Published in the January 2010 issue of Today’s Hospitalist
Kamal Ibrahim, MD, has no trouble remembering all the negatives of his first position with a hospitalist group: a brutal schedule, below-market compensation, bare-bones benefits and an onerous employment contract. The highly political environment in which his group and other hospitalists in the same hospital worked didn’t help either, because the doctors all compared notes on schedules, income and compensation.
"After three years in that job, I knew that I wasn’t doing the right thing for myself and my future," recalls Dr. Ibrahim. "I was earning $120,000 a year, getting only four days off a month and pretty much had no benefits compared to the other groups."
Then there was the non-compete clause in his contract that barred him from joining another local group “which he might have done “for one year after resigning. Rather than pulling up stakes and relocating, Dr. Ibrahim opted for what seems like an anachronism in hospital medicine: He decided to fly solo. While he still works at Detroit Medical Center in Michigan, Dr. Ibrahim’s an independent hospitalist.
Hospitalists who choose to work as solo practitioners are a tiny minority. According to the 2009 Today’s Hospitalist Compensation & Career Survey, only 3% of responding hospitalists noted that they work in a group with only one full-time hospitalist. (The mean number of FTE hospitalists in groups around the country comes in at just under 10.)
But many hospitalists who choose to work alone claim they have no desire to sign up for group life. Cross-coverage arrangements provide collegiality, they say, and hospitals have such a need for physicians that solo doctors are under no pressure, at least for now, to join a practice.
Doctors can count on hospitals providing technological resources, which makes it easier to spread themselves thin. And the ability to set their own schedule and income, they claim, more than makes up for whatever they lose in strength of numbers.
Opting for flexibility
For Dr. Ibrahim, it was tough starting out as a solo physician. To build a practice on his own, he first worked nights "to get on my feet," then started covering weekends for local primary care groups. He also offered to take care of those physicians’ nursing home patients.
What he cobbled together soon amounted to "a decent census," Dr. Ibrahim says. Now, nearly four years later, he has a steady flow of patients from a half-dozen primary care groups, and he’s bordering on being too busy.
"I’m so overloaded sometimes that I’m looking to be a group," he jokes. Fortunately, as one of at least a dozen independent hospitalists at the 2,000-bed facility, Dr. Ibrahim can find another solo to spot him when he feels overloaded.
Other solos cite different reasons for going independent, with some setting up niche practices. Karen Leggett, DO, in Sarasota, Fla., for example, opted to work as a solo hospitalist after operating an outpatient practice.
"I like to get paid for the work I do, and I like to be independent with my schedule," she says. "The hospital gives me the opportunity to do that."
Dr. Leggett’s practice focuses entirely on very sick patients who’ve had long ICU stays in other facilities. She works primarily at HealthSouth Ridgelake Hospital and its nearby rehabilitation hospital, as well as Doctors Hospital, also in Sarasota. While she’s experimented with different schedules with a physician who provides cross-coverage for her, she’s decided that providing 24/7 coverage works best for patient continuity.
The obvious downside, Dr. Leggett points out, is "that I have to be available pretty much all of the time." But the upside is being able to maintain a patient census ranging between seven and nine patients a day. "If I want to go in at 6:30 a.m. one day and 8:30 the next, I can," she says.
Pick your census
For Harry Rosen, MD, in Tarzana, Calif., the appeal of solo practice likewise has to do with controlling census and directing care without a lot of interference.
"I like to see an average of about 10 patients a day, which is a lot less than most hospitalists see," Dr. Rosen says of his practice at West Hills Hospital in southern California’s San Fernando Valley. "In exchange for basically making less money, I can give patients the care and time I want and not have someone telling me I have to see more patients."
While he has nothing against the group model, Dr. Rosen says that it’s just not for him right now. With three children under age 5, he wants to work a basic 9 to 5 schedule and make sure he can take off every other weekend, with the help of other solo hospitalists at his hospital.
For another practitioner, however, flying solo means being able to clock more hours if he wants. Ardavan Afrasiabi, MD, a hospitalist at Oroville Hospital in the foothills of California’s Sierra Nevada range, elected for a solo practice after moving into hospital medicine three years ago from a general internal medicine practice. Being independent, he points out, suits his entrepreneurial spirit.
"I looked at how long people stay with some groups and saw that turnover was high after a few years," Dr. Afrasiabi says. "I figured that was probably indicative of the workload and the restrictive environment." He also found little negotiating room in many contracts he reviewed in terms of schedule and scope of practice, and few opportunities to advance.
"The impression I got was that ‘the position is what it is,’ which didn’t suit me," he explains. "Now I make medical decisions every day, and that’s all I make. I’m not under pressure to discharge patients if I don’t think they’re ready to go."
How much do you want to make?
Dr. Afrasiabi, whose average census is 15, is unusual in that he’s paid per shift, earning around $350,000 a year. (Solo physicians typically earn what they bill.)
He is also somewhat unique in that his hospital pays his malpractice premiums and health insurance, and handles his claims and billing. He has no employees or office backup, and he can take advantage of substantial tech support.
The hospital, which is going paperless next year, provides tablet computers and desktops in all units, and it has a wireless foundation. Plus, the staff at Oroville has near-instantaneous telemedicine support from the University of California, Davis, about an hour away, for a number of services not provided on-site.
"We have a camera and a computer," Dr. Afrasiabi says, "and we can communicate with a doc there within 10 minutes."
Dr. Leggett, who also operates without a formal office or staff, likewise receives substantial on-site support. Last year, she billed about $220,000, and with the help of her husband, who functions as her business manager, and a billing agency, she collected 92% of that amount. "That’s pretty much unheard of," Dr. Leggett allows, "but it works here because it’s a specialty-oriented hospital." (She notes that a billing agency charges her 6% of collections.)
Dr. Ibrahim’s practice pulls in about $350,000 a year. He does, however, maintain a small office and employ two assistants full time who handle dictation, communications with referring physicians and claims submission.
Dr. Rosen, on the other hand, is perfectly happy with his annual income of about $225,000. He says he’s also fortunate to have a family member trained to handle his billing. Besides paying that part-time salary, he says, "My overhead is basically my pager and my malpractice, which runs about $7,000 a year."
Technology also plays a big role in his being able to maintain his practice, which wouldn’t survive, he says, without online, off-site access to lab and imaging results.
"In the evening when the ED calls me about a patient to admit, I tell them I’ll call back in 10 minutes," Dr. Rosen explains. "Then I go over all of the tests and information I can get a hold of, and call them back with admission orders."
Without that kind of access, he points out, "I’m just working on what someone is telling me over the phone, someone who’s also managing five other patients at the same time. I won’t do that."
Spreading yourself thin
Having that access, however, underscores a significant downside of solo practice: needing to provide close to 24-hour coverage. Even though he’s on-site for only eight hours, Dr. Rosen takes calls from the floors in the evenings, which can add an additional hour or two. He also averages two admissions a night, which he typically manages by phone.
"But if it’s an ICU admission, I go in to ensure the patient is stable," he says. "That happens about once a week." He also takes call panel once weekly, which he admits he’d "happily not do if I had the ability, but I’m not there yet."
Dr. Leggett also fields calls from the floors at night, even though she’s developed well-oiled arrangements with nurses in terms of orders and medication adjustments. Her patients have all "had horrendous courses at larger facilities," she points out, and most have been or are being weaned from ventilators. Their average length of stay is about 28 days, and her rounds take about four hours a day, half of which is for dictation. A single admission, says Dr. Leggett, typically takes 2.5 hours.
For Dr. Ibrahim, the price of flying solo is having a daily census that sometimes tops 25 patients, a 70-hour workweek and a "pretty typical" day that can last from 6 a.m. to 10 p.m. "I’m definitely looking at hiring a PA soon," he admits.
Dr. Ibrahim also has a tough time arranging back-up when he takes more than a week’s vacation. He’s planning to travel to his native Sudan early this year, and says he’s doing some horse-trading to get arrangements in place.
Dr. Afrasiabi, who does most of his own procedures including paracenteses and thoracenteses, knows that burnout is "a huge risk." He sometimes feels like he’s getting close.
"I think one of the main issues with being a hospitalist is staying a hospitalist for a long time because the environment is stressful," Dr. Afrasiabi says. When burnout simmers, he takes fewer shifts, beefs up his extracurricular activities and takes on more administrative work, mostly in quality improvement. This year, for example, he is the hospital’s chair of medicine.
A precarious position?
And for Dr. Rosen, there is another potential downside that is longer term. He thinks the days of solo hospitalists are numbered by virtue of the pressures hospitals are under to establish formal on-site programs, despite the fact that they’d have to pay for services “such as ED call-panel coverage “that "they now get for free."
He also worries that health plans and HMOs might decide to hire dedicated hospitalists, in which case the number of patients he treats, mostly referred by local primary care physicians and specialists, might dwindle.
"If that happens, it would be hard to remain solo unless you’re with a hospital that doesn’t align itself with anybody," Dr. Rosen says. "That’s the precariousness of my situation, but whatever happens, I’ll deal with it." Unlike many other solo hospitalists, he adds, "I’m not averse to joining a group."
Bonnie Darves is a freelance health care writer based in Seattle.
HOSPITALIST GROUPS “large and small “are definitely the dominant players in hospital medicine. But there’s a niche for solo hospitalists who can identify an amenable market and a willing hospital and who have an entrepreneurial spirit.
Although opportunities are out there for solos, hospitalists eyeing independent practice should plan ahead for the transition and be able to navigate political waters and cash-flow crunches. To that end, solos offer the following tips:
- Gain solid experience with a group before considering solo work, Kamal Ibrahim, MD, a Detroit, Mich., hospitalist advises. "You need two to three years with a group to understand the business of medicine, the billing system, the coding and length of stay," he says. "Most of all, you have to establish relationships with physicians so that you’ll have some patients to start with."
- To build a practice and keep cash flowing, be flexible and willing to take on the work “and the call duty “that others hand off, advises Harry Rosen, MD, a solo in Tarzana, Calif. "Being a solo hospitalist has a lot of fluidity to it, but you have to be willing to move and shake along with it," says Dr. Rosen. "I’d like to be able to give up the call panel, but I’m not there yet because I need that income."
- Create your backup network from day 1, Karen Leggett, DO, of Sarasota, Fla., advises, by hooking up with other solos in hospital. She and her "backup partner" experimented with several sharing arrangements before settling on a traditional model of simply backing up each other as needed and for vacations.