Some rheumatologists find that an option other than working in a private practice makes the most sense for them. The reasons rheumatologists choose hospital or academic employment vary.
Explore this issueThe Rheumatologist: Vol 11 – No 4 – April 2017
Also by this Author
When Lisa Criscione-Schreiber, MD, MEd, associate professor of medicine and rheumatology training program director, Duke University, Durham, N.C., was finishing her fellowship in 2003, she chose to stay in an academic setting. She wanted to teach and remain in an environment where she would be surrounded by physicians who, as teachers and researchers themselves, would stay at the forefront of advances in rheumatology. “This would push me to keep my medical knowledge current and comprehensive,” she says.
At the time, Dr. Criscione-Schreiber was primarily planning to have a clinical career and considered working in private practice. “But the [practice] I liked the best was in a rural area, and there weren’t any employment opportunities for my husband, so we chose to stay where we both had opportunities,” she says. “Additionally, the local private practice I was considering was not able to offer guaranteed salary or leave opportunities. Because I didn’t have children yet, I made a partially economic decision to stay at Duke, where I would have benefits, such as a set salary, coverage for malpractice insurance and paid maternity leave.”
David Fernandez, MD, PhD, rheumatologist, Hospital for Special Surgery (HSS), New York, chose hospital employment because he wanted the opportunity to participate in basic and translational research. He appreciates having a wealth of established investigators and clinical colleagues at hand, and a large and diverse patient population.
Like others, Laura B. Hughes, MD, MSPH, associate professor of medicine, University of Alabama at Birmingham, chose an academic, hospital-based practice for the research prospects, in addition to mentoring and teaching opportunities—both didactic and in the clinical setting. The opportunities offered by the university for collaboration, both in clinical care and research, were advantageous, as were having a variety of daily tasks and minimal administrative duties. She says the many positive aspects counter-balanced the lower salary offered in an academic setting than she would have earned in private practice.
Because his profession is in pediatric rheumatology, Matthew Stoll, MD, PhD, MSCS, associate professor in pediatric rheumatology, University of Alabama at Birmingham School of Medicine and Children’s of Alabama, chose to work in a hospital-based setting, in part, because he observed that it was most common for pediatric rheumatologists to work there.
“Perhaps this is due to the rarity of pediatric rheumatic disease and the complexity of many cases,” Dr. Stoll says.
Rheumatologists who work in hospital settings have reaped many rewards. For Dr. Fernandez, having a large administrative support structure means that others take care of many of the headaches that come with managing a private practice, such as selecting and paying for malpractice insurance, maintaining active participation status in private insurance networks, ensuring regulatory compliance and maintaining a social media presence and website.
Further, Dr. Fernandez has access to a plethora of specialists at HSS and its affiliates, which makes it easier to care for patients. “The size of the practices means that patients can generally be seen in a timely fashion,” he says. The electronic medical record systems can communicate with each another, making it easier to follow up on the outcomes of consultations or view laboratory or imaging studies. By being in a large group, coverage on weekends and consult service is less frequent and demanding. Access to other resources such as in-person translators and social workers has proved valuable.
Abby Abelson, MD, chair, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, has also found that having administrative support and infrastructure enables rheumatologists to focus on what they were trained to do—clinical care, research and education—so they can reach their full potential.
Dr. Abelson also appreciates the opportunity to collaborate with others throughout the institution without silos or financial barriers. “Many of my colleagues have introduced me to physicians from other specialties to help manage our complex patients with multi-system diseases; I have done the same for other staff as they joined us,” she says.
In addition, rheumatologists are supported in their quest for leadership positions. “I have been able to take many leadership courses and served on our Board of Governors and our Physician Leadership Council, where decisions are made about institutional strategy and policy,” she says.
“These skills have enabled me to contribute to other organizations, including the ACR and Rheumatology Research Foundation,” says Dr. Abelson.
Dr. Stoll has found that having instant access to other hospital specialists for informal or formal consultations is a significant advantage. “If a patient gets an X-ray, I can easily ask a surgeon in real time for a diagnosis, rather than refer the patient to orthopedics and wait for an answer,” he says.
Of course, hospital employment has some downsides, too. “It is difficult to make changes to how a practice is run at a large academic institution,” says Dr. Criscione-Schreiber. “However, we have a relatively small division of 14 rheumatologists on our faculty, so we are able to pilot changes fairly readily.” Clinic staff have their own management structure, so faculty partner closely with the nurse manager and other staff supervisors to work toward agreeing on changes.
Dr. Fernandez has similar sentiments. “The size of a hospital means that making changes can be challenging, because it requires navigating various channels when reaching consensus,” he says.
Regarding income, “When comparing salaries in private practice against those in hospital-employed practices, a lot depends on where you stand in the organization,” says Dan Jennings, regional vice president of the Atlanta-based The Medicus Firm, which places physicians of all specialties in both hospital and private practice settings. “If you own or are a partner in a private practice, then you will more than likely have a higher income than your counterparts who are employed by a hospital.
“In fact, a national survey showed that private practice rheumatologists tend to outperform hospital-employed rheumatologists by almost $40,000 annually. This difference may be due in part to the fact that physicians who own their practices have complete control of overhead, retain all of their collections and have the ability to collect on ancillary services. Typically, these are factors that do not apply in a hospital-employed practice, where a physician has a base salary and usually receives a production bonus on work-relative value units (wRVUs) or collections for their professional charges. But this added income does come at a cost, however, including assuming the risk for the practice, taking on the burden of running a practice and time required to run the practice.”
Although the numbers point to private practices as the ideal place to be an owner or a partner, if a rheumatologist has just finished their training or is simply looking to be employed in a practice (and doesn’t want the responsibility of ownership), then a hospital-employed setting will more than likely be the better landing spot financially.
“Our firm has found that through our recruitment efforts, a hospital will have the ability to offer a physician a higher starting salary right out of the gate—typically along the Medical Group Management Association median income,” Mr. Jennings says.
Coping with Challenges
For Dr. Criscione-Schreiber, it is challenging to know that certain changes could make care easier for providers and better for patients, but that the changes would take a long time to become a reality. For example, she has to work in the electronic environment that the health system chooses. “Changes we may want to make to improve our clinical care flow enter a larger work queue with requests from all of the other departments and divisions; we have to wait our turn for the changes to be made,” she says.
Dr. Fernandez says the most difficult aspect is having to change gears throughout the day and remain productive in all of those areas. He does research, sees patients in the office and on the inpatient consult service, and teaches fellows and residents.
“If you are in a purely clinical position, you can see more patients and build efficiency,” says Dr. Fernandez.
Along these lines, Dr. Stoll has found it challenging to conduct competitive quality research while still performing other responsibilities. “When applying for research grants, I’m competing with physicians with PhDs who have more time to devote to research,” he says. But on the other hand, he has the advantage of having the ability to learn from his patients and develop research questions around what he sees in his clinical practice and conduct research on his patients.
Rheumatologists who work in a hospital setting have reaped many rewards …. [O]thers take care of many of the headaches that come with managing a private practice, such as selecting & paying for malpractice insurance … & maintaining a social media presence & website.
For Dr. Hughes, the biggest challenges are dealing with the lack of autonomy. “Policies are set for the good of the hospital group and not necessarily for the individual physicians,” she says. To overcome these challenges, she advises physicians and hospital administration have clear expectations of their roles, put physicians in leadership positions in administration and require input from physicians prior to implementing any big changes affecting the practice.
At the end of the day, some rheumatologists choose to work in a hospital setting rather than private practice because the advantages outweigh the disadvantages.
“I have incredible variety in my work,” Dr. Criscione-Schreiber says. “I began my career as a clinician–educator and then became a program director. This led to my further interest in education and obtaining an ACR Clinician Scholar Educator Award. This, in turn, led to becoming a funded education researcher. I’ve done clinical research and collaborated in basic and translational research. I’ve been able to impact the national conversation about education in rheumatology. I’ve had the opportunity to help lead improvements in mentoring for medical educators at Duke. In 2003, I never would have imagined that I’d do all the things I’ve done, and I’m sure that I’ll do all kinds of things I haven’t thought of yet in the next 13 years!”
An additional benefit of being in a setting where you can do research and have less time devoted to patient care time is flexibility. Dr. Criscione-Schreiber is able to leave early or come in late sometimes to tend to her children without working part time because she controls her work hours.
Dr. Hughes likes the stable work environment and good benefits, such as retirement planning options, health insurance benefits and paid vacation time.
At the end of the day, the best position for a rheumatologist depends on what you want long term. “If you are entrepreneurial and are willing to take on additional work outside of your clinical practice, then private practice would be an attractive target,” Mr. Jennings says. “On the other hand, if you simply want to be employed and enjoy a busy practice with a competitive income, then you may want to consider a hospital-employed setting.”
Karen Appold is a medical writer in Pennsylvania.