2010-06-07 16:32:28 UTC

How to Maintain a Vibrant, Useful and Productive Career, LIfelong

Dec. 1, 2007

Private Practice
By Cecil H. Chally, MD
Minnesota Gastroenterology, PA

By Marshall M. Kaplan, MD
Professor of Medicine, Tufts University School of Medicine, Chief Emeritus, Division of Gastroenterology, Tufts-New England Medical Center

Private Practice
On July 1, 1965, I began my Internal Medicine internship and residency at the University of Minnesota. The training period was interrupted by a two-year stint in the Air Force, where I became interested in gastroenterology. I returned to the Uni­versity of Minnesota and later the Min­neapolis Veterans Hospital for the remainder of my residency, chief residency in internal medicine and fellowship in gastroenterology under Drs. Les Zieve, Stephen Silvis and Jack Vennes.

At the end of my gastroenterology training Drs. Arnold Kaplan, Joseph Tombers, and I began a gastroenterology practice that grew significantly and became an integral part of Minnesota Gastroenterology (MinnGI) in 1996. Over the next decade MinnGI grew to include 48 gastroenterologists, five endoscopy centers and a clinical research center. During my leadership of the practice I was involved in this growth as well as the promotion of quality assessment and the development of colonoscopy guidelines. The quality initiative has been enhanced and expanded by my younger partners.

Challenges have been numerous and have been driven by group growth through the years and by a change in the culture as younger physicians with different expectations have been added to the group. The addition of many younger well-trained gastroenterologists added to our knowledge base and skill capabilities. Changes have been stimulated by growth of the group, outside forces such as hospitals and insurers, the advent of electronic medical records, as well as our patient’s needs.

Adjusting to the role of being an older physician has been a challenge to me and my partners in the group. I have felt a lack of recognition by the younger members of the “sweat equity” and creativity that helped to build the group to what it is today. There is no question that a less intense work schedule and the ability to work part-time is an optimal goal as we physicians grow older. We have been fortunate in our group to have an increasing income stream from the endoscopy centers to offset transition to part-time status.

Night call should be less frequent or there should be no call at all. Buying out of call as well as buying out of the practice and endoscopy centers should be equitable and determined in advance of practice cessation so an objective agreement can be accomplished. Currently in my practice, individuals who choose to decrease their time cannot buy out of call, but can reduce to 75 percent night and weekend call if they choose to reduce their work time.

Emphasis on the business of medicine should be tempered by creation of ventures that are economically beneficial for better patient care, yet create new income streams such as endoscopy centers, clinical research centers and pathology laboratories. The value of the endoscopy centers to outside interests, such as a national endoscopy company, is much higher than when the centers are owned entirely by the medical practice. The true value is realized only when there is a sale of a share of the asset (the endoscopy centers). However, the price of a share of the asset needs to be balanced keeping in mind that new partners need to be able to buy in as well.

Continued knowledge acquisition is an absolute requirement for our role as physicians and for patient satisfaction as well as our individual satisfaction. For me, advances in stem cell research and molecular biology and their potential to solve many diseases energize my thinking. I also need to be able to adapt my individual practice to allow time for hobbies, time for family and grandchildren, and time for personal education. I believe a group should provide older physicians a place to practice medicine, as long as the physician is interested and competent and an equitable arrangement satisfactory to both the individual physician and the group can be worked out.

Physicians should be able to prepare themselves for the future in a new and satisfying career either within or outside of medicine.

— Cecil Chally, MD

The request to write about “The Aging Gastroenterologist” was an initial turn-off. Although older than most of my colleagues, I do not view myself as old, at least in the physiologic sense. I am healthy, compete successfully on the tennis court with players more than 30 years younger and remember liver function tests of most of my patients. Nevertheless, as one matures, goals and interests change and many of us choose to spend less time at work and more time with family and other interests.

Academic medicine offers many opportunities for us to decrease our medical activities yet still contribute in a meaningful way. Most of us have pension plans such as TIAA-CREF that have appreciated greatly over time. These give us the financial security to alter our careers as fits our interests and skills. For example, I stepped down as chief of our division in order to do what I enjoy most: care for patients, teach, write and continue my clinical research. I took a voluntary cut in pay in order to feel free to work less and travel more. While I have moved to a smaller office, I generate enough income and scholarly activity to justify a secretary and fringe benefits. My institution, Tufts-New England Medical Center, has few endowed chairs and a small endowment. Thus, a less-than-full-time physician has to be productive enough to earn his support. Institutions with larger endowments may have the luxury of requiring less tangible productivity.

Most of us who have been at one institution for many years are aware of the support that our institution can offer as our productivity decreases. Some colleagues have chosen different career changes as they age. Some have given up private practice entirely but continue to teach house staff and fellows several days per week. Colleagues who generate little income have opted to take minimum or no salary, but still get malpractice insurance.

Depending upon the institution and its financial strength, there are other options. Several colleagues have opted to attend on in-patient medical services and supervise fellows’ clinics; they do not want the responsibility of caring for private patients. Many who chose to attend on in-patient services are at medical centers that have hospitalists. They can devote all of their time to teaching and not be burdened with the paperwork that third-party payers require. One colleague, a popular teacher, left gastroenterology completely and donated his time and expertise to teaching problem-based learning to medical students. He desired no salary, office space or secretarial support and got his reward from the sheer joy of teaching appreciative students.

Most of us who have been in academic medicine for many years have accumulated significant personal databases and have learned that there is no substitute for clinical experience. This is often called wisdom. It is something that develops with age and experience. Younger physicians recognize and appreciate this. The aging gastroenterologist has much to offer his younger colleagues and most institutions acknowledge and support this.

— Marshall M. Kaplan, MD