Episode 005: Things to Consider Before You Commit: Joining a Group Practice

Speaker 1: You're listening to Your Practice Made Perfect, support, protection, and advice for practicing medical professionals, brought to by SVMIC.

Brian: Thank you for joining us. Today's podcast, we're going to be talking about what to look for when you're joining a group. I'm Brian Fortenberry and joining me today is Dr. Matt Perkins. Welcome.

Dr. Perkins: Brian, thank you for having me today.

Brian: Absolutely. So Dr. Perkins, as we get started, tell us a little bit about yourself.

Dr. Perkins: I'm Dr. Matt Perkins. I practice internal medicine and pediatrics in Smyrna, Tennessee, which is down in Rutherford County. What that is, is a modified family practice. I'm also very pleased to serve SVMIC on a number of the committees including the board for about 10 years now. In our community of Rutherford County, I also help to run an independent practice association.

Brian: So thank you so much for being here today. Why is this important for you to speak on? You're really here talking about what it looks like to join a group. Why is this an important topic for you?

Dr. Perkins: Since my private practice has been the goal of my entire adult life, and the culmination of, well in this case, decades of work. As I mentioned, I've been in practice nearly 20 years, starting the group from the ground up. My partners as I have brought them on, I spend more time awake with my partners and my nurse than I do with my children or my spouse.

Brian: Yeah.

Dr. Perkins: So attracting a new physician to our group is that important to me. My own personal philosophy, the philosophy of our practice is, I'm going to be your physician 24 hours a day, unless for one reason or another we part company. Now granted, people take vacation and they're off and that sort of thing. Something a partner for me, must be capable of doing, is being able to take care of my mother if I'm not in town for example. That kind of trust is important to me. So as I'm visiting with a young person, or somebody new to the community, that's the question, are you going to be dedicated enough to take care of me or my mom for example, if we're sick?

Brian: Excellent. Whenever we start looking at joining a group, that can be even something right out of school, say you just wrapped up residency and you're getting ready to take your first job, or it could be moving into an area, taking over a new job and have been in practice for a while. What is one the very first things that you look for or that is good to look for when making that decision?

Dr. Perkins: So, if I'm a brand new resident, freshly minted, going into private practice, the number one thing residents ask themselves is, "How much money did you get offered?" When in fact, it's the last thing you really want to know once you've moved and made the commitment to a new community, hospital organization, private practice, et cetera.

Brian: Sure. Is there some first impressions that one can get whenever they start that interview process? Maybe they're vetting out an area or a location. Is there some kind of observation that would be important to key on?

Dr. Perkins: First thing I think somebody should look at, unless they're moving home and know the community, is can I live here and if it's appropriate, raise a family? Because outside of the business of medicine, you still have to create a home where you're going to go and there's a lot of people that chase an opportunity, sometimes money, or a center of excellence and then find out that they're miserable when they go home at night because it's just not where they want to live.

Brian: It really makes sense then that when you're initially making these decisions, that you take into account work life balance and you're taking into account the whole aspect of your family and your life, not just your career.

Dr. Perkins: Absolutely.

Brian: Do you feel that when you're looking at these types of places, are there certain things that you look for within a practice that you go, that is a red flag to me of why I might not choose this particular location?

Dr. Perkins: One of the first things I would suggest a person consider is during the interview process is to show up unannounced at the front desk of the practice.

Brian: Ah, okay.

Dr. Perkins: I think it's important to see how a patient at random, or a stranger off the street is greeted at the front desk. I think it's important to see how the staff interacts with one another even from the front desk forward. Staffs that are happy are probably treated well by the doctor. Staffs that are unhappy are often not treated well by the doctor. 70% of a patient's interaction in a given office is all about the staff, and a little bit to do with the physician and so if you want to have a real success in your private practice, you've got 30% to work with. So, joining a group that has an unhappy staff is just going to set you up for failure.

Brian: So Dr. Perkins, give us a perspective if you can when you're coming right out of residency, and you're getting ready, and you've got this interview set up, and you're headed into this office to be interviewed, what would you expect to see? What could you expect to be asked and be asked of you when you're going into this interview blind for the very first time? What does that look like?

Dr. Perkins: A typical interview day, if you're going to be coming in from out of town, would likely come in the night before, probably stay in a local hotel, possibly with the hospitality of one of the physicians in their homes, that sort of thing. Usually the day will begin at the hospital, the local hospital, often because the income or the recruitment may be supported by a local hospital. So typical perhaps the CEO, CFO, or the chief medical officer at the hospital would be included in that process usually.

As far as the group or the private practice is concerned, if it's a larger group, possibly the administrator, a smaller group, perhaps one of the doctors would begin the day, most usually there'll be a tour of the hospital or hospitals plural. The office or offices if there's more than one site. Usually the tour includes obviously the clinical areas, introduction to some key personnel, that sort of thing in the office settings. Usually introductions to the office staff themselves. If there are partners, however many of those folks are on duty will be introduced. Usually that will also include a meal, often times lunch, because it's an easy time to get the physicians to sit down and visit with someone.

Through the course of the afternoon, often is the standard real estate tour. Here's the community. They'll have a local realtor show you the highlights of the places that people tend to either wanna live or the things that of interest in the community. Often that night if you're going to stay in town, the partners are usually get their families together, including if the physician has a significant other with them out to dinner for the evening. During the course of that day, of course there's light conversation back and forth. Most of the times not a sit down grudge match of questions. The residents usually have done some preparation in advance, often times they've explored the website for example.

Brian: Sure.

Dr. Perkins: And those are usually the standard questions. How much am I going to make? How many years to be in partnership? And those are important and all, but the more important questions tend to be, please kind of give me an idea of what my year three or four would like in your group. Perhaps, how many of your partners have left the group and what is your attrition rate among your partners? What is the retirement plan for the senior physicians in your group, and am I coming on to replace someone or am I going to be largely building my own practice from scratch? What are your physician's interactions in our community, specifically are they involved with church groups, or the American Red Cross, or whatever that happens to be? Do they live in this community or commute in? And do they do anything together outside of the office? I think is an important question to ask.

Brian: That is some fantastic information because really, you're looking at going on these interviews, it's going to be a day or a two-day process that you're really going to be entrenched in not only your surroundings of the city, but the hospitals, and the practice itself. You're really going to have an opportunity to see the practice's best foot forward, but they're going to be able to see your best foot forward in this as well. As the one that would interview someone coming into that practice, what types of things would you say ask a new resident? What type of information would you want from them that they could be best prepared for when going out and seeking out these positions?

Dr. Perkins: As I've had that interview process, some of the questions that I'll ask of a new person coming to our group, which is one, are you comfortable working more than 40 hours a week? Because you need to be, and while we may have a 40 hour week in front of our patients, there are responsibilities outside of being in the office if you're going to take care of a group of people. What is your commitment to this community? And I need to know, at least from our philosophy at my practice, that you're going to engage in at least two projects outside of the office, not being a doctor. What is your goal for your family if you have one, coming to this community in terms of educational opportunities, recreation, that sort of thing?

Additionally, what is your long-term or your five year plan, if that's a good way of putting it, regarding where do you see yourself in five years? Do you see yourself in five years wanting to be in a different specialty all together and this is stepping stone for something else? Do you have administrative aspirations? Do you see yourself going into a different line of work? It's important to put somebody on the spot because some people after their residency are still really considering whether or not they want to specialize and just need a little bit of time to catch up bills for example.

Brian: Wow, okay. What would be red flag issues for you if you're interviewing someone? What kind of responses are going to be red flags for you?

Dr. Perkins: The person who is uncomfortable with their year three or four income maybe being lower than the guaranteed income that all groups offer to get somebody to come take a look at them. The incomes that any group can offer on the front end, are the things that all residents ask for, and then they scratch their head determining that, well, gee, that's how much the partner can earn after 10 years of maturing a practice, and you typically have to work pretty darn hard to maintain that.

Brian: And so it is important to have realistic expectations for people that are getting ready to go out on that interview process to know what's expected of them then?

Dr. Perkins: Absolutely and in some training programs, and I can only speak to primary care in this setting, some training programs are teaching traditional medicine, in-patient and outpatient, some in-patient online, some outpatient only. My practice for example is traditional practice. It does both. And so a prospective partner for me, needs to be willing to basically be on duty period. Now granted, we have our call schedules and that sort of thing, but only doing shift work for example in my practice, just doesn't do it. That has been an important factor in the line up of our physicians over the last 20 years or so.

Brian: You are, as you said, in Smyrna, Tennessee now and you are part of a group. When you joined this group, take us through that, kind of walk us through that experience so we can kind of associate a real life circumstance with this.

Dr. Perkins: So my particular circumstance in private practice probably represents an atypical example, at least what people will be doing nowadays.

Brian: Okay.

Dr. Perkins: So very few people coming out of training generally speaking will set up private practice on their own. I set up a private practice on my own. And so in our group of six physicians, I'm the old guy and the one who decided to borrow a bunch of money and roll the dice and see how it goes. Subsequent to my other partners joining, I can kind of give you an idea of what they were looking for I suppose when they joined me.

Brian: Okay, yeah, that would be helpful. As they were coming to join you, what kind of questions did they ask that you thought, man, that's intuitive, that's really introspective? They're trying to get something. What are some of the things that they ask of you when coming in?

Dr. Perkins: And so a question that was not necessary was, can you make me busy? Obviously I practice primary care, which is a needed specialty in any community. The questions that my first two partners put to me were, how much money do you owe? And what is your plan on retiring the debt of the practice? I don't want to join a practice that's going to somehow include me in a losing proposition. How many patients per day can I see? What's your mix of Medicare, Medicaid, and private insurance? Because that will matter to your bottom line at the end of the day. Do you do traditional in-patient medicine, outpatient medicine, or a mix? And then the most common question after what will you pay me, is how fast can I become a partner?

Brian: Do you think that when someone is looking for this type of opportunity to join a practice like that, do they first need to look after the family aspect that we talked about in living there? Should they really look at the business aspect because it sounds like that the people that came in with you really were looking at a lot of questions from the business aspect, not as much from the medicine aspect?

Dr. Perkins: Yes, that's very true and there's several different groups of young physicians who come out and what they're looking for. Some really want to practice medicine and be very much a part from the administrative aspects of things. And some are much more desirous of being in kind of control of the things going on behind the scenes, the person behind the curtain if you will. And so, having those questions in your mind on the front end, obviously in our current environment, more and more people are going into hospital owned practices, that sort of thing. Clearly there can be a support of an income that can be perhaps higher than if you're on your own, but there is a trade-off, which can be here's your schedule, and this is the schedule we're going to give to you and some trade-off of income for autonomy.

Brian: Yeah, to me that would probably be a big part of that, whether you're driving the ship rather than just riding on the ship itself. If you are in this situation of you're joining a new community, how important is it to look at maybe facilities that are around you? Certainly hospital associations and things of that nature. Is that an important component knowing that, certainly if you're in primary care, or something of that nature, where you'll be referring to, is that something you take into consideration?

Dr. Perkins: Oh absolutely. In particular, in some of the smaller communities one of the disadvantages that they have in trying to accommodate or rather attract some specialty care is what do you do in a small town getting the first neurologist to come to town?

Brian: Right.

Dr. Perkins: He or she is going to be on call 24/7, and very often they're just not willing to go there. It's much more common to see them wanting to be doctor number five in a group of four because then there is back up, call sharing, they don't feel as if the weight of the world is going to be on the shoulders.

Brian: So it does probably greatly depend on the heart of the individual. There are some people that I know probably are just more drawn to rural medicine whereas some are drawn to academic, some are drawn to more metropolitan areas. With that, is going to come challenges within a group as well, correct? I mean, those are going to look very different. A group in a rural community as opposed to one in downtown Nashville, Tennessee is going to probably look a lot different, correct?

Dr. Perkins: Yes, absolutely.

Brian: If you had to give some advice to a brand new resident that is getting ready to jump out of the education realm, straight into a career, and they're trying to make that hard tough decision of, do I go into private practice or do I go into a group? And they've made the decision now, I think the group route is best for me, but I'm really concerned about the key components that I'm going to need to take into consideration. What are two or three things that you'd say, these are got to be top list priority that go a little deeper than just the obvious questions?

Dr. Perkins: I think certainly a young resident is going to want to be clear on what will be my roles from an administrative perspective? Are you going to want me to where hats outside of my day practicing medicine? Be it staffing, scheduling, dealing with various areas in a given practice. If I'm going to join a group in a city, exactly what is my call relationship going to look like? So for example, general surgery in Memphis, am I going to be covering four emergency rooms when I'm on-call through the metropolitan area? If I'm going to be moving to a small area in Arkansas, or Tennessee, exactly what sort of back up do I have on a Friday night in our local emergency room with a hospital of 25 beds if I've got an acute abdomen or a head injury?

Brian: Sure.

Dr. Perkins: And as I am the primary care doctor in this setting, am I the only person on town on a weekend if there's a baby with meningitis? And so, as I personally look through the communities, in this case, Tennessee, during my search process, I found that for me, a medium-sized city in this case, Murfreesboro and Smyrna, had enough back up for me not to feel as if I'm on my own. I'm certainly not a person that is a big city person and had no real interest in academia, or the tertiary care setting.

Brian: Sure.

Dr. Perkins: But I'm certainly not ready to be in the middle of Utah, 100 miles from town.

Brian: So as you have set up your practice in Smyrna, you have a group of several physicians now. What has been your experience, your track record in your own group?

Dr. Perkins: Yes, we've had a wonderful track record over the last 20 years or so. We currently are a group of six physicians. We have actually been recruiting continuously really that entire time. We have tried to be incredibly choosy for exactly the reasons I just mentioned, and we've had a low attrition rate. The physician that chose not to remain with us, largely was just a misunderstanding regarding expectations in our practice, specifically that you're a doctor for your patients all the time.

Brian: Thanks for joining us today Dr. Perkins.

Dr. Perkins: Thanks for having me.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast. The content of this podcast are intended for informational purposes only and do not constitute legal advice. Policy holders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time.