Career: To Partner, or Not?

Consider the case of Ralph Conti. Upon graduating from medical school in 1990, the pediatrician launched a solo practice in Henderson, Nev. But just four years later, he changed course. His penchant for collegiality and desire to spend more time with family won out over issues like autonomy and flexibility. “I don’t like working alone,” says Conti. “I need to bounce cases off other doctors, and I like it when they bounce cases off me. I love the intelligent banter.”

So Conti forged his first partnership with three other physicians. The group flourished and quickly grew to include 14 doctors. But disagreements erupted about the compensation structure. When Conti eventually lost his veto power, he left.

But he was undaunted and undeterred. Conti is now part of a successful eight-physician partnership with five offices in the Henderson area.

Has it been worth the time and effort? “I survived,” he says, laughing. And he learned a lot. Here are some things you should consider before making the decision to partner.

Where there’s a will

Collegiality certainly factors into the decision, says Kenneth Hertz, a senior consultant with the Medical Group Management Association. That, and seizing the right opportunity. “Suppose the doctor from a small town is fresh out of medical school,” says Hertz. “He knows a senior doctor there who’s retiring.” Hertz explains that a smooth transition - the new doctor is ramping up his practice as the senior doctor is winding down - can be one good reason to partner and grow a practice.

But you can fly solo and still enjoy collegiality, says Randall Zarin, senior manager with UHY Advisors - a national tax and business consulting firm that serves the healthcare industry - although you may have to go out of your way to do so. Reach out to other colleagues in the community. Their feedback won’t always be immediate due to varying physical proximity, but the intellectual exchange will be worth it if collegiality is your goal.

Call coverage is another major factor. Patricia Raymond, a gastroenterologist in solo practice in Chesapeake, Va., says primary-care physicians generally like to partner because they handle the lion’s share of patient calls - every runny nose, every high fever in the middle of the night. There’s strength in numbers, she says, when handling a boatload of calls.

But don’t count out solo practice if that is your calling. You can work with other solo practitioners to provide call coverage. “Sometimes, the only other choice in some areas is to turn to your competition, or join a network of solo practitioners to provide coverage when you want time off,” says Owen Dahl, a practice management consultant based in The Woodlands, Texas. But it may be worth it for Gen Xers, he argues, who place time off and involvement with family high on their priority list.

Zarin maintains that solo physicians shouldn’t be deterred by the possibility of losing their patients to the competition. There’s an ethical code between on-call physicians, he says, where emergency patients still belong to the primary physician. That doesn’t always stop your patient from fancying the on-call doctor and deciding to switch, but all in all, Zarin says, it’s a congenial atmosphere. “You cover for them, they cover for you. It’s a give and take.”

Specialists enter the picture when the emergency is acute - say, a surgeon for a ruptured appendix. And, while a group of physicians in the same specialty area create a center for excellence by playing off each other’s strengths and enjoying a high level of collegiality, mixed specialty groups often encounter problems with compensation, says Zarin. Namely, who is worth more?

But sometimes, more so than compensation, it all boils down to personalities. Communication is the key. For the most part, physicians try to work things out, Zarin says, but personalities can get in the way. Raymond advises physicians to say what’s on their minds, and seek an environment that works best for them.

Seeking answers within

“Why do I want to partner or stay solo?” That’s the one nagging question a doctor has to answer clearly, Hertz insists. Write down the pros and cons on a sheet of paper. He’s quick to point out that a physician shouldn’t be surprised by the negatives of partnership - for example, loss of autonomy and less input on staff management.

It’s important for physicians to know themselves, as well as the groups on all sides of the fence, says Raymond, who was a member of two partnerships before going solo. Take some time to investigate your own core values:

• Do you cherish autonomy? Doctors who like to do their own thing might find switching gears to a protracted decision-making process a harrowing experience, says Dahl. Physicians must acknowledge how much control they can comfortably relinquish. When members of Conti’s first practice decided to change the payment schedule from the “earn as much as you work” plan to a more communal strategy, Conti’s veto power was usurped.

• Do you thrive better in a group? A veteran doctor often enters a partnership because of fatigue, Hertz explains. The burden of running the business alone and being on call all the time is exhausting. However, he warns, once a physician decides to partner, things will be different. Decision-making, staff management, and payment structures, to mention a few, will change when creating a partnership. The question becomes: How much change can you live with?

• Do logic and data rule your brain? A new physician often partners because it makes sense, says Hertz. Negotiating managed-care contracts - where often there’s more strength in numbers - purchasing technology, navigating medical bureaucracy, and figuring out the complexities of modern healthcare make it difficult for solo doctors to do well, and often require the finesse and emotional stamina of a veteran medical “jack-of-all-trades.” Raymond explains: “We don’t get enough business classes in medical school.” She advises new doctors to decide how they want to practice medicine, and then to focus first on the management side.

• Is practicing medicine a job or a passion for you? Raymond encourages physicians to ask themselves, “Am I working to live, or living to work?” There are those who want to work long hours and those who don’t. And the two sides rarely understand each other, Raymond cautions.

Each practice marches to its own tune, with the physicians deciding which song to sing. Raymond’s first practice was a democratically run group where everyone got a vote. In her second, one physician assumed the decision-making role and everyone else was fine with that. Both practices were great, she says, recalling wonderful colleagues. The first group was very efficient and made great money, but it wasn’t the ideal setup for Raymond to take time off for speaking engagements or seminars, something she loves.

A partnership is most worthwhile when the physician gets the right fit, Raymond says. Despite enjoying a successful “marriage” with both of her partnerships, she yearned to have more control over determining her own office hours. So, ultimately, Raymond went solo, where she now works part-time hours to allow for other pursuits: “I figured out how much I needed for overhead, how much I wanted to take home, and how many patients it would take for me to achieve that goal.”

Get it in writing

Consider everything before leaping into a partnership. How often do you want to see your family? How much money do you want to earn? How good are you with managing staff and collections? Are you satisfied with your negotiating power with managed care organizations and insurance companies?

If you decide to take the plunge, make sure you get all of the details in writing. “Partnering is like a marriage,” Hertz says, “Easy to get into, not so easy to get out of.” For doctors who aren’t happy, whether they’re continually outvoted on critical decisions or they find themselves working with physicians with whom they’re clinically incompatible, it becomes too much of a burden to maintain the relationship, Dahl explains.

When a well-written contract spells everything out, breaking up isn’t that hard to do. “Physicians tend to work things out amicably,” says Zarin. But bear in mind that even the most meticulously planned contracts can go awry, Conti says, recalling a long-ago legal snafu concerning ownership of patient panels after the departure of a partner, and all the usual hassles of paperwork and stress that subsequently ensued.

High-tech & secure

Michael Nochomovitz, president and chief medical officer of Cleveland-based University Hospitals Medical Practices, a 400-physician multispecialty practice network, says medical training grooms doctors to make independent decisions. This is a dilemma for solo-practice doctors who are considering a partnership, he says. The group Nochomovitz created, part of the University Hospitals system, embeds private practice culture into a group environment by allowing doctors to govern their individual multispecialty clusters, while still having access to the support of a larger network for issues they may not want to tackle, such as collections and accounting.

Another benefit to being part of a larger group is greater access to technology, Nochomovitz says, referring to electronic health records, document imaging systems, and other modern marvels that allow physicians to access patient test results or write prescriptions electronically. Solo practitioners and small group practices don’t have the resources to purchase all the technological bells and whistles. “The dollars aren’t substantial enough for a solo physician or small group to justify their cost, but what doctors need more than anything is less paper,” he explains.

Hertz adds that larger practices can add ancillary services by purchasing high-tech diagnostic tools and equipment. For primary-care doctors in a group, he says, this can significantly augment their income.

Charles Pavluk, a Westlake, Ohio, internist with University Hospitals, was searching for security and guidance to help him grow a practice that would provide quality care for patients. “I was in an independent group practice before, and it fell apart,” he says. “We all enjoyed working with each other. But my biggest worry was, what happens when I die?” Pavluk’s father, also a physician, died unexpectedly, and Pavluk’s mother was thrust into running the practice until someone else took over.

“As a group,” he remembers, “it was hard for us to address what would happen if one of us became disabled, died, or couldn’t practice medicine any more - what do we do with a buyout?” So the physicians split.

Pavluk partnered once again, but it was difficult sharing veto rights. So he went solo and was relatively happy until Nochomovitz came along with a proposal to partner with his unique network. Pavluk signed on and now enjoys greater security. He also has some say, presiding over budget issues and other administrative tasks for his multispecialty cluster of 12 physicians. His decision to go big, really big, was worthwhile for him.

The bottom line

Ultimately, each doctor has a mission, says Hertz. Recognize what’s best for your practice and whether partnering is the answer for you. Core values such as family time, patient care, business decisions, and earning potential all come into play. Weigh the issues carefully and write them all down. Proceed with a little caution, a good sense of humor, and plenty of optimism; you’ll probably need it.

You may also need some time to get it right. Conti admits to making several mistakes in striving for the ideal partnership, where collegiality thrives and he has enough time to spend with his wife and son. He assists new doctors entering into limited partnerships and gives salaried doctors quarterly bonuses based on production, while holding onto his leadership position. “I want everyone to be happy,” he says.

Jacqueline M. Duda is a freelance writer in Monrovia, Md. She can be reached via editor@physicianspractice.com.

This article originally appeared in the January 2008 issue of Physicians Practice.