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I will be the first one to tell you that practice is hard. Private practice is even harder. Sure, you can go to work for a private equity firm or a big academic institution. You’ll guarantee yourself a steady paycheck and good “work-life balance”–a buzzword all the rage these days. But there are disadvantages, too–the little things that nobody talks about. Do you want to incorporate a new device into your practice? You want to go to a meeting or stop seeing patients at 3 p.m. on Tuesdays to take your kid to soccer? Well, you need approval from your employer for that, too.

For as long as I can remember, I always set out on my own path. I learned a lot from my mentors. They were all great dermatologists who practiced in a variety of settings. I learned what I liked and what I didn’t like by observing their unique practice settings. All had plusses and minuses. I realized that I liked the kind of control that you can only get from owning your own practice and being your own boss.

Private practice is hard. I say it often because it’s true. I have been knocked in the face more than a few times. Private practice takes grit and determination. If someone calls out, it’s your problem. If you are short-staffed at the front desk, you’d better get on Indeed and find someone. Your medical assistant is out sick? Well, it’s going be a rough day for you and your crew.

Most residencies don’t teach you the first thing about the financial aspect of running a practice. A resident can tell you every subtype of Pityriasis rubra pilaris (PRP), but they don’t know what a CPT code of 99213 reimburses. There is something fundamentally wrong with this picture. I learned a lot along the way. The first deals I made with providers were bad. I felt a sense of desperation, so I overpaid them. But you learn things as you grow and mature. As an owner, you truly are in the driver’s seat. You can turn left, right, or stop at any moment. Each day offers a chance to do something different. You have the ability to be nimble and change. You are able to write off expenses that an employed dermatologist would not. The cap on continuing medical education is defined only by you. There are tax advantages depending on your practice structure. If you have a multi-clinic structure, for example, you may be able to have Management Services Organization (MSO) that can be taxed at a lower rate.

If you want to grow your practice, you have to be lean and efficient. America is not the way it was 10 or 20 years ago, and neither is medicine. We have to change and not be relics of a past time. Reimbursements are declining, overhead is up, and inflation is here to stay. Lidocaine costs a fortune, and the news never talks about this shortage. No one cares unless you are a dermatologist in private practice. When I started my practice 3 years ago, a 25-pack of lidocaine was $100. Now, if you are lucky enough to find any, you may get it for $400. Talk about inflation! That same medical assistant who used to cost $20 an hour… well now it’s $25 an hour. Everything keeps getting more expensive. So, you see more patients, but you aren’t making more money because your expenses are crazy. And you’re working really hard. I am talking about double booking every 15 minutes and seeing 50 or 60 people every day on top of administrative duties. You can get burned out.

In medicine we are taught to not talk about money. It is taboo and looked down upon. But whether you like it or not, a private practice is a business. To survive, you have to make tough choices. So, I transitioned my call center from within the U.S. to overseas. Because I was able to absorb increased costs in other areas, I didn’t have to cut staff or provider pay. Some patients don’t a foreign call center. Well, have you called a lot of major companies recently? They all have call centers overseas for the same reason: it is cheaper. There, I said it.

So you fixed the call center issue now. But you are still seeing 50 or 60 every day and your wait list is getting longer. You care deeply about your patients. Perhaps you think about bringing on a physician’s assistant or nurse practitioner. Some dermatologists will say that’s blasphemy. Let me tell you, I would love to hire only dermatologists if I could, but there aren’t enough dermatologists to go around. You try your best to find, train, and keep good advanced practice providers (APPs). I used to believe that only docs could see patients, but I was wrong. In my practice, the APPs are vital. They handle the acne, the warts, the rosacea, and medical issues that are relatively simple. I could not practice without their help. Having them on board also generates revenue for the practice and helps patients be seen in a timely fashion.

I am not the authority on anything. Just because something has worked for me does not mean it will work for you. Each day we evolve and grow. There is no such thing as failure, only an opportunity to learn and do better.

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