My name is Howie Chen. I am a comprehensive ophthalmologist located in Phoenix, AZ. Unlike Ho Sun, who started from solo right out of residency, I was too scared to go out on my own immediately after training. I thought a government or group job would be safer. So my first job was with the government at the Indian Health Service. At first I was happy simply with an attending’s salary and getting to do a lot of retina lasers and injections, as well as cataract surgery. I even got to fly in a private plane six times a month to Indian reservations which was was fun at first, but those made for long days as the plane left awfully early and the Arizona heat caused lots of turbulence in the air. Additionally there was no room for growth, especially with my cataract surgery volume which was about only 80 per year. Trying to change anything required a herculean effort, and my suggestions to make the clinic more efficient were met with resistance.
At this point I was reading Ho Sun’s blog and thought about starting on my own. I even spoke with some practice startup consultants. The lay and medical press were publishing many articles about how the field of medicine was consolidating, how safety for docs was in big groups, how big groups were buying practices left and right. So instead of going solo, I thought the safest thing to do would be to join one of the biggest multi specialty groups in the Phoenix area.
Just like my first job, I was thrilled at first- the salary was good, over twice what I made in the government and well above the average for ophthalmologists. My cataract surgery volume shot up dramatically. There were some things about efficiency I was surprised at, such as how long it took to get the purchase of a OCT approved, or how I had to write a financial analysis to justify a sixth exam room at one of our offices when we had two docs and four techs (each of which needs a room to work out of) when combined we were seeing sixty patients a day.
In contrast to my solo practice, our overhead was high because the group took a big cut, probably because of the multiple level of administrators they had to pay, but we more than made up in this with volume. But changes were being made- one day they held a meeting, and told us that a certified letter would be sent to our residence with our 90 days termination without cause! But they didn’t want us to leave, all we had to do was sign a non negotiable “standardized” contract with a large restrictive covenant, among other “improvements”, to continue working there. Just their way of telling us who’s in charge.
Many other docs in different departments were leaving. I decided to join them. But I would be going out on my own. I carefully read Ho Sun’s blog (almost have it memorized) and followed his steps to start a solo practice. It took me several months to prepare everything to open doors. While it was a HUGE pay cut and drop in patients and surgeries, I actually enjoyed every minute of the startup process. People told it might be months before I broke even- I was surprised when I made a profit my second month, and it’s been uphill since then. I thought that in solo practice there would be NO chance of reaching my salary in my group practice. While I’m not there yet, I know which direction I’m heading in and should be close to Ho Sun’s numbers sometime soon.
But the biggest advantage of going solo is the freedom to make your own decisions. If I decide I need a new piece of equipment, I don’t have to go to some administrator and grovel for it- but I have to pay for it myself. If my employee isn’t doing their job the way I want, I let them know, not report to my department manager who may or may not understand, let alone do anything about it. If I want a Friday day off for a long weekend in San Diego, my patients get moved, no six week advance notice required. The point is going solo you’re your own boss and you can live with the rewards or consequences of your own decisions, not someone else’s. I’m fine with that. It’s actually worked quite well for me, as well as most of us who have chosen this route.
It’s very true that even though I’m earning less, I’m not as burnt out- it’s a pleasure for me to come to work every day to the office I chose to lease, with the equipment I purchased, working with the people I selected to hire, and seeing patients referred by docs that trust me or heard of me from their neighbors or family members that were happy with me as their ophthalmologist. You just don’t get that same feeling when you work at a practice that someone else owns, or that is corporately owned.
The ironic thing is that shortly after I left, two of my three colleagues from this job also left- to start their own solo ophthalmology practices (the other one joined a group of two). And after a few years my group SHUT DOWN their ophthalmology department and outsourced it!! So much for big groups providing job security…
I don’t regret my time with the government as it significantly improved my clinical skills, it was the equivalent doing another residency; I don’t regret my time at the big group because I got much better at cataract surgery and got efficient at seeing patients. But it’s better to have decisions made by those who actually practice, not some administrator who doesn’t understand what we do. Those of you in who have worked in ophthalmology groups know that often junior (or even senior) employees are treated less than fairly. It doesn’t do us any good if other doctors are controlled by a senior partner or administrator. We hope to show them that solo practice is a viable if not preferred option, as well as to help existing solo practitioners run their practices more efficiently.
When I started my practice there were many people who, without any expectation of compensation, offered to help me out by giving me advice for my startup. I met three practice managers who I picked their brains for advice. A ophthalmologist colleague who I met over the phone when was checking references for my EHR introduced me to a used equipment dealer saving me at least $10,000. Ho Sun’s original blog saved me at least $20,000 and a month or two of my time. Writing this blog is my way of “passing it forward” to the ophthalmic and medical community.
Ho Sun and I have shared a lot of useful information in our discussions on solo medical practice startup and management. This blog is a extension of our discussions. Much of our advice would extend to any type of medical practice, not just ophthalmology. Both of us strongly believe that the field of ophthalmology, and medicine as a whole, would benefit from more physicians going solo. There’s nothing I want more than to see other solo practitioners, especially ophthalmologists, be successful and happy.
How do you feel things might have been had you gone solo straight out of residency rather than having had those other jobs to further hone your surgical skills? I’m a current resident, and would love to run my own practice. But I know that my first year or two might be slow surgically and I worry about losing or not improving on the surgical skills I finish training with.
Regardless of what situation you’re in, be it solo or with a group, you’ll need some time after training to hone your surgery skills.
While high volume numbers and breadth of experience in residency and fellowship are definitely necessary to learn the ins and outs of surgical, preoperative and postoperative decision making and provide framework to build on, they are simply a launching pad for your surgical career, rather than a be all end all.
Personally, I was glad I had the two jobs before I went solo as it gave me more confidence, but Ho Sun (and many others I know) have went solo straight out of residency and have done just fine.
And before anyone thinks that going solo means being surgically slower than joining a group, this may or may not be true. My boss at the government told me not to go solo but to join a group as it would be “impossible to find patients.” In my government job I was only doing about 80 cataract cases per year, but much to my surprise in my first year solo I performed 100 cataract cases.
I’ve heard of docs graduating from residency joining another doc- only to find that the senior doc is instructing their scheduler to “shift” all the cataract consults onto their schedule. The new doc is doing 50 or less cases their first year! Some experienced ophthalmologists have told me their second or third year solo were they far exceeding the number of cases they did in their group- no partners to “compete” with for cases. If you build a good reputation (get good results and provide good customer service) they will come, even in a competitive area.
Of course, not all docs and senior partners are like this. Some of them really want you to succeed so you can buy in (and buy them out) eventually. This is why everyone needs to be careful when they are job searching- to find the true motives behind why someone is hiring.
On the other side of the coin, there are high volume practices, usually contracted with capacitated plans, that have a junior associate do 10-12 cases per week but still pay them only $250-300K a year. Someone is getting passive income off someone else and it sure as heck isn’t the junior associate getting rich…
Hi Howie, I have a very similar experience as yours. It took me several years, however, to say enough is enough before I resigned my partnership. Although I have to work away from home until my non- compete ends, I have no regrets with my decision. I plan on returning in 2018 to finally open my solo practice. I organized an LLC to purchase the land and build my office. I will lease back to the LLC. The office space has been designed to maximize my work flow and efficiency utilizing minimum staffing. I structured this based on my various experiences with my previous practice as well as from locum and temporary employment opportunities. The equipment choices were easy for me to choose from, however, trying to come up with a favored EHR has been quite time consuming. I used Med Flow, Epic as well as Nexgen. I did not find them to be efficient as I would like. Do you have any resources that can help me narrow down my choices? Any suggestions would be greatly appreciated.
Phil Alabata, DO
I spent very little time choosing my EHR. Ho Sun’s original blog talked about how much he liked EyeMD, so I went to a local office to test drive it. I also spoke with several docs on the phone who used it and said they were happy.
The cost is significantly less than some of the larger systems, at $10k upfront and $300 per month.
I still remain happy with it. If I had a choice I wouldn’t go back to paper.
To top it off, although I didn’t know it at the time, fortuitously they are one of the EHRs integrates with the IRIS registry to avoid Medicare quality (MIPS) penalties. As of today, I recommend getting a EHR that integrates as it’s the easiest way to avoid penalties. We will have posts about choosing a EHR and MIPS up soon but here’s the list of integrable EHRs: https://www.aao.org/iris-registry/ehr-systems
For those of you in other fields especially if you see a lot of Medicare patients (ophthalmologists are among the highest given the conditions we treat) check with your specialty organization and/or its registry.
Some other EHR systems popular in our group are EMA, MDI, Integrity and Compulink. I may have left a few out. Make sure they’re in the list.
I’ve heard of some folks using “free” EHRs like practice fusion or Drchrono. Although others will disagree sometimes you get what you pay for.
Thank you for the insights. I will look into the link that you posted. Certainly integration with the IRIS registry is a plus. I will also see if the listed EHRs have their own practice management system and is cloud based.
Phil
Also just out of curiosity what made you decide to buy the building and land? And how did you find the login and temporary employment? Just curious as this is much harder to find for ophthalmologists than say hospitalists, ER or anesthesia.
I formed an LLC in order to purchase the property for my office. Low interest rates made this a great opportunity. The LLC is in the process of developing the land and building my building. My practice will then lease back to the LLC. Over the next 15-20 years, the LLC will recieve dividends that can help pay down the debt of the LLC and I will have a nice investment property when I retire. This, of course, is not for everybody.
To answer your second question, I also thought that locum positions for ophthalmology was rather scarce. On the contrary, there are numerous opportunities out there if you don’t mind traveling away from your family. I had a great experience with locumtenens.com. The company paid for my travel to the location, rental car and hotel stay. They even accepted my re-negotiation terms as my patient load, surgical load and call volume increased. You essentially have no expenses, other than food, but you can negotiate that as well. I continue to receive locum offers from Barton Associates, CompHealth, Staff Care and Weatherby and of course locumtenes.com
Phil
Hi Phil,
I just added you to our Solo Eye Docs group. You can find some good information by searching our message archives. FYI, those big dog EHRs you mentioned are all rip offs, Nextgen especially. The fact that you have to bring in and pay a technician to modify your template, after spending $50,000 on the software license, is ludicrous. I spent $8,000 on my EHR in 2010, and I still love it.
Ho Sun
Hello,
I am in solo practice also and wanted to know how to join the solo eye docs group. I would love to participate.
Thank you for your interest in soloeyedocs. Please read the September 15 2017 comment at the bottom of this post for more information about joining our google group:
https://solobuildingblogs.com/2017/07/17/iballdoc-resurrected/
I am planning to buy out a retiring ophthalmologist in the next year or so and will be in solo practice then. If possible, I would love to join the solo eye docs google group as well.
https://solobuildingblogs.com/solo-eye-docs-group/