Solo Vs. Group Practice: Which Offers the Most?

Solo.

This solo practitioner says he is best able to determine a care plan for each patient and is less tied to return on investment.

By Robert M. Conenello, DPM, FACFAS, FAAPSM

After 34 years of private clinical practice, I can share my “truths” concerning the advantages of solo practice over group practice in an era of practice consolidation.

Recently, I had a major health issue and faced the reality of not being able to practice during my recovery. Fortunately, I was given a choice: continue status quo and improve on it or accept an opportunity from a private equity group that would take over much of the parts of practicing that personally add to my stress level. They promised to streamline operations, provide financial stability, and reduce the burden of administration. As a seasoned sports medicine podiatrist, I stand firmly in defense of the solo practitioner model.

As I physically and mentally created my personal decisional balance sheet, the primary point of concern for me always comes back to autonomy. In all my years of private practice I have never had to answer to a higher-up. I have always been the captain of my ship, and I direct it in the direction that works best for my lifestyle.

How a Solo Podiatry Practice Benefits Patients

As a solo practitioner, I can determine the best plan for each patient to help them reach their goals. I do not have to worry about what will give me the best return on investment of my time as calculated by an algorithm. I enjoy developing relationships based on communication and trust with my patients. Many times, this means slowly getting to know these individuals over time. I always start each patient session with the statement, “Tell me your story.” My follow-up question is, “Tell me about your goals.” This may lead us on a journey that may include conservative, surgical, or alternative services not offered by their insurance plans or by my competitors.

I believe patients appreciate seeing the same provider consistently, which enhances continuity of care. This is especially important in a sports-focused practice, where understanding patients’ goals and unique biomechanics leads to better outcomes. I can take the time to listen and collaborate with therapists and other practitioners, which gives the patient a sense of personal involvement in their care team.

I always preach that I want to be an innovator. I do not want to feel stifled by a large group that may limit my flexibility with care to create uniformity. You can get Italian food at a mall restaurant or choose the small neighborhood experience where you are greeted by the staff and chef who want you to feel special. Both offer nourishment, but I want to offer an experience. In my practice, I can incorporate new technologies and treatments such as shockwave, microwave therapy, and advanced orthotic solutions without navigating bureaucratic red tape. This allows me to be on the cutting edge of my profession and makes me stand out.

Financial Considerations in Solo Practice

Financial stability is usually the greatest perk larger groups and private equity extend. Often, a generous monetary carrot is offered, which is quite enticing. On top of that, there is the comfort of knowing your compensation is guaranteed if you continue to perform. This is where there may be a gray area. Individual practitioners may find their income linked to a performance-based metric and feel pressure to “upsell” treatment plans they may not feel comfortable with. Additionally, these groups risk being sold to larger entities with different philosophies. I find this may raise instability and stress for the practitioner and the patient.

As I expressed in my opening paragraph, being a solo practitioner has its own set of challenges, especially when unexpected scenarios such as illness arise. Carefully managing overhead and focusing on high-quality care is imperative for the solo practitioner. This may come with lessons learned over time but can also bring financial stability if managed correctly. It also means you must stay humble while at the same time not being afraid to take certain calculated risks to better one’s position and learn from the outcomes of those risks.

As a solo practitioner, I am deeply embedded in my local community, from working with non-profit organizations such as Special Olympics and the YMCA to my involvement in team sports on the local, collegiate, and professional levels. My independence allows me to engage meaningfully with those I serve. I have also been able to pursue new practice opportunities as an international lecturer and key opinion leader for many corporate organizations. An unexpected outcome has been ancillary revenue streams outside of my practice that may help when presented with challenging times. Group practices constrained by corporate policies may not encourage or support such involvement.

Challenges of Practicing Solo

Admittedly, solo practice is not without its challenges. I struggle with the administrative burden and the fear that I may not be able to produce enough income to maintain my business. Through the pandemic experience in 2020, I had the opportunity to pause and reflect on my situation. I read the book The ONE Thing by Gary Keller during that time. This bestselling self-help book focuses on the idea that success is achieved by narrowing your focus to the most important task or goal rather than trying to accomplish many things simultaneously.

As podiatrists, we learn to be the primary practitioners of the foot and ankle. As a result, we constantly wear different hats with the pathologies we are presented with. I do not feel this strategy can work in today’s system as everything does not matter equally, and multitasking often proves inefficient. The most challenging part of this philosophy is learning to say no to distractions to stay focused on your top priority. In my case, it meant eliminating certain aspects of my practice for which I was well-trained and focusing on those from which I gained the most joy.

My sports medicine practice has shifted from a surgical to a fee-for-service, regenerative model. That does not mean I no longer advocate for surgery if needed, but rather, I have partnered with others who have more of a focus on this aspect of their career. The greatest surprise of this change was the extreme number of referrals I received from my colleagues and other specialties as I developed a positive reputation for managing difficult musculoskeletal pathologies with my innovative techniques. My new challenge is now accommodating all these new patients in a timely manner.

In Conclusion

The bottom line is that the setting in which one practices is completely subjective and personal. I firmly believe there is still a place for the independent solo practitioner in medicine. It will take a commitment to prioritizing patient relationships and offering the highest standard of care. If done right, it will allow you to enjoy economic comfort while staying faithful to your healing calling.

Dr. Conenello is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow and Past President of the American Academy of Podiatric Sports Medicine. He is an Honorary Police Surgeon for the New York Police Department and the Clinical Director of Special Olympics New Jersey and practices in Orangeburg, NY.

Group.

This group practice podiatrist says his practice model allows him more focus on patient care rather than business matters.

By Howard Osterman, DPM

Evolution: Darwin defined it as “descent with modification.” The idea is that species change over time, give rise to new species, but share a common ancestor. This may also be said for the practice, and business, of medicine.

I write this from the perspective of a practitioner of 33 years. The first 22 I spent in private practice and the last 11 in a single-specialty, group practice. Rob Conenello, DPM, and I will come to the same conclusion that there is no “right way” to practice our profession.

I was hired out of my residency to work in a one-doctor/one-office practice. After 6 months, my wife and I decided that this was not the right fit. I joined a practice in the Washington, DC/Maryland suburbs, and it was a better fit. We had two officers and two doctors. We became partners in 1994 with a deal for a buy-in and buy-out to occur. This is not a unique story at all. The practice grew and we took on associates over the years. As my senior partner got closer to retirement, he had a mechanism built into our contract regarding his buy-out compensation. This is not a common scenario in today’s medical practice. I loved what we had built, but our associates were in no position to commit to the financial burden I had agreed to. I needed to find a way to secure the practice’s viability and financial future.

Finding a Group Practice That Works for You

Group practice is not a single model. There are many options for a group practice, each with benefits and risks. There are single-specialty groups, multispecialty groups, hospital-owned groups, independent practice associations (IPAs), and academic centers. Each has some nuance to it.

Finding a group that has a similar philosophy to how you want to practice takes some research. I decided I did not want my practice owned by a hospital group, despite the benefit of having a multispecialty referral source built in. Hospitals like to refer to their own employed physicians. I also wanted a way to find a way for my associates to be able to “buy in” to a practice without having to buy me out fully. I knew the financial burden we had. Our practice, like Dr. Conenello’s, is slightly “out the box.” I am the team podiatrist for multiple sports teams and wanted to preserve that part of our practice. My associates have also been able to cover games, and if we joined a particular hospital, not the official partner of the teams, we might lose that affiliation. We enjoy that part of our practice and it has been a tremendous marketing tool. It was part of the equation.

Managing a podiatry practice is not just seeing patients; we all know this. Some like the challenge of running a small business and are particularly good at it. It’s not one of my strengths. Compliance, negotiating contracts, credentialling, billing, and managing staff have all become more difficult in recent years. There are companies that can help us manage those things, for a fee. Some are excellent, some not so much.

I decided to join a group of local podiatrists that had merged to consolidate some of these services. At the time, there were 14 of us. Our group consisted of my “competitors” in our area. We all like to protect our practice and what we feel we have cultivated. Giving that up is very unnerving. The vetting process is also scary, as the companies comb through your billing/collections, record keeping, documentation, etc. We ultimately joined the group Foot and Ankle Specialists of the Mid-Atlantic (FASMA), and some of my “competitors” became partners. The group had an HR team that handled compliance, credentialling, health insurance, a retirement plan, staffing, billing, etc. We did have to change our electronic medical records, but that turned out to be a positive.

Quality of Care and Operations in a Group Practice

One of the scary parts of joining a group practice is how it will affect the everyday flow of the office and our quality of care. Quality of care comes from within and should not be dictated by a management company. We love our staff members—they are often like family, and how will this change affect them? We have had to change some vendors, but we have benefitted from group purchasing and can negotiate better pricing. It is definitely a change.

Our group has grown, and in 2018, we merged with a private equity group. We are now called US Foot and Ankle Specialists and are in half of the states of the US. When we joined the private equity group, my associates had the option to buy shares and become stockholders. It really can change things when you have some level of ownership in a practice.

There has been no oversight to dictate the way we practice. This is important on choosing a group to partner with. On the contrary, we have been able to expand the services we offer our patients. We do not do much wound care or participate in the diabetic shoe program; some of our partners do. We do shockwave therapy and do more sports medicine than many other practices. The group is now much more likely to inter-refer and not send outside our group. Our younger doctors have been able to split offices to work in various locations and stay busier. We have all hired new associates and may only be able to fill 3 days a week. They can now go to a different location and fill days there. It just changes the dynamic. This pertains to staff as well. Staff is cross-trained for front and back duties and if a team member calls out, or takes a leave of absence/vacation, we have staff from other locations that can fill in. This can prove invaluable as we have all had days when someone calls out, we have a full schedule, and need some help. It is exceedingly difficult to mitigate this in private practice.

We cannot ever fully anticipate things, and we had our own event that solidified my decision to join a group. We had a car drive through the side wall of our Maryland office not long after joining the group. The driver hit the building’s water pipe and flooded our office in addition to causing physical damage. We could not use the office for two months. Two of our partners offered space to see patients on some of their lighter days. It was not ideal for us, or them, but it worked very well until our office was fixed. If you are in a private practice, this becomes much more difficult. Hurricanes, tornadoes, wildfires, floods, or cars driving through the side wall, cannot be anticipated, but we were able to continue some ability to practice.

In Conclusion

Nothing is perfect in practice, and I really enjoyed being my own boss, but evolution is inevitable, and keeping up with the changes is a personal choice. Some will continue to thrive in private practice, but in my observation, it has been increasingly difficult, and I prefer to concentrate on my patient care rather than the business minutiae.

Dr Osterman is Past President of the American Academy of Podiatric Sports Medicine. He is the Team Podiatrist for the Washington Wizards and Washington Mystics. He is board certified in foot surgery by the American Board of Foot and Ankle Surgery. He practices in Washington, DC and suburban Maryland.