What I'd like to introduce you now to is Dr Joseph Vacari, who is probably going to present a different style of practice to you and probably he's going to be just as equally passionate about what he does. He works in the Roxford Gastroenterology Associates and he is a very, very strong advocate for ASGE, particularly in the area of practice management. And this is an area I think for you all as being the next generation of gastroenterologists and as Jason sort of alluded to, there is going to be more thought about practice management, the business side of things. So I'd really like you to welcome Dr Joseph Vacari. Well, thank you, Ferga, and I know Klaus is not here, but thanks to my good friend Klaus for inviting me. Before I jump into my talk, just a comment on the final question. As you can see from my slide, even though I am in private practice, I have an appointment at the University of Illinois College of Medicine at Rockford. So there is a model, or there are models, where you can work at a university or teach at the medical school and be in a private practice. It's a medical school. It has about 50 students. We do all the teaching for GI for all of the students. We do actually do some research. We do research projects with the students. So there is that model and there's very low pressure for us. So that does exist and it's not unique to Illinois. I have no financial relationships or disclosures to make. And first I want to congratulate all of you. You're near the end of a very long and fun process, finishing up your fellowship. But it's an exciting year, trying to figure out where you will go, the type of practice model that fits. And I think that's a big point for us tonight is finding that right fit, finding the practice model, whether it's academics, one of the private practice models, or the VA, that really aligns with your values. Because as we look for new partners and we recruit, we're looking for a long-term relationship and you should too. You're a very valuable asset that you'll bring to an organization and should take that view that you are looking for a long-term relationship. So you've chosen well. I think the field of GI is a very fun field. Many of the things that Jason talked about you can actually do and we'll mention some of those in private practice. Most importantly, we are at a time when in private practice, like in academics, we can deliver high quality, cost-effective care when it really matters. Payers, patients expect value. And with the amount of cognitive support we have from evidence-based studies and great technologies, you can deliver high quality care. I think we have a perfect field. The balance of office work or cognitive work and procedural work in GI is fantastic. I guess many of you are like me. I could not sit in a clinic all day. I would lose my mind every day, all day doing clinic. And there's a great balance of cognitive work from simple to challenging, to procedural work that's simple to challenging. And this technology that will ultimately help keep us happy in our work, letting us do many different fun things, it continues to evolve and improve. The good news for all of you, whether you're looking at an academic or private practice job, there are many great opportunities right now. Lots of good jobs that you can find to align with your values. And as Jason showed, you will be well compensated for what you do. You'll be in the top 1% of salaries in this country, allowing you to have a fun professional and personal life, care for your families, save for your future. So those are just some general comments. The rest of this I'd like to focus on for private practice and independent practice specifically. Organizational structures, discuss some of the economics, get you familiar with terms. And then culture, which I think is really important to talk about, especially in private practice. We'll focus more tomorrow in a talk I'm giving on practice finances, on economics, but we'll talk about some general economics in this talk. Okay, so you have, my slide didn't quite come out as I planned, but on the left should be an arrow that shows autonomy, an arrow going up that shows autonomy, and an arrow going down that shows administrative. So if you start at the top, and I'll talk about different models, you can establish a practice, a solo practice, a small independent practice, a large independent practice, and then you'll hear later on about multi-specialty groups, hospital-owned groups, and corporate partnerships. I will comment a little bit on private equity or equity groups. So you won't see many solo practices anymore. If they exist, they tend to be in rural areas. I actually do have a friend who's in solo practice. Lots of autonomy, but very little administrative help. He's kind of on his own. They can work, but they're difficult. We have, we still see some small independent groups, although these numbers are shrinking. Many of those are being absorbed by private, sorry, by hospital models and by private equity. We still have a lot of independents in a small group, and that's usually five or less in a small group. A lot of decision-making. You can control your workday and your workflow. So a lot of independents, but not a lot of administrative help. Large independent group. I think if you really want to be in an independent group, that's the group to look for. My group is about 15 right at the moment. We have seven advanced practice providers. You give up a little autonomy because decision-making is not an individual basis. The group makes decisions for the whole group, and your administrative burden goes down, but you really can control your own destiny. If we need a scope, we can go out and immediately get a scope. We don't have to go through a bureaucratic process. We need recruits. We can make that decision quickly to recruit, whether that be doctors or APP. So a lot of autonomy, and since we have a number of people, we do have administrative help. We have our own business administrator. We have our own in-house IT. We have clinical administrators. So lots of people in the organization to help us run our workday. And private equity. I view private equity as kind of a blend between an owned model and an independent practice. Your autonomy goes down a bit. Others are telling you how your workday will go, but your administrative burden is very little. So that may be attractive to you. I think the key in choosing an independent model, again, is trying to align your values and your needs with the type of practice setting. Oh, there are my arrows. I'm not very technologically savvy. So autonomy up top, and it goes down as you descend, and administrative burden changes as well. Okay, so let's get to some details. How do the independent practices work? What drives the operations? What drives the organization? So I think important questions you want to ask when you get to these interviews and you're looking at independent practices, who actually owns the practice? Do all the physicians own the practice? Are they all partners? Or is there a model where some physicians own the practice, and you're an employee within that practice? I would tell you that is not a practice I would go looking at. I would suggest you should focus on practices where it is physician-owned, and you have the opportunity to become a partner or owner in that practice model. Who leads? Who leads the group? Classic leaders within private practice would be a managing partner, and then the physician owners make up the board members. So you, as a partner someday, would be part of that leadership team, leadership process, making decisions for the organization. So if you like that, if you'd like to be involved in decision-making, if you want, you can, if you want to pursue a career in leadership within your group, you can. I obtained an MBA after I joined my group because I became interested in practice management and physician leadership. To me, this is a very important question, especially in private practice, and we'll talk more about culture as we go on. What is valued by the owners and leaders in the organization? And I, it doesn't matter to me what practice model you're in. Private practice, academics, VA, it's always patients first and the delivery of high-quality care. In our organization, we kind of view a hierarchy as follows. Patients come first, everything we do is driven to deliver high-quality care. Employees come second, create an environment that is safe for the employees, one that promotes mentorship and growth and long-term employment. The needs of the organization comes third, and some of my younger partners were almost appalled when they joined the group, and I said, the physicians' needs come last. If you focus on the patients, the business model always flows and flows successfully. So look for a group that values quality, quality outcomes, the patient experience. Look at what type of productivity system you want to be in. I'll come back to that in a moment on culture. Are you looking at a system that is purely productive, meaning you take home what you see, so the more you work, the more you make? Or would you be in a model like mine, where all the money is thrown into one big pot, it's split up at the end of the year, and we can focus on the interests of the physicians and what they would like to do in their daily workday. Work-life balance. Let's spend a few moments on this. We'll talk more, Colleen and I will talk more about this tomorrow. I think this is, after patient care, to me, this is a big point. You're looking for a long-term relationship. You want to be happy at work, but you have to be happy in your personal life. If you're working seven days a week, 12 hours a day, not much family time, very little vacation, you will become unhappy and become unhappy soon. And burnout can occur in young physicians. It's not just for the old physicians like me. It can happen at any stage. So look for that work-life balance, where there's time off, at least in the private practice world, at least six weeks. Look at your daily schedule. Are you seeing patients every 10 minutes, every 15 minutes, or is it a group like ours where we do 30-minute slots for everybody? So as you go to these practices, start to ask these questions. What's their workday like? How many hours are they in the clinic? What's the endoscopy split? And make sure you have plenty of time off and vacation to enjoy life with your family and balance that work-life career. How do you go from a new hire or an employee to partner? How long does it take? Is it a year? Is it three years? Is it five years? What is the cost of that? Do you have to come up with a new loan to pay for that partnership? Are you buying into the practice? Are you buying into the ambulatory surgery center? Are you buying to both as one? So try to ask these questions of how do you become a partner, what's involved in that, buy-ins, buy-outs, and how does that process work? What's the age distribution within a group? If you are looking at a group that has eight people and half of them are 55 or older, that may have an impact on your future work life, your future work schedule. Do you need to recruit more if older physicians are retiring? So look at that age distribution as it may impact your work life moving forward. So practice culture drives MD compensation philosophy. The group culture will determine how you get paid and how you work. So if you are looking for a culture, again, that is about productivity, about work or salary forward, what your compensation is most important, then you will be looking for a production system that has longer work hours, maybe works weekends, as opposed to a philosophy that's a little bit more like Jason might be, in an academic environment where perhaps the pot is split like ours, your workday is very reasonable, and you're really focused on getting patients in, good access, keeping your endoscopy center busy, but focusing on the whole organization growth and having a better work-life balance. So the culture, the values they place on salary will determine how you're paid and how that works. Benefits, I think it's important to ask questions about benefits. Obviously medical coverage health insurance is important, and that's standard. Malpractice insurance, disability insurance, retirement plans. There are several different retirement plans that you will hear about and should ask about. 401k plans, defined benefit plans, profit sharing, pre-tax plans. You're just starting and you'll be focused on salary. Many of you will have debt, but someday you will retire and you need to start planning for that when you start looking for your job. So ask questions about the retirement plan and what type of retirement options are available to you. Your workday schedule, very important as I mentioned earlier. What type of work schedule are you looking for? Is your focus to deliver a high quality care, have a good daily professional life, where you might see patients every 30 minutes, or are you going to be looking for a practice where you'll see old patients every 10 minutes, new patients every 20, double book, work over lunch, maybe maybe work into the evening. That's not the type of practice I would be looking for, but that's something again you have to align with your values. These are questions you need to ask when you go in, and as a general rule you should be asking lots of questions. When you go on job interviews, these the organizations at University need to be transparent. So if you have questions and they don't want to answer them or they don't want to show you their daily schedule, these are red flags to me, and when red flags come up or alerts come up on interviews, they're not going to get any better when you show up. So anything that that is a red flag or red alert, pay attention because it won't get better when you get there. Vacation, we talked about in private practice, minimum of six weeks. Our group, we take 11 weeks. We value that work-life balance, so look at different groups, see what aligns with your values. Something else I would add, that time off allows you to do other things. So I've been doing this now for 25 years. I still love the clinical part of GI and the endoscopic part of GI, but a great source of professional happiness for me has been the ASGE. I've met great people, made many friends. It kind of makes your professional life very interesting. It doesn't have to be the ASGE, it could be something else, but you can't do that if you take two weeks off or three weeks off. So again, look for that work-life balance, look for a robust vacation policy, and look for groups that will give you opportunities to grow professionally outside of your average or daily workday. And then CMEs. Other things you should ask and inquire about and understand about groups are their ancillary income. So the standard income comes from seeing patients in the clinic. If there's an endoscopy center, there's revenue generated from that, and we'll talk more about that tomorrow. But there are other ways for groups to bring in revenue. So I mentioned ambulatory surgery center, but most groups now in independent practice, especially larger independent practice, will have histopathology labs. They may only process the slides and then farm that out to be read by a pathologist, or they may have in-house pathology as well as slide processing. They may have an anesthesia company. If they have an endoscopy center, they may have an anesthesia company that they have created that the anesthesiologists provide sedation analgesia. It's at least, at this point in endoscopy, at least 60% of endoscopy in the United States is done with monitored anesthesia care. And if you're in a private practice, do they have an anesthesia company? And how are you able to buy into that? Infusion centers have become very big in private practice and another source of income. It's very expensive to have infusion services at the hospital. They've now moved into outside of the hospital. And so many GI practices have created infusion centers to create a new line of revenue. More recently, pharmacy research can be another source. And this is industry-sponsored research and then weight loss clinics. Other ways to bring in income to these practices and questions should be asked about what are your ancillaries? How do they work? And how does one buy into that? Is it part of the overall buy-in or a separate buy-in? Information technology is important in all aspects of medical practice now. We have our own IT. We have in-house IT. Smaller groups tend to farm that out. We could not run without IT. Obviously, it's important for the office and the endoscopy center. Does the group have a health information exchange? I can tap into the hospital records. They can tap into our records. And that makes patient care easier, makes my work easier. Can you access records from home? And how does the group communicate with patients? Patient portal, nurse phone calls. Another important part of IT are recalls and reminders. How do people know to come back for their endoscopy, for their surveillance endoscopy? How is the recall set up? How are the reminders go out? Who works on that? And how can that be run successfully through information technology? Another important question you want to ask when you go to your job interview, the demographics, patient demographics. Patient demographics tell you a lot about the diversity of insurance products that the group accepts and works with. So, a friend of mine practices in Florida. They have about 85 percent Medicare in his group. It's easy. They really are only dealing with Medicare. But the problem when you deal with a few insurance products is if there's a small change that's negative, I'm sorry, a big change that's negative, that can really impact your revenue. So, I like a wide variety of patient demographics as it relates to insurance. Our group has about 35 percent Medicare and then a variety of other insurance products. We see all patients in our group, no pay, Medicaid. So, I think the wider the array of demographics gives you some economic opportunities to grow within those products. Does the group have real estate? Do they own real estate? And importantly, what type of debt does the group have? It's hard when you're going into practice to talk economics. Tomorrow, hopefully, I'll educate you more on the language of economics and the language of finances. But you really need to get some access into the finances and into the cash flow of businesses. Any practice that is looking for a long-term partner should be very transparent. If you come and interview at our group, the books are open. You'll see monthly cash flows. We will show you several years of cash flow. We'll show you salaries back 25 years. We'll show you call schedules. Transparency is really important when you're looking to develop a long-term relationship. Culture. We could spend the whole half hour on culture. The group culture really drives the way they deliver care to patients, how they treat their employees, how they treat their partners. There's a definition by someone named Edgar Schein on culture that I like. It's the integrating mechanism or glue that keeps a diverse group of people trying to work for a common goal. And there are many types of culture. Jason alluded to earlier that medicine is kind of a team sport. I think it's the ultimate team sport. So I'm looking for a group or a practice that deals or embraces something called group culture, which is based on teamwork. It fosters professional growth. It fosters mentorship. It fosters personal happiness. So you want to look at a group culture that puts the highest value on those things and, most importantly, puts the highest value on delivering high-quality care. If you want to learn about that group when you're interviewing, talk to the nurses. So if they hide you from the nurses as you're going around a practice in your interview or hiding you from the employees, that's a red flag. If you have the ability to talk to some of the staff and nurses when you're at a practice, they will tell the truth. They will tell you about the practice, what they think about the practice, how the physicians treat the staff, how the physicians treat the patient. So group culture, staff counts. Go to the staff. They'll tell you a lot about the organization. You won't have a chance to talk to the referral base or the referring PCPs, but they will tell you a lot about a group as well. Hospital leadership, they can give you an idea about groups. So if you go to a group and they take you to the hospital that they practice in and you get to meet some of the hospital leadership, talk to them. Ask them, how's the relationship with this group? How does it work with this group? And anything you can do to get more information to build that chance of a long-term relationship. Diversity, diversity from the social definition. You want to have a diverse outlook and a diverse group that embraces the population you serve. But there's also the diversity of your workday. So if you have an interest in IBD, can you have a subspecialty IBD clinic within that practice? One of my partners, Sumit Tiwani, is here this weekend for the Golden Scope competition. I hardly see him, and I'm happy to hardly see him. He's an advanced endoscopist. He's at the hospital. He's doing what he loves. I'm not an advanced endoscopist. I spend a lot more time in the clinic. I spend a lot of time doing bread and butter endoscopy. I'm kind of a ditch digger. But we're both happy. The group allows us to pursue the things we like to do. And so make sure that you have that diversity and practice opportunities to pursue the interest you have. They don't only exist in academic medicine. You can see a lot of IBD in private practice. You can see a lot of liver disease. It's just if the group will allow you to do that. What's the on-call schedule like and the experience on-call? When you start in the group, how much call will you take? Does everybody take the same amount of call, or do the senior partners opt out of call? I think that's something you need to be careful about. I think everybody in the group should share the same call schedule. The call schedule is the same for everybody in our group. You have a track at the end of your career where you could buy out for a couple of years. But it's a pretty significant financial penalty. So look and see how the call schedule is, and is it fair? How often are you on-call, and what is the call night like? Are there journal clubs? We have a journal club. We're in private practice, but we have a journal club once a month. We skip in the summers because it's busy, but we do a journal club about nine times out of the year. You can do those things in private practice to enhance your learning, keep you interested. Malpractice history of the group, malpractice insurance. In the end, as I talked about earlier, happiness factor, that work-life balance, what does the group value, and what's going to keep you happy? So asking these questions are important. And as I said earlier, too, how were you treated on the day you were there? Any red flags that pop up, they're not going to get better. So ask questions. Expect transparency. I don't think there are really any questions that should not be asked. We'll talk more about financial statements and things tomorrow about asking the finances of the group. But this is a long-term relationship, and the best way to build that long-term relationship in private practice is with transparency from the start. I think we might have some time for questions. Thank you, Dr. Vicari, for such a great talk. There's been a growing trend for private equity taking over some of these private practices across the country. What are your specific tips for us fellows in terms of things we should look out for, things we should ask about? Because you hear about some good experiences from people, but we also hear about the poor things. Getting ready to walk again, Fergus. I'll stay here. So private equity, I'm not the biggest fan of private equity. However, if you look across the board, about 60% of GI physicians right now are in some type of employed model, whether that's academic or employed by hospitals. I think about 10% to 15% are probably in private equity, so leaving a much smaller, maybe 20%, 25% in independent practice. So I think we're going to see more private equity. I think the downside of private equity, if you're joining a group and in a year or two they pursue private equity, I view it as almost selling out the young within the group. It's perfect for a guy like me who has a retirement date coming soon. I'm an older guy. I could get a big payout. But I tell my partners, I would not do it. I think you lose autonomy. And you now have someone telling you what to do. And you could do that in academics and have a great career. You could do that in people who have done it really well in the hospital employed model. Private equity, the business aspect of it is really important. It gets turned over about every five years. They really want to make a profit, about 20% a year. So I'm not a big fan of it. I don't like what it could do to the young partners and the culture within the group. It's really a big financial windfall for the older partners. And again, I view this as a hybrid. I think you're partly owned, partly private. And you may find people who love it. But I think it's all about the dollars and not necessarily about professional happiness, professional growth, mentorship, and enjoying your career. Very nicely stated. Anyone else from the audience who would like to pose a question to Dr. Vakari? I hope nobody from private equity is sponsoring this evening. No. It all stays within the room. Actually, oh, we have a virtual question. OK. Yeah, we have a few here. So the first one is from Ryan. Are there any book recommendations on your talk that have been published in the last five years? Books. Colleen, anybody? I don't know of any books. Some articles. There are articles, but I don't know of any books. You could certainly do literature searches on contracts and negotiations, strategies on interviews, things like that. But I don't know about any specific book. If they have any questions, they can feel free to email me. Just let them know that this is from the Fellows course. Otherwise, I might not answer. Another question from Soot is, what is the importance of CME? In the days of up-to-date and virtual courses, I think separate or individualized CME time, as opposed to an allotted time off, has become less important. You can get so many CMEs from up-to-date. You can do so many virtual courses. I think if you are looking for a block that's only for CME, I think five days is very reasonable in the private practice world. But in a group like mine that has 11 weeks off, or in groups that have eight or nine weeks off, it could just be blended into that. So I think CMEs are important. I don't know that it's important if you have a lot of vacation time, as far as a separate block. Any other? There are a couple more questions here. How are different call schedules set up in private practice? And how much time, both during the work day and on call, are split between clinic outpatient endoscopy versus inpatient work? I'll take the call part first. I'm going to have to ask you to read that again. Multiple levels, yeah. Your call volume depends on the number of people in the group. So in my group, as an example, there are 15 of us in the call schedule. On average, that gets us about the way it works. We separate out Friday night from the weekends. We do about 22 weeknights to 24 weeknights, and about eight weekends a year. So the more people in the group, the less call you have. And again, I think it should be fair amongst all partners. Senior partners shouldn't do less call in our model than the junior partners. And what was the other part about? And then he's asking, how much time, both during the work day and on call, are split between clinic and outpatient endoscopy versus inpatient work? So with the GI hospitalists, there are many practices and independent practices now where physicians do not go to the hospital because they have dedicated GI hospitals. In groups like ours, again, it depends on how many docs. But we all do about, we go to two hospitals, we all do about six weeks of hospital work. And when we're at hospital work, it's dedicated hospital work. I would recommend, if you're at the hospital, just work at the hospital. And when you're in the office, you're in the office. And in the office should be a nice blend of clinic and endoscopy. You tend to do a little bit more endoscopy than clinic. For another question. I'll tell you what. I'm here after dinner. I'd be more than happy to take any questions. We may take just one more question from the audience because I think people are sort of getting more stimulated as you get into it. Jason came down with gauntlet. He got me a little fired up about this academic, you know. No, no, I think this is wonderful to see. This is exactly what we want to see because everybody in the audience has probably preset ideas as to where they'd like to be and what they would like to do. But I think this is an ideal opportunity to pitch you some questions that may ask you to rethink or else to reinforce your thoughts. So I think we had a final question for this particular session. Go ahead. In your experience for folks who take a track of employment towards partnership, what does that tend to look like on average in terms of timelines and like how that is paid? Like what are the models that exist that define that relationship? They range from a short period of time like my group for a year, but I would say most, and I'll ask for Colleen to chip in, about three to five years. Colleen, is that fair? One to three. One to three. So my model's limited to about one to three. And I think the key thing to try to figure out is how do you pay into the partnership? So you're coming out of training. You may have debt. You may need a house. Do you want to start living a real life? And so how is that buy-in funded? Do you have to go out and get a loan? Does the group make special arrangements? Or is it something like ours where we have a passive buy-in? And I could explain that more to you offline. So in our group, you're not going out and getting a loan. It's just a ramp up to full salary, but nothing is coming out of your pocket. I'll leave you with this. You're a highly valued resource asset. Do your homework. Make sure that the group you go to is aligned with your values. I can't emphasize that enough. No matter what practice model, it has to align with your values. You need to be personally and professionally happy. Thank you.

gastroenterology practice models

work-life balance

patient demographics

compensation philosophy

private equity in healthcare

interviewing with a practice

continuing medical education