Massive Debt — Can I Open My Own FM Practice Out of Residency?

[Metamorphosis.DO]

*Open to anyone’s thoughts. Seeking those with firsthand experience.*

Going to Graduate as a Quadruple Amputee from a Private DO school in 2025. (both arms and legs = $450,000). I am almost totally set on FM. Also never considered opening my own practice until speaking with other practice owners recently.

Can/Should I do it with that debt?
Should I focus on paying it down some/entirely first By working for a group first?
If I do this, how realistic is it to retain a decent number of patient panel in my own practice Given I open A Practice Close by? (non-competes common?)
How important is this?

Costs Of a new practice?

Pros/Cons? Is it a thing of the past?

Recommended Books For a business-ignorant medical student?

*open to being teased for my lack of understanding regarding these questions^*

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[ortnakas]

Can you? Yes
Should you? Don’t know
Non-competes? Pretty common so that part’s a little non-realistic
Cost? Don’t know

Sometimes local hospital systems “sponsor” a new office, so that could be an option, but isn’t exactly being independent either

 

[ontiquicuo]

You might get better insight in the FM forum.

Family Medicine

Family Medicine discussion forum

forums.studentdoctor.net

 

[Cranjis McBasketball]

*Open to anyone’s thoughts. Seeking those with firsthand experience.*

Going to Graduate as a Quadruple Amputee from a Private DO school in 2025. (both arms and legs = $450,000). I am almost totally set on FM. Also never considered opening my own practice until speaking with other practice owners recently.

Can/Should I do it with that debt?
Should I focus on paying it down some/entirely first By working for a group first?
If I do this, how realistic is it to retain a decent number of patient panel in my own practice Given I open A Practice Close by? (non-competes common?)
How important is this?

Costs Of a new practice?

Pros/Cons? Is it a thing of the past?

Recommended Books For a business-ignorant medical student?

*open to being teased for my lack of understanding regarding these questions^*

Investingdoc.com is a great website about all this. So many different factors to consider so theres no right or wrong answer

 

[Mass Effect]

Can you? Yes
Should you? Don’t know
Non-competes? Pretty common so that part’s a little non-realistic
Cost? Don’t know

Sometimes local hospital systems “sponsor” a new office, so that could be an option, but isn’t exactly being independent either

Some states outlaw non-competes so if you're in one of those states, you're good. Many non competes are also for a specific location (like within 10-30 miles of where your employer's clinic is).

OP, the problem is that to start your own practice, you need some business acumen. Do you know anything about running a business? If not, I would join a private practice for a couple of years. Maybe see about a partnership track (you'll be there many more years but you'll have support). You can always start the PP after a few years.

 

[Med Ed]

*Open to anyone’s thoughts. Seeking those with firsthand experience.*

Going to Graduate as a Quadruple Amputee from a Private DO school in 2025. (both arms and legs = $450,000). I am almost totally set on FM. Also never considered opening my own practice until speaking with other practice owners recently.

Can/Should I do it with that debt?
Should I focus on paying it down some/entirely first By working for a group first?
If I do this, how realistic is it to retain a decent number of patient panel in my own practice Given I open A Practice Close by? (non-competes common?)
How important is this?

Costs Of a new practice?

Pros/Cons? Is it a thing of the past?

Recommended Books For a business-ignorant medical student?

*open to being teased for my lack of understanding regarding these questions^*

Opening a practice is a helluva ordeal. I can't imagine trying it as a brand new attending.

@Mass Effect is right, start out in an established practice setting and then figure out what you want your long-term career to look like. Some of the assumptions you make in residency may turn out to be false or misleading.

 

[BobbyKoch]

an anecdote for you, take from it what you will.

I rotated with two FM docs who opened their own practice right out of residency. They initially had a 3rd partner, an EM attending who I think was in practice for 10+ years, and due to credentialing they bought a chiropractic practice and rebranded it as an urgent care. Something about the credentialing for urgent care being faster while they wait for whatever they need to become a primary care practice. For whatever reason, the experienced EM doc left shortly after they opened and they are now running it themselves with a small staff (MA, receptionist). They were able to retain some of the chiropractic patients because they offer OMM and the space was basically set up for manipulation. They are trying to capture the urgent care walk-ins as long-term patients and it seems to be working, although I'm obviously not privy to their data.

they are consistently months+ behind in billing due to various issues (mainly being swamped with patients and running COVID testing). as I concluded my rotation they were looking to contract a billing service. I occasionally was alarmed by the lack of oversight there, especially with more complex patients, peds and ObGyn complaints. By oversight I mean there was no one for the docs to consult about their dx and plan. It was just me and them in the office googling and reading up-to-date to each other. Obviously for emergencies they sent folks to the ED or directly to specialist care, but it really showed me how valuable it would be to have at least one experienced attending in your practice to curbside when necessary. Personally, I don't think I would be comfortable opening a practice as a newly-minted attending without some kind of net. These guys are getting it done and I'm sure learning a ton about both business and medicine as they do it. I don't know what their finances are like but given the billing issues they told me about, I doubt they are anywhere near maximizing their earnings. at the same time, they are in the office 9-5 3 days/week each, both have young families and other business investments going. they are both older/non-trads with backgrounds in other fields before medical school--chill people who are simultaneously driven and business-minded.

 

[Metamorphosis.DO]

an anecdote for you, take from it what you will.

I rotated with two FM docs who opened their own practice right out of residency. They initially had a 3rd partner, an EM attending who I think was in practice for 10+ years, and due to credentialing they bought a chiropractic practice and rebranded it as an urgent care. Something about the credentialing for urgent care being faster while they wait for whatever they need to become a primary care practice. For whatever reason, the experienced EM doc left shortly after they opened and they are now running it themselves with a small staff (MA, receptionist). They were able to retain some of the chiropractic patients because they offer OMM and the space was basically set up for manipulation. They are trying to capture the urgent care walk-ins as long-term patients and it seems to be working, although I'm obviously not privy to their data.

they are consistently months+ behind in billing due to various issues (mainly being swamped with patients and running COVID testing). as I concluded my rotation they were looking to contract a billing service. I occasionally was alarmed by the lack of oversight there, especially with more complex patients, peds and ObGyn complaints. By oversight I mean there was no one for the docs to consult about their dx and plan. It was just me and them in the office googling and reading up-to-date to each other. Obviously for emergencies they sent folks to the ED or directly to specialist care, but it really showed me how valuable it would be to have at least one experienced attending in your practice to curbside when necessary. Personally, I don't think I would be comfortable opening a practice as a newly-minted attending without some kind of net. These guys are getting it done and I'm sure learning a ton about both business and medicine as they do it. I don't know what their finances are like but given the billing issues they told me about, I doubt they are anywhere near maximizing their earnings. at the same time, they are in the office 9-5 3 days/week each, both have young families and other business investments going. they are both older/non-trads with backgrounds in other fields before medical school--chill people who are simultaneously driven and business-minded.

Great information and more than anything, it’s good to think about. I often think that when the day comes where I am finishing residency, I will just want to get to work in what I love most and passively learn the business side and get my experience with some seasoned physicians. I think it would be best to join a group as an associate and then open up shop after paying down loans/getting settled… perhaps 5 years later?

 

[Med Ed]

Great information and more than anything, it’s good to think about. I often think that when the day comes where I am finishing residency, I will just want to get to work in what I love most and passively learn the business side and get my experience with some seasoned physicians. I think it would be best to join a group as an associate and then open up shop after paying down loans/getting settled… perhaps 5 years later?

You may be familiar with the phrase "man plans and God laughs."

That's not to say you shouldn't have a plan, but between now and the end of residency your perspective on things could change... a lot. To that end, I agree it would be wise to assume you should start out in an established setting with more senior doctors. There will be plenty to learn.

 

[FrechToastFries]

Am I the only one that read this and though OP was literally a quadruple amputee?

 

[tracheatoedoc]

Your priority should be reducing your student loan debt. I would find a hospital that offers student loan relief. I doubt if you will find a place that will pay it all, maybe half? Then live frugally and try to be debt free in 5 years. The debt is your biggest issue, not starting your own practice.

 

[TruthInMedEd]

Another factor to consider is what the practice will provide. Full spectrum FM in a rural setting can be very productive and allow you to pay down that level of debt. However, you need to understand that you are going to be busy and have to provide services in house instead of referring everything out. In office procedures generate revenue for the practice. Many rural communities will help you get started with guaranteed salary for the first 1-3 years with productivity should you build the practice quickly, then allow you to move out on your own after a few years. There a multiple ways you can approach this situation to pay that loan off ASAP.

 

[Candidate2017]

You can do both. Work part time at a clinic or urgent care, and do direct primary care or concierge care. Many people are willing to pay a monthly fee to be able to get in to see a primary care in a timely manner, as well as having unrushed visits. No need to deal with costs and hassles of taking insurance, with the bonus of patients who care(!) about their health and value your input. Govt student loans can be paid via income based plans.

 

[Candidate2017]

I occasionally was alarmed by the lack of oversight there, especially with more complex patients, peds and ObGyn complaints. By oversight I mean there was no one for the docs to consult about their dx and plan. It was just me and them in the office googling and reading up-to-date to each other.

That's called being an attending in the real world, and wearing the big boy/big girl pants, which actually begins July 1 of intern year. No physician knows enough about everything, nor is expected to.

Yes, the training process is designed to give you expertise in your specialty, but the other valuable aspect of training is for you to understand sick/not sick, recognize your limits, recognize the appropriate issues for which to research, and when to seek help/refer out. Medicine is about lifelong learning.

When you finish residency, you should have cultivated a group of former co-residents and mentors with whom you can readily curbside. A more experienced colleague may or may not be valuable. Many times, older doctors are plain bad. Also, there is a likelihood your senior colleagues only care that you are the new meat from which they can take a % of your billings, dump the call schedule on, and hand off difficult patients they don't want to deal with. Those gunners from med school may be your boss. And guess what? This is not med school or residency where they bring in new meat annually. You will be the new meat indefinitely until someone senior leaves. This is one of the important business lessons.

 

[hallowmann]

*Open to anyone’s thoughts. Seeking those with firsthand experience.*

Going to Graduate as a Quadruple Amputee from a Private DO school in 2025. (both arms and legs = $450,000). I am almost totally set on FM. Also never considered opening my own practice until speaking with other practice owners recently.

Can/Should I do it with that debt?
Should I focus on paying it down some/entirely first By working for a group first?
If I do this, how realistic is it to retain a decent number of patient panel in my own practice Given I open A Practice Close by? (non-competes common?)
How important is this?

Costs Of a new practice?

Pros/Cons? Is it a thing of the past?

Recommended Books For a business-ignorant medical student?

*open to being teased for my lack of understanding regarding these questions^*

Opening up a solo practice with that much debt right out of residency? I wouldn't do it, especially not in primary care where you are already going to be dealing with so much just to keep up to date. Plus, its crazy easy to find a position offering loan reimbursement in primary care. Most places I see are offering on the order of $50k a year for 3 yrs to pay down loans, on top of a >$200k salary. If you open you're own practice, even something with relatively low overhead like DPC, you are going to be taking out more loans in the first year, compared to paying down six figures with one of those employed jobs.

If you join a system or practice, there will likely be a non-compete, and you 100% should try to make it as small or as limited as possible. One telehealth company has a non-compete for their docs nationwide, and you better be prepared to walk away from anything like that. Even if its legally unenforceable, its still time consuming to have to fight it, and often you end up just having to settle to the tune of $50-$300k (I've known people in this situation).

If you know you want to open a practice, join a well established one that seems to treat its people well and is well organized. Learn all you can about it and plan to branch out a few years later when you have a lot of the debt paid down and you are a bit more established as an attending. There actually are some established DPC clinics that you could join as well, and some will look even more favorably over someone with a few years of experience.

 

[Metamorphosis.DO]

Opening up a solo practice with that much debt right out of residency? I wouldn't do it, especially not in primary care where you are already going to be dealing with so much just to keep up to date. Plus, its crazy easy to find a position offering loan reimbursement in primary care. Most places I see are offering on the order of $50k a year for 3 yrs to pay down loans, on top of a >$200k salary. If you open you're own practice, even something with relatively low overhead like DPC, you are going to be taking out more loans in the first year, compared to paying down six figures with one of those employed jobs.

If you join a system or practice, there will likely be a non-compete, and you 100% should try to make it as small or as limited as possible. One telehealth company has a non-compete for their docs nationwide, and you better be prepared to walk away from anything like that. Even if its legally unenforceable, its still time consuming to have to fight it, and often you end up just having to settle to the tune of $50-$300k (I've known people in this situation).

If you know you want to open a practice, join a well established one that seems to treat its people well and is well organized. Learn all you can about it and plan to branch out a few years later when you have a lot of the debt paid down and you are a bit more established as an attending. There actually are some established DPC clinics that you could join as well, and some will look even more favorably over someone with a few years of experience.

Thanks for the input. I’m seeing how it is beneficial, not just in terms of compensation, to wait and learn for a few years before starting my own thing. Who know, I may be satisfied by just working in a small- medium group and taking on more management responsibilities with time.