Family Practice Management
Selecting the Right Practice:
A Guide for Graduating Residents and Other Job HuntersOut there somewhere is the right practice opportunity for you. Here's how to tell when you've found it.
Bo Greaves, MD
Covered in FPM Quiz
Tool inside
SPEEDBAR® » Because services can differ from one family practice to another, learn what services you will be likely to provide in each practice you consider.
» Learn the practice's expectations of you in terms of daily patient load, call coverage scheduling and the days you will be required to work in the office.
» Meet as many of the physicians in a practice as you can to get a sense of their personalities and the camaraderie among them.
» A review of HMO report cards, patient charts, continuity of care practices and wellness programs will tell you much about a practice's quality of care.
» You want a practice with patient flow that runs at a steady clip, patient satisfaction that ranks high and office staffing that's neither too fat nor too lean.
» Make sure your new practice "home" feels just right to you with the appropriate examination rooms, equipment and overall professional ambiance.
The variety of practice opportunities available to family physicians today is breathtaking. The classified advertising sections of medical journals are jammed with ads, and if you are a third-year resident, your mailbox is probably overflowing with offers. Some promise the "perfect location," others a "guaranteed salary that will top your wildest dreams." All of them imply that choosing their practice will make your future happy and secure.
Location: The first cut
Your choice of location may narrow your search considerably. It's not unusual for graduating residents to start practice within 50 miles of their residencies -- a tack that has its advantages. If you settle near your residency, you will already be known by other physicians and by the community, which helps to build your new practice. You also already know the specialists, ancillary providers and community services, making it easier to get started. If you have another region of the country in mind, you can congratulate yourself on having selected a profession and specialty that let you pick your location and be almost certain of a need there for your services.
Family demands may influence your location choices, too. They did mine. My wife and I leaned toward moving to a small city in Oregon, but our children had different ideas. They had moved once when I started medical school and a second time for residency, and they let us know in no uncertain terms that they had no intention of moving again. Needless to say, that simplified my job search considerably.
The literally hundreds of job offers that flood graduating family practice residents reflect the truth of our times: The development of managed care has increased the demand for family physicians to historic levels. In response to this demand, the marketplace has pushed up starting salaries for family physicians dramatically in the past five years.
Along with this opportunity comes a dilemma. How do you decide which practice opportunity is right for you? It may be fairly easy to arrive at a short list of offers by excluding those that clearly aren't right in terms of location, practice type or some other major determinant (see "Location: The first cut," page 55, and "The menu of practice modes," page 54), but how do you get from a short list to the best choice? While there are no simple answers, there are strategies for getting the information you need to make a decision. The questions you should ask before you sign on any dotted line generally fall into two categories: practice characteristics and economic considerations. We'll talk about the first category in this article and the second next month in a companion article on economic analysis of practice opportunities.
Is it your kind of practice?
The first thing to ask yourself about a likely looking practice is whether you would be professionally and personally satisfied there -- whether you'd be able to pratice the kind of medicine you want and whether you'd have all the infrastructure necessary for efficient, high-quality care. You need to scrutinize several aspects of the practice (and you can use the practice assessment report card to guide you):
Learn the scope of practice. If you want to do obstetrics, make sure that's an option open to you. Find out if there is obstetrical backup, if other family physicians are available to cover during your absences and if malpractice insurance is provided. Ask similar questions about procedures such as skin surgery, flexible sigmoidoscopy and colposcopy if you would like to be able to perform them.
Know the practice's expectations of you. Is there a daily quota of patients you will be expected to see? What is the call schedule? Are all associates treated fairly? What days will you work? In many areas, four full days in the office are considered full time; that one business day out of the office often becomes crucial for balance in your life.
Assess your associates. Because you will work closely with your new associates, make sure there is a good "fit" between you and them. Meet with as many of them as possible. Are they nice? Do they treat each other with respect? Has there been a large turnover of physicians? If any associates have left the practice recently, ask for their names and phone numbers. Get their version of why they left the group. Remember that you will be entrusting your patients to the care of your new associates when you are out of the office. Do your fellow physicians practice high-quality family medicine?
Decision-making policies vary widely from one practice to another, so find out to what extent you can participate in decision making. What control will you have over office staffing and policies, clinical issues and the business direction?
The menu of practice modes
Most family physicians practice in solo, group, multispecialty, closed-panel-HMO, academic or public-service settings. Each comes with its own strengths and weaknesses.
Solo practice. Very few family practice residents want to start up a solo practice from scratch these days, although it is still possible (see "Where residents are going"). The start-up costs are often prohibitive. And there's a question of viability. Solo practice may work in rural areas and certainly has the advantage of maximal autonomy because you make the decisions. But it may be less viable in areas where managed care delivery systems are driving physicians to organize into larger groups, negotiate for better contracts and provide more comprehensive care.
Group practice. Family practice or primary care groups are much more common choices. This type of practice offers more security and stable, up-front income as you are building your practice. Clearly, decisions must be made collectively, but at least your partners are all primary care physicians whose philosophy and perspective you are fairly likely to share. Group practices do face pressures as well. The movement today is to merge and become larger, to bargain with MCOs, to assume greater risk and, with luck, to reap the higher revenues that come with more efficient care.
Multispecialty clinics. Large groups of 100 or more physicians often provide even greater stability of income and organization. This stability, of course, comes at the cost of having even less autonomy. It is becoming increasingly important to determine what roles the primary care and non-primary-care doctors play in governance and in salary distributions in any multispecialty group. Beware of a group that focuses on maintaining the power and incomes of non-primary-care specialists. Not only would your future there be in jeopardy but so would the actual future survival of the group.
Salaried HMOs. Closed-panel HMOs such as Kaiser Permanente represent a particular form of multispecialty group. This physician group works within an integrated delivery system and cares exclusively for the patients enrolled in that HMO. These organizations tend to be very stable and have had the most experience with prepaid managed care. Salaries tend to be somewhat higher, but there may be a clear expectation of numbers of patients you must see. Your freedom to do obstetrics and procedures may be more limited as well. Certainly your autonomy in making changes in your office policies would be restricted in these large organizations.
Academic medicine. If you become a faculty member in the department of family medicine in a university medical school, you will be responsible for research, teaching medical students and residents and some patient care. Published research is often required to achieve tenure. Your decision-making autonomy may be tempered by academic bureaucracy. As a full-time salaried faculty physician in a community-based residency program, you will likely spend more time in patient care, and the requirements for research and publishing are less rigorous. Your decision-making autonomy might be greater as well. In either academic setting, your skills are needed because the demand for family physician academicians has steadily increased in recent years.
Public service. Salaried positions in public health clinics or community health centers give you an opportunity to serve in communities that need you. These practices often allow you the opportunity to work with civic leaders in developing programs that will improve health in those communities. Salaries tend to be somewhat less than in private practice, but often there are programs available to help pay back student debt for working in medically underserved communities.
Where residents are going
Residents entering practice in 1994 flocked to join family practice groups -- and avoided solo practice. In that respect, at least, their pattern of practice choices is markedly different from the overall distribution of practice modes among AAFP members.
Sources: AAFP Research and Information Services data, 1995, and Facts About Family Practice. Kansas City, Mo: AAFP; 1995.
Assess quality of care. Ask some hard questions to prevent you from ending up in a practice where you find the quality of care substandard. How is quality measured? Many HMOs regularly perform audits and issue report cards for practices on certain quality measures such as childhood immunization rates, mammogram rates, Pap smears and thoroughness of charts. If report cards have been issued, ask to see those for the past year.
Ask to confidentially review some patient charts picked at random, and find out if you would be comfortable working in that office and caring for those patients. Also see if there are programs in place to enhance health maintenance and promote wellness and prevention.
In a multiple-physician office, make sure the structure promotes continuity of care and encourages each patient to have a personal physician. If the staff includes nurse practitioners or physician assistants, ask how they work with physicians and to what degree supervision occurs.
Find out if there are restrictions on referrals to specialists. Is the rapport between the practice's physicians and referral specialists good?
An unhappy, frequently changing staff may spell trouble in your future practice. Observe the office's efficiency. Know how smoothly your new "home" will function. Is scheduling done in a way to ensure steady patient flow? You don't want to thumb through journals one hour and then scramble to see eight patients the next. Look at the schedules for the last week of all the practice's doctors, including the same-day, work-in appointments. Also find out the average delay for a patient to schedule a comprehensive physical. Ask how long the average wait in the office is for patients. The industry standard is less than 30 minutes.
Are patients satisfied with this practice and the office? How is patient satisfaction measured by the practice? Many practices will regularly perform patient surveys to collect feedback and suggestions from patients. If so, you should see the compiled data from the last survey. In addition, ask to spend some time in the waiting room to observe the efficiency of the operation and to get an indication of patient satisfaction.
Look at office staffing. Spend some time with the office manager, the receptionists and back-office nurses. They are the ones who make the office work and have tremendous interaction with patients. Try to gauge their job satisfaction and their commitment to quality patient care. Find out the amount of recent staff turnover. An unhappy, frequently changing staff may spell trouble in your future practice.
As with that first used car, get a subjective feeling by just sitting in the office. Check out the facility. It's just like buying a used car. You need to check the structure and functioning to make sure it meets your needs. The physical plant must be big enough for you to run at least three exam rooms at a time. Make sure the practice has or will buy the equipment you need for your scope of practice (surgical instruments, sigmoidoscope, colposcope, Doppler fetoscope, to name a few).
And, as with that first used car, get a subjective feeling by just sitting in the office. Does it feel right? Does it feel like a place where you could be happy spending a lot of time seeing patients? Because if you join, that's exactly what you will be doing.
As you can tell, this whole search process is anything but simple. Worse, if you are now moving from residency into practice, don't be surprised if your best efforts to find a practice that's just right for you aren't enough. Many family physicians move on to another practice opportunity within one to three years. After all, there's nothing like working in a practice setting day in and day out to determine whether it's right for you. Nevertheless, preparing for that first practice opportunity increases the likelihood that you will find the first practice experience a rewarding one. And the more time and energy you can afford to devote to it, the better off you'll be.
Practice assessment report card
You may find a report card like this helpful in evaluating practices you are interested in. Using whatever scoring system makes sense to you, assign scores for each practice in the categories listed below. The scores will help you make comparisons in your final selection process.
Practice 1 Practice 2 Practice 3 Practice 4 Location Scope of practice Malpractice insurance for your scope of practice Autonomy of practice Your voice in practice decisions Patient load per physician Call coverage Patient mix Patient scheduling Patient satisfaction Quality of care Quality of colleagues Colleague rapport Office staff satisfaction Physical plant Mode of practice Other Other Other Other Totals In a companion article next month, Dr. Greaves will explain how to evaluate the financial health of practices you are interested in.
Dr. Greaves is a practicing partner with Primary Care Associates of Rohnert Park, Calif., and a clinical faculty member in the department of family and community medicine at the University of California-San Francisco.
Copyright © 1996 by the American Academy of Family Physicians.
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