What to Consider When Joining an Orthopedic Practice

A glance at the help wanted section of Archives of PM&R shows numerous job opportunities in orthopedic practices. Have orthopedists recently discovered that our specialty exists?

The idealistic notion of following a conservative treatment course prior to surgery is appealing to physiatrists and perhaps one reason why orthopedists are interested in hiring physiatrists. Sadly, this is typically not the case and in most instances the desire for physiatrists to join orthopedic practices is to increase the groups’ profitability.

The majority of the following information is from a “Hot Topics” course entitled “Physiatrists in Single Versus Multi-Specialty Practices: Myths and Realities” that was presented at the 2003 AAPM&R Annual Assembly by Michael Robinson, MD; Douglas Wayne, MD; and Michael Furman, MD, all practicing physiatrists in orthopedic groups. The information is not meant to promote the idea of physiatrist as de facto bone setter, since our residency training encompasses far more disciplines than just musculoskeletal medicine. It is aimed to provide residents who are considering this career pathway with useful information when entering the job market. Much of the information can be applied to joining any multi-specialty group.

Considerations When Interviewing With Orthopedic/Multi-Specialty Groups:

• Determine why the orthopedists want you in their group. Are they looking to you as a sieve for their chronic pain patients, or do they need inpatient management of hips and knees, EMGs, or interventional spine procedures? In Dr Wayne’s opinion, orthopedic groups are looking for proceduralists that can increase profits. In most cases they want fellowship-trained physicians.
• When joining any group, it is imperative to learn the working relationship among the physicians. Initially, you could spend far more time with them than your family, so collaborative teamwork is a necessity. Request the names of former physicians that no longer practice with the group to learn more about the group’s reputation and status in the medical community. Also, clarify if other physicians in the group will perform similar procedures, since this could possibly be an area of competition and conflict. Procedures you perform may decrease the need for surgical interventions and decrease other physicians’ income.

Financial Considerations:

• Evaluate the employee vs. partnership tracts in the group. Partnership in a group typically involves having voting privileges that govern the practice and allow you to sit on the board of directors. Voting and partnership can equate to equality and equity in the practice. If there is surplus revenue at the end of the year, partners typically vote on how this money is used. Partnership is typically tied to how much money you bring in to the group. Evaluate the time it took other physicians to reach partnership and determine if this is financially feasible for the services you are providing.
• If you are set on becoming a partner, you should demand in writing how the partnership tract is obtained when joining the group. Ultimately, you want to be treated as an equal in the group regardless of whether you wield a power drill or not. Don’t be afraid to ask if you are receiving the same contract that a new orthopedist would receive when joining the group.
• Review the financial statements of the group. If you do not feel comfortable with the financial analysis, consult an accountant or financial consultant to review the annual statements. In both cases, you want the group to be profitable, but in a partnership tract you have far more to lose if the group is in financial trouble, since your end-of-the-year bonus could be connected to the group’s profits.
• Don’t fixate on a huge first-year base salary. Try to predict your career path. If you see yourself in the prospective group for a long period, a large first-year salary isn’t crucial if your goal is to become a partner. If you see the career choice as short-term, negotiate a larger first-year salary.

Advantages of Joining an Orthopedic/Multi-Specialty Group:

• Groups can provide collaborative environments for newly graduated residents and fellows, since they offer more experienced physicians in a variety of disciplines.
• A large group practice decreases the fixed costs of running a business. These cost savings can help finance better practice infrastructure systems for coding and billing, pre-certification, and electronic medical records. Larger groups also have more clout when negotiating with insurance companies for reimbursement rates.
• Large orthopedic/multi-specialty groups provide a built-in referral base, so you do not have to spend time courting other physicians to refer their patients. A group can also bill for intra-group referrals from one specialty to the other. However, if you practice in an area with competing groups, you could lose out on referrals from these physicians. Also, if the group you join has a bad reputation for certain types of care, expect less referrals in those areas.
• Group practices, depending on their size and profitability, can afford imaging equipment and ancillary services such as physical therapists, acupuncturists, chiropractors, etc. All of these additional services are billable and income generators.

Disadvantages of Joining an Orthopedic/Multi-Specialty Group:

• Loss of physiatric identity. Some orthopedic group members may view you as a glorified therapist and have little understanding of your role as a physician. Your patients also may consider you an orthopedist. Consider if you would have difficulty performing your role in a group where orthopedists typically outnumber physiatrists and you may be a victim of orthopedic groupthink.
• Possible call issues for covering non-operative fractures/trauma. Establish during your negotiations if you are responsible for such call, since it could drastically affect your lifestyle.
• Orthopedic groups typically have higher operating costs because of their malpractice insurance and as a group member you are at financial risk for surgical misfortunes.
• Depending on your status in the group, employee vs. partner, your work could ultimately be a source of “passive income” for the group. If you do not negotiate that your salary is based on a percentage of your collections and instead receive a set annual salary, your blood, sweat, and tears will generate money only for the partners.
• If you are the first physiatrist to join the group, determine if the billing department is knowledgeable in the physiatric billing codes for your procedures. Improper billing and collections could be detrimental to your financial success in the group.

The information in this article is not meant to be an exhaustive manifesto on the perfect orthopedic group setting, but more of a primer on important items to consider before signing any group contract. For more information on different musculoskeletal practice settings, consult PASSOR’s Musculoskeletal Practice After Residency document, which can be found by logging on to www.passor.org. This excellent resource further explores the differences of partnership vs. employee relationships in a physician group.
Good luck in your job search!

John Lesher, MD, MPH
jlesher@u.washington.edu