Is your ideal practice fit within reach?

Private practice, including solo, single, and multispecialty settings, remains the most popular choice among U.S urologists. But it’s by no means a dominant option for practice setting in the specialty. In fact, just under half of urologists who are age 45 and younger choose private practice. Nearly 40% of today’s urologists work in institutional settings, including academic centers and public and private hospitals, according to the 2016 AUA Census.

Mr. TuttleDeciding on whether to go into (or switch to) private practice, academic, or an employed model means weighing potential pros and cons of each setting and looking in the mirror at character traits, likes, and dislikes that would make one setting more suitable than another.

For example, private practice demands lots of non-clinical, business-related contributions, compared to academia and hospital employment. (Also see Henry Rosevear, MD’s blog post, “Physician employment: Both good and bad results.")

“An entrepreneurial spirit is a must, as is the commitment of time-well beyond 40 hours a week,” said Gray Tuttle, CHBC, principal at Rehmann’s Healthcare Management Advisors in Lansing, MI.

Going it alone

Perhaps the most challenging of the options today is solo practice. Less than 10% of practicing urologists have chosen the model, according to the 2016 AUA report. By comparison, 20% of urologists were in solo practice in 2009 and 26% were solo practitioners in 2001, according to an American College of Surgeons report (Bull Am Coll Surg 2012; 97:46-9).

Private practitioner and Long Island, NY, urologist Richard A. Schoor, MD, says it’s difficult but he makes it work by offering what others can’t or won’t. His niche is male infertility.

Dr. Schoor“Over the past 12 years, I have developed not just a reputation [and] brand in the community, but an infrastructure that is difficult, if not impossible, for others to replicate,” he said.

Dr. Schoor has an andrology lab, which offers semen testing and fertility preservation services.

“I do the overwhelming majority of andrology surgical procedures, such as vasectomies, vasectomy reversals, testicular biopsies, and sperm retrieval procedures, in my office. Not only does this save my patients the extra costs associated with hospital and ambulatory surgical centers, it makes my office an efficient and delightful place to work,” he said.

The big con of solo practice: cost.

All costs, from payroll to office supplies, fall on the urologist. Still, it’s worth it, according to Dr. Schoor.

“If you can make it work financially, it is a wonderful way to practice medicine,” he said.

Next: Single-specialty group

Single-specialty group

Tuttle says there are a number of potential advantages associated with a single-specialty urology practice, if it has three or more urologists.

“In my opinion, it’s probably the best option when considering all pros and cons,” Tuttle said.

Among those potential benefits: more diagnostic service offerings, multi-hospital system coverage, greater geographic presence, greater and better technology, and better quality of life.

A two-person single-specialty practice falls short of offering the quality of life benefit, because it’s difficult, if not impossible, to manage coverage, according to Tuttle.

Mr. ZetterStill, one of the great advantages of a single-specialty private practice is the ability to run it the way you choose to run it, according to health care consultant and national speaker David J. Zetter, CHBC, of Zetter Healthcare Management Consultants in Mechanicsburg, PA.

“If there are no other urology groups in an area or your group has better outcomes than others, you can market and gain the referral base to be successful,” Zetter said. “A large group allows sharing in call and a more balanced work life. Larger groups also offer the potential for bonuses, real estate involvement, and ambulatory surgical center ownership.”

Among the drawbacks, according to Zetter: Referrals could be an issue if many primary care physicians are employed by the local health system, and keeping the practice going could be difficult if it’s competing against a health system that offers urology.

Multispecialty group

Multispecialty groups of any size are typically in large urban or suburban areas, according to Tuttle.

“There are some parts of the Midwest where multispecialty practices predominate the market,” Tuttle said. “Those are often behemoth practices that have been around for decades and offer stability and huge critical mass to recruit doctors.”

If primary care physicians are part of the group, there’s a built-in referral network, according to Zetter.

“[There’s] the ability to leverage the benefits of a larger group in contract negotiations and everything else, and the ability to work independently in the community, even if a large health system is present,” Zetter said.

That’s not to mention the potential financial benefits of ownership in the practice and real estate, bonuses, and more, according to Zetter.

On the other hand, the large size of a multispecialty group can lead to management challenges because of the complexity of a big multispecialty operation, according to Tuttle.

Next: Academics, institutionally employed

Academics, institutionally employed

Urologist Richard Pelman, MD, has been in private and academic practice. He says that his role as clinical professor of urology at the University of Washington in Seattle is the right fit for him after more than 30 years in the specialty.

Dr. PelmanDr. Pelman says the regulatory and documentation demands of today’s health care marketplace have made the academic model more attractive. A faculty physician working 4 days a week, Dr. Pelman staffs a general urology clinic and refers surgical cases to University of Washington colleagues.

“I’m not laparoscopically or robotically trained. I’m an open surgeon, and that style of surgery is disappearing for minimally invasive techniques,” he said.

Dr. Pelman says he likes it that each University of Washington department has discretion for hiring and has a budget, under the umbrella of the School of Medicine. In contrast, if he were employed by a hospital, the hospital administration might make the staffing decisions, he says.

“At this point in my life, I’m still working because I love the ability to see people. All the elements that sustain people’s practices, such as MACRA requirements, are taken care of through the university,” Dr. Pelman explained.

Academic practice is particularly popular among female urologists. Nearly 36% of female practicing urologists work in academic centers, compared to nearly 25% of men in the specialty, according to the AUA.

Angela B. Smith, MD, MS, assistant professor of urology at the University of North Carolina School of Medicine in Chapel Hill, says her practice is split between clinical care and research.

Dr. Smith“Being able to alternate between clinical practice and research-all while teaching residents and medical students-creates variety in my week and avoids monotony and burnout. I also enjoy the flexibility, which allows me to juggle being a mother and a surgeon researcher,” Dr. Smith said.

The positives of working in an academic setting greatly outweigh the few negatives, which include frequent travel for conferences and occasional weeks of long hours, when there are impending grants, conferences, and manuscript deadlines, according to Dr. Smith.

While Dr. Smith says the compensation in an academic setting tends to be lower than in private practice, but health and retirement benefits in academia can help to balance the discrepancy, she says.

Call schedules might also be lighter in academics, given resident involvement.

Next: Academic/employed model

Academic/employed model

Sometimes, academic and employed models come together.

As president of Cleveland Clinic Regional Hospitals and Family Health Centers, urologist J. Stephen Jones, MD, MBA, oversees 10 hospitals and 21 large ambulatory sites. Despite the responsibility of being a Cleveland Clinic executive, Dr. Jones says he still manages to practice urology in a way that he enjoys.

Dr. Jones“Physician executives at Cleveland Clinic continue to practice, although it is now a few hours a week and a few surgical cases a month,” Dr. Jones explained. “I have been able to focus on localized prostate cancer, especially in the radiorecurrent setting, and on challenging diagnostic dilemmas in patients with high PSA following prior negative prostate biopsy.”

Dr. Jones, who is also professor and Horvitz/Miller distinguished chair of urologic oncology at Cleveland Clinic, says his clinical practice is tied to his research interests, allowing him to stay on top of his game. However, he refers patients who are outside his focused clinical practice.

“In our setting, complex cases are sent to the surgeons with the most experience and expertise. I haven’t taken a stone out in years, but have multiple skilled partners who do so almost daily. By contrast, very few people in the country want to perform salvage procedures on patients after failure of radiation therapy. I am as comfortable with them as I am performing a prostate biopsy or cystoscopy,” he said.

“I sometimes wish I had more time for patient care because it is so rewarding, but know that I have remarkable colleagues… who are available for the breadth of urologic care.”

Dr. Jones, who spent 7 years in private practice, says working in the academic setting requires patience with the system and with residents, who are learning on the job.

“Both my parents were teachers, so education is second nature,” Dr. Jones said.

Surgeons who work hard and provide good care can make as good a living in academics as they can in private practice, according to Dr. Jones.

“We have to pay competitive salaries to keep top talent, but of course we expect those surgeons to provide unsurpassed excellent care as part of being in the practice,” Dr. Jones said.

Employed models with health systems or hospitals offer important benefits, according to Zetter. Among them, urologists don’t have to worry about cash flow, staff. or much of anything related to running a practice.

But urologists will likely have little to no input regarding how the practice is run, Zetter says.

“[You’re] just a cog in the wheel of the large health system,” Zetter said. 

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