Lessons Learned from an Employed-turned-Independent Doctor

Coming out of residency a few years ago, Landon Roussel, MD, had one goal in mind for where his career would be headed.

"I didn't see a way of doing clinical medicine and not being independent because if I were working for any insurance-based system, I'd be doing … factory medicine. That's not what I went to med school to do," he says. At the age of 32, Roussel, an internist, is where he wants to be, running his own direct primary care (DPC) practice in rural Lutcher, La., a Mississippi River community an hour outside of New Orleans.

But before he got to his ultimate goal, Roussel took an employed position, which only solidified his desire to be independent. Moving to Lutcher meant he didn't have an established patient base, coupled with not wanting to take out more loans left him with no choice. He took an employed position for a contract meant to last a year, a temporary arrangement until he could build out a patient base. The agreement ended after six months when the two sides amicably parted ways.

"As a hospitalist, I had 15 to20 patients on my roster per day, including a few discharges and admissions. You got paid for doing more; the quality was secondary. You get paid by CPT codes, so if you can rack up more CPT codes, that means more [relative value units], which means more compensation. That's the bottom line," says Roussel.

Roussel's DPC practice, Communitas Primary Care, is half full. He says it took a lot to attract new patients, but his marketing efforts are starting to pay off. By the end of the year, he expects to have a full patient base.

Physicians Practice spoke with Roussel about why he'll never go back to being employed, how he was influenced by an experience at Auschwitz, and advice to his fellow physicians worried about the lack of security in running your own practice.

Physicians Practice: What problems did you have with being an employed physician?

Landon Roussel, MD: The ‘more RVUs’ mentality [that hospitals have] is frustrating because RVUs don't translate into value to patients or society. We're stuck trying to figure out more ways to generate RVUs rather than give people what they want.. …[Hospitals are] just following the insurance money or the Medicare money, instead of actually providing value to patients where they need it.

PP: What are the advantages of being independent?

Roussel: All physicians should be as independent as possible. From my point of view, I'm actually able to see patients and figure out my schedule in a way where I can also take care of myself. And that allows me to be better to my patients. I think there is been a mentality with physician payment where you just got to keep a carrot on a stick and make them run as hard as they can. That's not a healthy mentality for doctors. It's not good for the patient and [doctors] know it.  From a personal level, I'm able to figure out my schedule a lot better. That translates to better physician wellness. Had I not gone this route, burnout was on the horizon.

The other thing is overhead. I'm in control of overhead and that leads to a reduction in waste. I can't tell you how much waste goes on in [employed] clinics where physicians are not paying the bottom line.…. I know where every penny in my practice goes. Every dollar I spend is going towards value. That translates to the patients. If I spend more, I have to charge more. As a result, I'm able to keep my costs substantially lower. I get paid on a monthly basis to provide value to my patients. If they need a prescription, I call it in. If they need a letter for work, I give them a letter for work. I can call a specialist for them….I can call an e-consult. I can't tell you how many orthopedists and dermatologists I've diverted referrals from by using an e-consult.

PP: Most young physicians are going the employed route, as they want a steady paycheck after accumulating so much debt. What made you switch to private practice and have this different mentality?

Roussel:  My original inspiration to go into medicine in the first place was my mother's father, who I didn't know much growing up. He was a newspaper editor in New Orleans. My dad was an engineer, his dad was an engineer. They worked for a chemical plant and I thought I'd follow in their footsteps and be an engineer. When I went to my grandfather's funeral, I learned about him and his life as an artist and a journalist. I saw in him part of myself. That combination of art and trying to understand the human condition and experience the human condition through the work you do, combining that with my talent in math and science, medicine was the answer for that. I couldn’t do clinical medicine in that way without being independent.

The other is studying ethics in medical school and I was perturbed by the lack of attention to medical ethics. I was particularly affected by an experience I had after my second year of medical school. Through a fellowship, the Museum of Jewish Heritage brought [me] and other med school students to Auschwitz and Birkenau [concentration camps]. We learned through that fellowship how doctors were instrumental in orchestrating the Holocaust. How our profession was used for destruction. That really affected me.

When I left the hospitalist position, I knew I was in for a lot of work, but I said to myself, ‘That's the price for doing the right thing. I've got one life to live and I'm going to live it, I'm going to do it in a way where I can live with myself in 20 years.’ If I spent the next 20 years as an employed physician, I probably would not be happy with what I did. This might be hard and I may suffer, but at least I can rest comfortably knowing I did my best and did the right thing.

PP: What advice you have to people worried about the lack of security that comes with running your own practice?

Roussel:  Seek every opportunity to develop knowledge on the business of medicine and the administration of medicine. You can't practice medicine in a vacuum. Medicine is a part of society. If you don't learn the structures and tools and systems in place to be able to practice it, someone else will tell you how to do it. Learn as much as you can.

The Second thing: Do your best. If you work hard to be a good clinician and take care of your patients and do your due diligence … people will come to you. Just do a good job. They may not come right away. It may take time. Form those relationships. They'll pay off. You have to deal with a little bit of uncertainty in terms of when the money is coming in, but it will with persistence and diligence.

The time couldn't be riper for physicians to be independent, it's what patients want and need. There's not a state where there isn't a shortage of primary-care doctors. Don't be discouraged by the mayhem with healthcare coverage because people will move their feet [to] a good doctor.