My Reason for Embarking Upon a Single Physician Private Practice

The decision regarding the practice model one chooses for a medical career can be guided by several factors. My decision to embark upon a single physician private practice was not my original intent and not even a consideration when I finished my training. I had to make my choice within a relatively short time frame as an adaptation to an unexpected change in strategy by the academic practice that employed me. After completing my glaucoma fellowship in Boston, I accepted an academic ophthalmology position in Massachusetts and was hoping to continue along this path. Unfortunately, my student loan debt was approximately 95 percentile compared to my peers, with my loan debt-to-income ratio approximately 25%, which required that I evaluate other opportunities. I was offered various practice opportunities including a position within a multispecialty group practice as well as an opportunity to practice at a tertiary care eye hospital in Saudi Arabia, each of which nearly doubled my academic practice compensation at the time.

I chose to travel along with my wife and two young children on a career adventure at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia. Along with a boost in compensation and tax benefits which allowed me to extinguish most of my student loan debt while I practiced there, I gained much more including the chance to interact with truly excellent ophthalmologists of several subspecialties and the experience of treating glaucoma patients with tremendously complex eye disease. When my wife and I sought to bring our children back to the United States, I was offered a position as director of two satellite offices of an academic practice in Boston. When the goals of the Bostonbased academic department changed, I was offered the opportunity to purchase the Worcester satellite office and take it over as a single physician private practice. This was frankly a frightening choice at the time since I had never considered running a private practice but also had no idea how to manage the business side.

I was fortunate to have several advantages at the time that may not be available to all physicians seeking to start up a singlephysician private practice. My ophthalmic office was fully equipped with functioning exam rooms and even some of the lasers I needed. I was also able to retain most of the staff, including one staff member who had knowledge of insurance contracting and billing. I was also fortunate to be able to finance the purchase of my former satellite practice directly through the seller, the Boston academic institution. These advantages gave me a shortcut so that I did not need to shop around for equipment, hire staff, and apply to banks for financing. Fortunately, I was able to find a local payroll servicer who helped me set up the processes necessary to take on the payroll functions necessary to compensate my employees. The local payroll processor was eventually purchased by a large national payroll and human resources company with which most of the interaction is now automated and online. I learned quickly the importance of establishing helpful business contacts. I purchased business and liability insurance and established relationships with a knowledgeable accountant, and a banker from a small locally-based bank who helped me finance additional equipment purchases. Sadly, the small bank was swallowed up by a behemoth of a national bank with a much less personalized business experience. Along the way, the requirements for running a medical practice became more complex with HIPAA requirements, electronic medical records, patient portals, and CMS requirements. I sought help from consultants to help us navigate CMS-related issues and other requirements, and discovered an excellent IT professional (who replaced a predatory disastrous relationship with an initial IT company that did a poor job of maintaining our electronic medical records system).

A large disadvantage when I took over my practice was the very sparse patient base (we saw about 25 % of our current patient volume) and my dearth of referral sources. I was fortunate to be able to offer niche services after garnering unique glaucoma surgical experience during my time in Riyadh, which allowed me to draw referrals from other practices. As a result, I was presented with a unique opportunity since without my local practice, these patients with complex glaucoma care needs would have had to travel to academic centers in Boston for care. This was important since most of the more routine ophthalmological services were already offered by the other long-established general ophthalmology practices in the area that held established ties to primary care referral sources. To build my referral base, I made myself conveniently available to new referral sources and was willing to accept patients with time-sensitive ophthalmic problems late on Friday afternoons and on weekends. I even distributed my mobile phone number to them. I marketed the more unique offerings of my practice with mailings when I acquired new equipment and offered procedures not available elsewhere in the Worcester area. I also held didactic sessions at my office for other eye care providers to teach skills pertinent to glaucoma care which provided me an opportunity to showcase my expertise in the subspecialty.

Running a small private practice is not for everyone. I have enjoyed the independence which has allowed me to buy any equipment I needed and to set a direction for my practice without seeking approval from partners. Like any other physician, I often must complete chart work on weekends, but then must play a role in the business side and financial functions of my single doctor practice. I least enjoy having to participate in the hiring and firing of personnel. I invest a great deal of time whenever I make new medical equipment and IT-related purchases and upgrades. I am always involved in selecting contractors or vendors required for repairs or to maintain our office functions. I have always had to do some sort of work 6 or 7 days a week. I recognize that starting a single doctor private practice today would be much more daunting with vastly greater initial complexities and expenses. Hopefully, this narrative describing how I fell into my career path will give early career physicians a very brief summary of what to expect should they contemplate hanging their own shingle, but this will also differ greatly depending upon medical specialty. Peter T. Zacharia, MD, is an ophthalmologist in private practice in Worcester who has been on the editorial board of Worcester Medicine for several years.