Careers in Medicine: Private Practice
A NextGen Pathways in Medicine Article
From an Interview with Ronald Arky, M.D., Harvard Medical School
During the past 50 years, private practitioners have witnessed many substantial changes to the U.S. health care system and have been pressured to change the way they practice medicine. Traditionally, private practitioners were individual physicians or small groups of physicians that were paid for their medical or surgical services directly by the patients or their health insurance companies. In the 1980's, the number of managed care organizations was growing, partly in an effort reduce the great variation in the quality of care provided by private practitioners by standardizing practices in accordance with new regulations. Since then, many physicians have joined these larger organizations (whether operated as private or academic institutions), yielding the independence of self-employment in favor of a fixed salary and job stability. "The patients you see in either system can be the same. The difference is all about the money and where it goes," says Dr. Arky.
Today, the proportion of physicians working as private practitioners is decreasing while the proportion of salaried physicians is rising. Physicians seeking to start private practices face greater challenges today than they have before, particularly with regards to managing finances. Few physicians can independently start a private practice without initial financial support from another source. In order to cope with real estate prices and increased operational expenses, private practitioners often join together in group practices that share space, secretarial help, business managers, medical technology and supplies, and computerized data management systems for patient records, coding and billing, etc. Among these expenses, the transition to digital records and the increasing reliance on expensive technology in current practices in medicine are most significant in placing severe financial constraints on the abilities of private practitioners to compete with larger organizations. Furthermore, these physician and hospital networks often have greater leverage with insurance companies in ensuring payments for procedures performed and services provided by their physicians: in some cases, the organization may receive twice as much as a private practitioner for the same procedure performed. Accordingly, private practitioners must be very conscientious about maintaining and improving the fiscal health of their practices.
However, private practice is not without its advantages and benefits, if the doctor is willing to be both independent and a "go-getter." Private practitioners, although they still must follow many of the standard rules of conduct upheld by managed care organizations for the care of patients, do have greater freedom in determining their day-to-day management and scheduling of patient care and their business. Private practitioners, fueled primarily by passions for patient care, can truly enjoy opportunities to develop relationships with their patients and see the health of their patients improve over time. Furthermore, private practitioners can refer their patients to whomever they choose instead of being restricted to selecting physicians working within the same managed care organization, although the choices may be limited by the patient's insurance plan if the patient isn't paying for the medical services out-of-pocket. These freedoms comes a responsibility that is less vital to the work of salaried physicians. According to Dr. Arky, "Private practitioners need to be builders of a network. To succeed, they have to have some traits of an extrovert; they need to reach out to others." Salaried physicians work within a system that provides easy access to knowledge (i.e. consultation) and technology resources, and private practitioners must compensate by being knowledgeable of the resources in their communities. For example, patients may need rehabilitation, social services, and other resources that are readily available in larger hospitals but may not be provided in a private practice. Connecting to these resources and connecting to patient populations is particularly important in rural areas. On the other hand, private practitioners in urban areas are often associated with local medical schools. These private practitioners can participate in clinical research trials and also are valuable resources for medical schools as teachers. Many teaching hospitals are tertiary or quaternary medical centers, and medical schools often prefer to send their students to the officers of private practitioners to "see what practicing medicine is really like."
As an advisor and mentor for medical students at Harvard Medical School, Dr. Arky has provided
guidance to many students interested in private practice. In some cases, medical students may
express interest in returning to a parent's practice back home and carrying the business through
another successful generation. Dr. Arky notes that "in 90% of cases, most people change their
interests [during medical school]." He advises students in their third and fourth years of medical
school to 1) spend time in another private practice besides the one that inspired them to consider
the career setting (i.e. not mom's or dad's), and 2) observe the differences between solo and group
private practices. "Private practice is disappearing at this time, but some are still convinced that
it will survive or even come back [stronger]." However, Dr. Arky notes that others points to the
increasing sophistication and technology of medicine, the absolute need to have colleagues to
discuss cases with and rely on for coverage, and the greater prevalence of debts and other
obligations as insurmountable pressures for new private practitioners. For those who do choose this
path, he says, "Be adventurous. Be willing to go out and earn your living. Be willing to take
chances." 
Lester Leung is the Editor-in-Chief and Founder of the Next Generation and a member of the Harvard College Class of 2006.
Ronald Arky, MD is the Charles S. Davidson Distinguished Professor of Medicine and Master of the Francis Weld Peabody Society at the Harvard Medical School. Dr. Arky serves as Chief of the Diabetes Section at the Brigham and Women's Hospital.