Residents live in a house next door to the clinic while they see patients in the clinic and operate with a group of private practice otolaryngologists. “Residents learn about private practice otolaryngology, as well as how to run a medical practice,” Dr. Kesser said. They learn how to operate a small business, including experience with accounts payable, accounts receivable, coding, billing, and collecting.
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April 2024“I think the experience residents get during this rotation is transformative,” Dr. Kesser said. They perform thyroid, parathyroid, endoscopic sinus, and facial plastic surgery—including rhinoplasty and soft tissue surgery of the head and neck. Residents perform 30 to 50 key indicator cases during the three-month block.
Residents also gain an understanding of the importance and value of in-office procedures. “Doing small cases in an ambulatory setting versus the operating room saves money and is good for patient care without sacrificing quality,” Dr. Kesser said. “Residents learn about healthcare utilization and how to use resources in the most efficient ways.
“Perhaps, most importantly, residents are empowered to be primary surgeons,” he continued. Residents don’t compete with co-residents for cases. They are the only resident on the Fredericksburg rotation, so they get one-on-one instruction. They learn to be the lead for an operating room, moving patients in and out. “Residents return from Fredericksburg as better surgeons and clinicians with confidence, expanded knowledge, and sharper clinical acumen and judgment.”
Dr. Kesser worked in private practice prior to joining the UVA otolaryngology department. He lectures about this experience and discusses topics such as contract negotiation, contract terms, reimbursement, the path to partnership, the experience of seeing patients, and quality of life.
Additionally, three private practitioners are on UVA’s faculty in Charlottesville. Although residents don’t rotate in the clinic or in the local hospital’s operating room with these physicians, if the practitioners have cases they wish to handle at UVA, residents join them. “In this setting, residents get excellent additional exposure to the field of otology, cochlear implants, sleep medicine, and the new technology associated with treating obstructive sleep apnea,” Dr. Kesser said.
UVA also has a graduate medical education institutional lecture series, which features financial planners giving talks about retirement planning, owning a house, insurance and disability insurance, and student loans.
Private Practitioners Reflect on Their Residencies
Although more efforts are being made to expose residents to private practice, otolaryngologists reflecting on their training said they had few discussions about handling the business of medicine or working in a private practice. Nonetheless, many pursued private practice as a result of their own motivations.
“During training, I didn’t want to choose just one area of otolaryngology,” said David Yen, MD, president of Specialty Physician Associates and chief of otolaryngology at St. Luke’s University Health Network, both in Bethlehem, Pa. “I enjoyed the breadth of the specialty and realized that I wanted to be a general otolaryngologist.”
While Dr. Yen was training in Philadelphia, an hour away from where he was raised, some patients from his hometown traveled there for care. “I realized that there must be an opportunity to return home to provide care there,” he said. Two years later, Dr. Yen joined a physician in private practice who had referred a patient to him.
Like Dr. Yen, Doug Henrich, MD, president of Burlington ENT at Southeast Iowa Regional Medical Center in Burlington, was motivated to enter private practice so he could see patients with a wide range of issues. “I wanted to work on an extensive variety of cases and fully use my training,” he said. “Our field is constantly changing and improving; private practice keeps pace with continued learning opportunities. New procedures, such as the Inspire implant, and new office technologies are available to motivated entrepreneurial otolaryngologists.”
Gene Brown, MD, RPh, president and CEO of Charleston ENT & Allergy, knew he would work in private practice before starting residency. “I was drawn to the entrepreneurial opportunities available in this setting and wanted to run a business,” he said. “As I got further along in training and some of my older colleagues graduated and started working in private practices, I got some confirmatory exposure through conversation with them.”
What’s Lacking
In general, Dr. Henrich said, residencies lack exposure to working in private practice. “A one-month private practice rotation for third- and fourth-year residents would be an excellent introduction,” he said. “This would expand their perspective, enable them to see a different practice model, and give them an opportunity to be involved in many cases and patient encounters at a fast-paced office. The business aspect of medicine is becoming more complex. Being mentored by successful private practitioners would bolster residents’ knowledge base and enhance their economic and financial skills.”
Private practice was never formally mentioned or discussed as an option during Dr. Yen’s residency. He believes that most practice opportunities remain outside of traditional academics (AAO-HNS statistics tend to agree; see Figure 1).
Dr. Yen thinks it’s important for future colleagues to recognize that there’s more overlap now between private practices and academics than ever before. His private practice offers a residency program and is quite active in clinical research.
“Residents need to see and understand the full range of career options during their formative years,” said Dr. Brown. Historically, general otolaryngologists have practiced in the private sector while subspecialists have practiced in tertiary care centers. This model has offered robust access for the exceptional care of more common otolaryngology problems in the community while also driving appropriate subspecialty referrals to academic centers, including exceptional care of less common diseases, he said.
Over time, however, a rapid expansion of subspecialty fellowships has occurred. “As training programs become more subspecialty centric, it shouldn’t be surprising that more trainees have pursued further specialization,” he said.
In the AAO-HNS workforce survey, 75% of chief residents indicated that they intended to pursue fellowship training. “As more graduates pursue subspecialty practice instead of general otolaryngology careers, I’m concerned that the resultant workforce imbalance may result in unintended consequences for the specialty and affect access to care in the long term for patients and communities,” Dr. Brown said. “If today’s residents had more experiences in general otolaryngology and private practice during training programs, I suspect that there would be a more balanced pursuit of general and subspecialty otolaryngology practice among trainees.”
Residents Weigh In
Many otolaryngology residents ultimately decide to work in private practice settings. But do these residents get enough exposure to this practice type during their training so they can make well-informed decisions and be prepared to work in this environment?
Roshansa Singh, MD, a resident physician in the department of otolaryngology at the University of Connecticut in Farmington, said her residency program provided just enough exposure to private practice. “We’ve had the good fortune of interacting with otolaryngology attendings that primarily staff a major, inner-city hospital while operating their private practice clinics in various locations,” she said. “We also work with another physician group that has transitioned from a multidisciplinary group to private practice. This has given great insight into the skills and capabilities required to manage a surgical subspecialty efficiently and effectively in the private practice setting.”
It would be interesting to incorporate the business and managerial aspects of private practice into our education, which residents often aren’t privy to unless they seek out these fields in their own time. — Roshansa Singh, MD