Practice DescriptionsSolo Practice UrbanOrthopaedic solo practice offe - PDF document

1 Practice DescriptionsSolo Practice: Urba
Practice DescriptionsSolo Practice: UrbanOrthopaedic solo practice offers the opportunity todesign and implement a practice specific to your indi-vidual needs and style. High levels of satisfaction can bederived from an independently managed and designedAn efficient, well-managed practice can produce signifi-cant financial rewards, but you must also enjoy the chal-lenges of monitoring and managing the business as wellas the clinical aspects of the practice. When the greatestportion of your time and energy is spent dealing withmanaged care or coverage issues, staffing, buildingmaintenance, and suppliers, you may become frustratedand wonder what happened to patient care. In addition, anyone entertaining solo practice shouldconsider their level of comfort with financial risk. TheAmerican Academy of Orthopaedic Surgeons offersresources to help evaluate your risk exposure and setupyour first practice. Contact for moreUnless you join an Independent Physicians Association(IPA), there can be significant contracting difficultieswith managed care organizations (MCOs). The IPAcontracts for the group as a whole, increasing practicerevenues, but lessening physician/owner control, usuallyone of the primary reasons for starting a solo practice.Another disadvantage to the solo practitioner is thatcoverage must be arranged for vacations and emergen-cies. As solo practitioners become Òmore extinct,Ó thesearrangements will prove more difficult. A solo practicemay not be a viable option for new graduates due to theinitial financial outlay and risk, as well as the changes inhealth care delivery systems.Academic PracticeAcademic practice contains a good balance of clinicalservice, intellectual activities, and the enjoyment and sat-isfaction found in sharing orthopaedic knowledge.Academic medicine offers a choice between full clinicaland tenure tracks. While clinical tracks vary betweenuniversities, they tend to emphasize teaching andpatient care over research. The tenure track can bedemanding and requires research with regular publica-tion in peer reviewed journals. ItÕs important to select anorthopaedic mentor early in the process to receive adviceon avoiding tenure defeating activities. Many find aca-demic practice more interesting than private practicebecause their responsibilities and the university cultureare more varied.Military PracticeThe military medical environment offers the opportuni-ty to practice orthopaedics without risk of economiccomplications for the doctor or the patient. Patient caredecisions can be made with remarkably little outsideinterference. Patients of all ages are represented and,while there is a large amount of trauma work, there isalso a full range of orthopaedic conditions to manage. Moving every two or three years may be a problem forsome, but military practice does allow for a variety ofbe obtained in civilian life without financial risk. ItÕseven possible to move between clinical practice and aca-demic research or medical management.Solo Practice: RuralSolo practice in a rural community is ideal for thosewho desire a less hectic pace and a safer environmentthan found in urban settings. Many rural practices aresponsored by the community hospital. Fewer practicedemands usually allow more time to spend with familyor to pursue other professional or personal interests.Rural solo practice physicians rely on the communityho

2 spital to a much greater degree than in
spital to a much greater degree than in urban prac-tices. A successful rural solo practice requires a financial-ly stable hospital with a welcoming and community-oriented leadership. Establishing supportive, collegial relationships can bedifficult to impossible because of the small town envi-ronment. A rural practice requires high self-reliance;there may be no colleagues with whom to share prob-lems and triumphs. As the sole orthopaedist in the area,you are Òon callÓ all the time and must make specialarrangements for vacations. As support staff are unlike-ly to have orthopaedic knowledge, you will be in the Adapted with permission from the ÒResident Mentor Pamphlet,Ó developed by the Ruth Jackson Orthopaedic Society (RJOS). enviable or unenviable position (depending on yourpoint of view and your talents) of training staff to yourmethods and standards. One issue endemic to a rural practice is deciding whichcases can be safely handled in a limited environment.Interesting cases within your capabilities may need to bereferred simply because the technical requirements orGroup PracticeA single specialty group practice was the standardorthopaedic practice not long ago. Many orthopaedistspractice in single specialty group practices and have nodesire to change. The advantages and disadvantages of group practice areflip sides of the same coin depending on a physicianÕsstrengths, limitations, and interests. The autonomyfound in this type of practice gives the practitioner con-trol over equipment, environment, hours, billing, andsupport staff. This same autonomy requires a signifi-cant expenditure of time and energy to participate inÒOn-callÓ hours are shared, and in a con-genial practice this is an advantage. In anuncongenial practice, Òon-callÓ hours oftenrescheduling becomes a burden. Grouppractice partners must be selected with care.Like family, you must establish trust, andfair and congenial relationships. Also likefamily, an incompatible partnership can be adaily nightmare and difficult to dissolve. The competition and requirements of man-aged care and HMOs are currently placingsingle specialty group practices in jeopardy.Depending on how medicine and reim-bursement of services evolve, the groupCapitated Patient PopulationIn this setting, the orthopaedist works in aof capitated patients in partnership withother specialists. The physicians share a sin-gle chart on each patient and the collegiali-ty of a team approach to providing compre-hensive health care. Colleagues from differ-ent specialties are close at hand to discuss aCapitation challenges the practitioners to provide costefficient services and work closely with discharge plan-ners and home care departments. Opportunities exist toemploy or develop leadership skills by becominginvolved in clinical management committees.Practitioners working in this kind of setting can developa sound business acumen and a knowledge of the finan-cial realities of health care by participating in all aspectsof contracting, marketing, financial planning, and The multiple specialty clinic structure may not be a com-fortable environment for all physicians. Resources, dis-persed according to greatest demand, are sometimes notallocated to the special needs of an orthopaedic surgeon.Income is by salary, rather than on a per procedurebasis. This offers added security and advanced financialNon-Capi

3 tated Patient PopulationOrthopaedists wo
tated Patient PopulationOrthopaedists working in a multiple specialty grouppracticing orthopaedic surgery. Ideally, this type of 2 practice is characterized by camaraderie, support andpatient care decisions. Colleagues are close at hand todiscuss patient care or clinical issues. While there are norequired business responsibilities, opportunities tobecome involved in the business aspect of the practiceare available through committee participation or admin-The bureaucratic reality of multiple specialty groups isthat administrative decisions are often beyond your con-trol and made without your input. Salary structures differbetween groups. Some group arrangements are competi-tive and based on production, while other groups prefer aset salary based on education and experience. Eitherarrangement can be positive or negative depending onyour own drive and abilities, and those of your colleagues.Specialized PracticesOncologyOrthopaedic oncology includes the treatment of bothsues of the limbs, limb girdles, and sometimes the spine.The majority of orthopaedic oncologists treat both chil-dren and adults, although some limit their practice toone or the other. Orthopaedic oncology offers the advantages of seeing awide variety of patients who present challenging clinicalproblems, and operating on many different anatomiclocations. The wide variety of tumors presented in thistype of practice provides constant diagnostic challengesand allows for a great deal of creativity in devising treat-ment strategies. Multidisciplinary approaches to patientproblems require close collaboration with physiciansfrom other fields, including radiology, pathology, andmedical and pediatric oncology, as well as radiationoncology. Most orthopaedic oncology practices are university-affiliated, although a few surgeons have practices in aprivate setting.A demographic review of U.S. and Canadian popula-tions shows a steady and predictable increase in averageage. This increase, coupled with healthier and moreactive senior citizens and longer life spans, has resultedin a large population of individuals who require jointreconstructive surgery. This fascinating surgical practice includes a variety ofchallenging surgical procedures highlighted by thereward of seeing patientsÕ improved function anddecreased pain. The expansion of technology has madehip, knee, shoulder, and elbow replacement common-place. The specialty includes primary joint replace-ments as well as revision surgery, often with extensiveThe competition between fellowship trained jointreplacement surgeons and general orthopedists for pri-mary joint replacement patients is a significant barrierin this field. Fellowship trained surgeons are more likelyto receive the complex revision procedures. Technicallymore demanding and longer, these procedures produceless reimbursement to the surgeon per time unit and arenot usually profitable for hospital centers.SpineA spinal surgery specialization allows the opportunity tocultivate definitive knowledge regarding a specific andchallenging area. This rapidly changing field burgeonswith new information and procedures due to prolificspinal research. The spine surgeon can train in the sub-specialties of scoliosis and spinal deformity surgery. Awide variety of spine problems such as cervical or lum-bar, congenital, and acquired or degenerative disordersoffers unique and di

4 fficult treatment decisions, spinalinstr
fficult treatment decisions, spinalinstrumentation, and fusion for this patient group. Insurance companies fail to recognize this specializationor tend to make compensation problematic. Surgery isexpensive and many managed care organizations do notpromote spinal surgery as a viable option. As the num-maintaining a practice that includes general orthopaedicSignificant opportunities for advancement exist in thisrelatively new subspecialty, yet few have entered the rela-tively uncrowded field of foot and ankle orthopaedicsurgery. Diverse foot and ankle problems allow the spe-sports or dance, or on specific aspects of the foot such aspediatric deformities, diabetic foot, forefoot deformities,post-traumatic and reconstructive foot, degenerative andand talar fractures.Foot and ankle orthopaedic surgeons compete withpodiatrists, and referring physicians and self-referringpatients often do not associate orthopaedic surgeonswith the treatment of foot problems. Presenting lecturesand devoting serious attention to physician networksmay be necessary to develop a strong referral base. 3 Sports MedicineSports medicine emphasizes early diagnosis and aggres-sive treatment for injuries that occur in both organizedand recreational athletics. Clinical skills that includehighly accurate and rapid diagnostic abilities are essen-tial to ensure treatment can be initiated as soon after theinjury as possible. Advanced arthroscopic skills are nec-essary to restore joint normality. Knowledge of specific rehabilitation programs and supe-rior communication skills are critical for establishing areputation of competence with the athlete, athleteÕs fam-ily, athletic trainer, coachingstaff, and physical therapist.Time demands are heavy dur-seasons, particularly on Fridayand Saturday nights. Thesports medicine physicianÕsÒtrophyÓ is returning the ath-lete to the playing field. Theprerequisite to all of thoseinviolable Friday and Saturdaynights is enjoying yourfavorite athletic events free ofTrauma The orthopaedic trauma sur-geon specializes primarily inacute fracture managementarily in post-traumatic recon-struction. Their scope of prac-tice is wide and varied, cover-ing all anatomic regions andage groups. Subspecialty areasof interest (e.g. upper extremi-ty, pelvis and acetabulum, etc.)may be developed and pur-sued. A trauma surgeon inherits an unpredictable sched-ule, long and frequently inconvenient hours, and anoften challenging work environment.The specialty trauma practice generally requires anurban location with multi-disciplinary service support.While opportunities exist in both academic and privatepractice, most orthopaedic trauma surgeons practice in agroup setting.Hand SurgeryFormerly, a hand surgeonÕs practice was usually universi-ty based or university affiliated. With the increase inmanaged care positions available, this is no longer uni-versally true. The hand surgery subspecialty permits care of a varietyof patients with problems affecting the hand and upperextremity. This breadth of exposure is hand surgeryÕsgreatest attraction. In any given week, the hand surgeonmay treat sports injuries and congenital anomalies, per-form tendon transfers for a quadriplegic, and replantMore and more, hand sur-geons trained in orthopaedicsare tailoring their practices tothe entire upper extremity:hand, shoulder, and elbow.Hand surgery fellowships arethe most

5 structured of theorthopaedic fellowships
structured of theorthopaedic fellowships andcompleting one is a require-American Society for Surgeryof the Hand. In addition, aCertificate of AddedQualification (CAQ) in handsurgery is mandatory forspecialty with the requirementas of this writing. Despite thecurrent trend in health carefor orthopaedic surgeons tomany hospitals require or pre-fer that hand surgery is per-formed by surgeons who arefellowship trained.PediatricsAs an orthopaedic subspecialty, pediatrics has the great-est diversity in the types of procedures performed andthe range of diseases managed. Although the patientpopulation is limited to children, every anatomic area istreated.Many patients receive treatment, physical therapy,braces, and follow-up care for years, however, theirchanging growth, development, and personalities pro-vide continual interest. More patients are treated in theoffice compared to other orthopaedic subspecialties. A practice in pediatric orthopaedics usually follows aone (1) year fellowship. At this time, a Certificate ofAdded Qualification is not available. A full-time prac-tice limited to pediatric orthopaedics usually requires anacademic setting or large pediatric hospital to providethe multi-disciplinary care needed for complex cases.General Practice InformationWhen looking for an orthopaedic practice, considerboth practice type and practice locale. You may alsowant to consider: 1) your personal life and responsibili-ties; 2) professional training, skills, and interests; and 3)financial requirements and goals. Practice type and location are often interconnected.Urban centers offer privacy andanonymity, and a great opportunityto subspecialize, but market compe-tition is intense. Small city andtive living arrangement and easierdriving, but once again, the moredesirable areas will have increasedA rural practice is usually less busyand less competitive, but has lessopportunity for high financialreimbursement or subspecializa-tions. With the steady increase inmanaged care, establishing a solopractice is becoming more andmore difficult. Personal considerations shouldresources, and education are avail-able for you and your family. Try tomatch your needs and interests to the location.Ultimately, the most important factor in locating a prac-tice is where you and your family want to live. Financial ConsiderationsReimbursement and salaries vary significantly from placeto place, between specialties, and even within the samespecialty. The many practice variables have led to diverseand often contradictory perceptions among orthopaedists.We strongly advise residents who are considering a prac-tice arrangement, location, or subspecialty to thoroughlyexplore the question of reimbursement and salary withthe principals concerned in the arrangement. You mayalso contact your mentor, or members of the AAOSCommittee on Diversity at MENT OR@aaos.org Certain common sense facts remain valid. Rural prac-tices often have fewer patients than urban practiceswhich in turn yields lower salaries. Recently, however,hospitals have begun to sponsor one or two year con-tracts with competitive and above average salaries toattract graduating orthopaedists. The salary may dropwhen the guarantee expires or the salary may increase ifthe practice is very busy. Urban competition, particularly where managed care isprevalent, may lead to lower patient loads for independ-ent practices

6 . Military salaries tend to be competiti
. Military salaries tend to be competitive.Managed care salaries vary greatly by salary computationand how income earned is divided among the variousspecialties. Academic salaries also vary as some institu-tions reimburse by salary, and some based on production. Reimbursement for subspecialty procedures does notusually reflect the difficulty or lengthiness of the proce-dure. Fees paid for procedures also vary across the coun-try. The Medicare system of reimbursement has far-reaching implications for certain procedures and subspe-cialties. For example, total joint and adult reconstruc-tion is most often performed on Medicare patients.Reimbursement for a revision procedure is hardly a per-centage point above a primary joint replacement, eventhough revisions are often lengthy complex proceduresthat utilize many resources. Fellowship trained surgeonsperform more revisions with less relative reimbursementfor their effort. Both foot and ankle, and hand procedures are paid lessper operation compared with other specialties such astrauma or sports medicine. For the amount of timespent operating, arthroscopy is one of the highest reim-bursed procedures. Other factors affect reimbursement as well. Children arethe most underinsured sector of our population andtherefore, outside of managed care situations, reimburse-ment for pediatric procedures is unpredictable. Spinesurgery is perceived as expensive, so managed careorganizations often discourage spine surgery, decreasingthe number of procedures, and thus impacting income. Regardless of practice type, the best advice is to knowhow your salary is determined. Women and minorityorthopaedists throughout the country can help youunderstand the complexities of salary computations,youÕre considering.Unless you are considering opening a solo practice with-out affiliation, retain a lawyer to review your contract.Contracts may have illegal or non-binding clauses whichThe preferred and most equitable buy-in arrangementoffers full partnership, including ownership of the prac-tice facility building, accounts receivable, stock, andequipment. Some arrangements offer participation inthe accounts, but not the depreciable assets. vary running anywhere from six (6) months to three (3)years. One (1) year is the most common. It is customaryto agree on a salary for the time period preceding theSalaries also vary extensively depending on the area ofthe country and the locale of the practice (e.g., ruralversus large city). It is important to understand all theterms of the buy-in before accepting a position. Neveraccept a position before all details are settled, and bewary of joining an orthopaedist or group who are hesi-HMO and multi-specialty group contracts are not usu-ally negotiable. There is usually no buy-in arrangementavailable and salary computation methods vary fromgroup to group. Some organizations offer a salary with-out production considerations. Some build in increasedpayment for increased production. Again, know inadvance the terms of the group you are joining andweigh the pros and cons regarding your own style, inter-ests, skills, and preferences.Most academic institutions base payment on productionwith a set salary to encourage teaching and research.However, some institutions pay set salaries without pro-duction incentives.Malpractice InsuranceTwo basic types of malpractice insurance are available toorthopae

7 dists: Òclaims-madeÓ and Òoccurrence.
dists: Òclaims-madeÓ and Òoccurrence.ÓClaims-made coverage is based on incidents (or mal-practice claims) that take place and are reported duringthe covered time period. Premiums are based on theof time a physician practices increases, the potential fora claim also increases, and the premiums escalate. The advantages of claims-made coverage are that thepremiums are based on actual past and current experi-ence, and are usually less expensive. Liability limits maybe changed to reflect changes in the professional liabilityThe disadvantage of claims-made coverage is the needfor ÒtailÓ coverage for malpractice suits which occurredduring the time of the coverage, but were not reporteduntil after the coverage stopped. This occurs whenchanging practices, changing companies, or moving to anew state. This additional coverage must be purchasedfrom the carrier upon leaving the insurance company.Your ability to purchase such coverage should be guar-anteed prior to accepting the coverage. The length oftail coverage should also be reviewed. Each state has different statutes governing how longafter an incident a suit can be filed (e.g., three (3) yearsin Wisconsin). A good insurance policy will offer tailcoverage at no charge at a given age, for permanent andtotal disability, and in the event of physician demise.Occurrence coverage insures the physician for any inci-is in effect, regardless of when the incident is reported.Premiums are based on projected possible suits. Ratesmay fluctuate and tend to overcompensate for our liti-gious society. Premiums for occurrence insurance aremore expensive than for claims-made coverage. Theadvantage is coverage without need of tails when chang- 6 American Association of Hip and Knee Surgeons .aahks.org Association of American Medical Colleges .aamc.org Arthroscopy Association of North America .aana.org AAOSAmerican Academy of Orthopaedic Surgeons .aaos.org ACPOCAssociation of ChildrenÕs Prosthetic and Orthotic Clinics .acpco .org American Medical Association .ama-assn.org AMWAAmerican Medical WomenÕs Association .amwa-doc.org AOAAmerican Orthopedic Association .aoassn.org AOFASAmerican Orthopaedic Foot & Ankle Society .aofas.org AOSAmerican Orthopaedic Society .a-o-s.org AOSSMAmerican Orthopaedic Society for Sports Medicine .spor tsmed.org American Shoulder and Elbow Surgeons .aaos.org/wor dhtml/ases/homeaese.htm American Society for Surgery of the Hand .hand-surg.org Internet And Email ResourcesAWSAssociation of Women Surgeons WS@adminsys.com Cervical Spine Research Society .csrs.org Federation of Spine AssociationsUnknownHip Society .hipsoc.org Knee Society .kneesociety .org North American Spine Society .spine.org Orthopaedic Research Society .ors.org OTAOrthopaedic Trauma Association .ota.org Pediatric Orthopaedic Society of North America .posna.org Ruth Jackson Orthopaedic Society .rjos.org SICOTInternational Society of Orthopaedic Surgery and Traumatology .who .int/ina-ngo/ngo/ngo118.htm Scoliosis Research Society .srs.org ACKNOWLEDGMENTSThe ÒResident Mentor PamphletÓ was prepared for the Ruth Jackson Orthopaedic Society by Holly J. Duck, MD, inassociation with Leslie Anderson, MD, Sybil Biermann, MD, Linda Ferris, MD, Mary Lloyd Ireland, MD, Vicki Kalen, MD, Mary Ann Keenan, MD, Kathy Kramer, MD, Amy Ladd, MD, Alice Martinson, MD, Peggy Naas, MD, Kathy Peter, MD, Susan Swank, MD, and Janet Walker, MD.