent job. [See "A Physician’s Guide to Locum Tenens," FPM, February 1999, page 41.]

6. Legislator

Please, please, please get yourself elected. With the current debates over patients’ rights, medical errors and the uninsured, what this country needs is more family physicians in government. Look at state and federal levels. As there are many physician members of the house and senate on the federal level, you won’t be a pioneer, but family practice (and its emphasis on public health, family function and preventive medicine) is under-represented.

State government does not pay well compared to a physician’s usual income, but federal legislators’ incomes are comparable to what family physicians earn. Since many state governments are in session only a limited portion of each year, you may be able to keep a part-time practice, or an alternative practice, going during the rest of the year to supplement your income.

7. Urgent care and emergency medicine

No other specialty prepares a physician better for urgent care than family practice. Family physicians have a breadth of knowledge, understand the whole patient and can diagnose quickly, all important skills in urgent and emergent care. Income in urgent care can be comparable to that of traditional family practice. Call is often optional. Inpatient care is usually absent. In other words, lifestyle tends to be a strong positive. The downside (or upside, depending on your view) is a very limited scope of practice without the traditional strengths of family practice, such as continuous relationships with families, long-term follow-up and preventive care. Urgent care centers can stand alone, or they can be part of an existing office (often open during the office’s off-hours) or an emergency facility where patients are triaged into urgent or emergent groups and routed accordingly.

Family physicians are also the ideal choice for emergency care. Moonlighting in emergency departments is quite common among family physicians, as is making emergency medicine a full-time career. The benefits include income superior to that of most family practices, no call, shift work and much more time off. The downside is the same as that for urgent care work listed above.

8. Hospitalist

Family practice hospitalists come in two flavors: full time and rotating. Relatively few are full-time, every-day-of-the-year hospitalists. If you have the training and the interest, though, there should be nothing holding you back. In fact, since family physicians can cross boundaries such as patient age and gender, you would be a very efficient (read “cost effective”) choice for many hospitals. If you aren’t comfortable with some of the more invasive monitors or procedures, you would simply need to use consultants, but don’t be ashamed about this. When was the last time an intensivist helped a new mom with cracked nipples, or a surgeon managed a stroke?

The rotating variety of hospitalist is more common for family physicians. For example, if there are five physicians in your practice, you would each take one week out of five covering the inpatient service.

Rotating hospital responsibilities is an attempt to manage time, whereas the full-time hospitalist is a career unto itself. Both are useful strategies in the right circumstances.

9. Administrator

How many of us hate administrators? They can’t possibly run things well since they’re just a bunch of bean counters. Along with the government, administrators are the root cause of all things wrong with health care, right?

Well, let’s look at it another way. During the rise of HMOs, how many of us ran for the hills, and how many of us decided to help steer the ship? What would have happened if more physicians had helped steer the ship?

Beat them at their own game. Accept some administrative responsibility. Then do their job better than they do it. Who would you rather have making health care decisions in your system: a physician administrator or an accountant? And who would you rather have as that physician: an anesthesiologist, an ophthalmologist or a family physician?

It is easier to train a physician to be an MBA than to train an MBA to be a physician. And the good news is that you definitely do not need an MBA to be an excellent administrator. The truth is that most systems are looking for physicians for leadership positions, but the pool of quality physicians interested in administration is insufficient. I blame our medical education system (of which I am part) for making medical administration a four-letter word instead of the essential medical specialty that it is.

We need to give physician administrators our thanks and support, and we need to foster this as a career track for our young physicians if we are ever going to straighten out health care. Besides, the pay is good, call is great and you can (and should) keep a hand in seeing patients. Looking for a change in your career? Think administration. [See "Becoming a Physician Executive: Where to Look Before Making the Leap," FPM, July/August 1999, page 37.]

10. Focused practices

As family physicians, we all focus our practices to some extent on our areas of relative strength and interest. Some of us go on to obtain CAQs in sports medicine or geriatrics or even second boards in other areas such as hospice or emergency medicine. Some of us go on to concentrate our entire practices on one patient segment, such as patients with AIDS. If this is what your heart tells you to do, go for it. If someone throws the epithet of “specialist” at you, point out that you are fulfilled. See if they can say the same thing.

I suspect, for example, that family-physician geriatricians have an advantage over our internist colleagues due to our broader training in family dynamics and behavioral medicine, and our often-different approach to death and dying.

I, for one, hope to open a hospice on the coast of Maine toward the end of my career and concentrate solely on this special population and their families. Then again, maybe I’ll make the move the next time I lose funding for a necessary program, service or employee.

11. Public health and epidemiology

Some physicians get into the field of public health and epidemiology as an adjunct to their regular practices by becoming medical director of a local public health department. However, this important field can also be made into a career.

Additional training in public health (master’s degree or PhD) is often necessary, and having an interest in research is important. Pay is usually less than in private practice. Opportunities for full-time employment tend to be located in cities.

12. Research

Physicians – especially family physicians –are needed in research. You’ll have to decide whether you want to add research to your current practice or move to full-time research. Office-based research is perhaps the most-needed type of research since it generates outcomes data. This is the final proving ground for all those promising new ideas, and yet outcomes are the scarcest type of data available to the practitioner. This type of research is woven into your practice. The beauty is that you do not have to change what you do or how you do it, you just need to be methodical in collecting data. If you are interested, look for collaborative research networks (where data are collected concurrently at many offices, such as your own). Stipends are paid to the principal investigator at each site (you). Think of this as flavor for your existing practice, not as a new practice.

Full-time research positions (with or without a small clinical component) can be had in a university setting, a business setting or in the government. You will be exchanging production based on patient volume for production based on publications and completed research projects. You just have to ask yourself where you want your pressure to come from and what activities you want incentivized. Pay is often less in universities than in private practice, but commercial research can be lucrative.

13. Private business

To this point, most of the alternative practice options mentioned have been related to the clinical setting, but there are still other career paths to explore in the private sector:

Lecturer. It is surprisingly easy to start speaking professionally. Talk to a pharmaceutical representative about an area that you have some comfort with and where you have a personal preference for a specific medication, and you are off to your first speaking engagement. Expect to make $300 to $500 initially for each talk. With more experience, you’ll be making $750 to $1,000. Become a national speaker and you’ll bring in more, plus some very nice trips.

You can do this once a year or up to a few times each week. The downside is travel time: time away from family. If you make this a fun part of your day job, and only take the out-of-town jobs that will result in a pleasant trip for you and your partner (and sometimes family), you’ll avoid most of the downside.

When you start speaking, you may be asked to go to a speaker training session in some awful, desolate, no-fun location such as San Francisco, San Diego, Las Vegas, Orlando, Park City (Utah) or Los Angeles. It’s a hardship you’ll have to endure (all expenses paid, gourmet food and fine hotels).

Author. There are a surprising number of physician authors out there. A few make it big (Michael Crichton to name only one). If you include magazine article authors, script-writers, Website authors, etc., there are thousands of physicians who add to their career by writing. If you include journal authors (and humble contributing editors), the list is huge. Go ahead, submit an article. Write the great American novel. Just remember who got you started on the road to riches when you strike it big.

Consultant. There are numerous consulting avenues family physicians can pursue. As a legal consultant you will be paid for giving your opinion about a potential or current malpractice case. You can stop at providing a case review (for a few hundred dollars) or can move on to giving a written opinion, a deposition and finally testimony at trial. The further along the list you go, the more time is involved on your part. Time away from a practice to testify can be tricky since court dates are not made to be convenient for you. Depositions are usually taped at your convenience, and case reviews and written opinions are on your time. Remember, you are already an expert. Don’t be shy. Some hired gun who hasn’t seen a patient in 57 years, and who will say anything the other side wants to hear just to get paid, is no match for you. The legal system certainly needs more honest family physicians who are willing to look at a case and render an unbiased opinion.

As a business consultant you will be asked your opinion on anything from “How does this new drug name sound?” to “Will you come to our system and tell us how to do what you did?” You might be paid a couple hundred dollars for the former or $10,000 for the latter. You can consult for a drug company at night and on weekends or go into a full-time consulting business to help health systems or private practices succeed. You could develop a treatment strategy for diabetes, for example. At first, you might need pharmaceutical company sponsorship. Later, if you can offer a complete package with training and educational materials, a health system might hire you to revamp their approach to diabetes management.

As an entertainment consultant you will be paid to help make shows like “ER” plausible… well, at least possible… well, exciting anyway. “Sure, Mr. Director, an ER doctor might do a brain transplant on a pregnant woman to save her unborn Siamese twins whom he would then go on to deliver via C-section in the hallway using a can opener. Absolutely!” Have fun. It’s good work if you can get it.

Sales. I’ve known residents over the years who have owned their own medical supply business, home health agency, computer consulting agency and even a moped rental business. The moped rental business owner was the wealthiest of them all. It got me thinking. Why not me, or you? As a supplement to your existing practice or as a separate career, the sky is the limit. CEO of your own Internet health site? Why not?

The pharmaceutical industry is always on the look out for bright, well-spoken physicians. If this sounds interesting to you, give the regional manager of your favorite pharmaceutical company a call and look into it.

14. Education

There are three approaches to adding teaching to your career. The first is medical school oriented. By joining the faculty of a medical school, you could teach a pre-clinical segment if your background would support this. You would likely have research requirements and should expect to make less than your clinical counterparts. If you had a university-based clinical practice, you could be an attending for a clinical rotation, possibly with research responsibilities as well. Pay in this case could be equivalent to private practice, but most likely it will be at the lower end of the spectrum. You could also be an attending for a primary care rotation for medical students in your community practice, generally an unpaid position.

The second approach is residency oriented. Options here include a full-time position as a residency faculty member or as a volunteer community preceptor who spends a half-day each week or month at the residency family practice center. Pay for faculty tends to parallel the lower end of pay for traditional clinical practice, but there are large regional differences. You could also be an attending for month-long primary care rotations for non-family-practice residents. This is typically an unpaid service.

The third approach makes no financial sense but is appealing on a personal level. Give up all or some clinical practice at some point in your career and go back to school as a teacher – college, high school or grade school – whatever gets your juices flowing. If you’re thinking of retiring but want to stay intellectually stimulated, consider becoming a college professor.

Final thoughts

All of us change. We change as people, change our job, change our interests, change our goals and change our needs. The worst tragedy I can think of as a family physician is to feel imprisoned in your job because of some unnecessary stereotype of what a family physician is supposed to do. Whether you are between jobs or at a point in your life where a change makes sense, don’t be afraid to take the road less traveled. Have fun.

Dr. Giovino is director of the Mercy Health System Family Practice Residency Program in Janesville, Wis., and is a contributing editor to Family Practice Management.

 

1. American Academy of Family Physicians. Member Attitude Survey, 2000.

Copyright © 2001 by the American Academy of Family Physicians.
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