All right, well, I guess I'll start off and talk to you guys a little bit, and I'll make a quick try to stay in my 10-minute time slot. So the question is, what practice setting is best for me? And the answer is, it's the one that fits your long-term goals the most closely. I will tell you that I've been in private practice my entire career, and there's a lot to be said for private practice. And so I'll limit myself to that right now. But I'm not going to say anything bad about any other form of practice, because it depends on the individual. I do want to let you know, though, some trends that are impacting what physicians are thinking about right now as far as their careers. And I've seen these firsthand for the last 30 years. That's how long I've been in practice. There is a dramatically rapidly changing environment in health care right now. And you probably all heard about some of the macro changes nationally. This is also important from a very local standpoint, because it does trickle down to a local three or four-doctor office pretty quickly. There's decreased payer reimbursement, and if you don't have clout in your local market, you're going to struggle to have a successful practice. In concert with that, there is ever-increasing CMS regulations that, you know, the government never gets rid of rules. They just invent new ones. And that certainly is true for medical practices, and that has intensified with the advent of electronic health records. You guys probably weren't around in the time of paper charts, but I was. And when EHRs became a thing, the regulations increased probably 50 percent. Remarkable. There's huge competition for patients, for staff, for even physicians with hospital systems, with academic institutions, with other colleagues in the community. Staffing and overhead expenses are not going down. They are going up, and they are outpacing general inflation. So getting more expensive to run a practice. And obviously, loss of clinical autonomy is also making people's decisions more difficult, and they're concerned about that loss of control, because if you lose clinical autonomy, you lose control of your profession. And obviously, limited operational decision-making. If you have a problem and you can't fix it, that is extremely frustrating to people like us, who have always been top 5 percent of our class, smartest people in the room. We do know how to do these things, and if we don't have the authority to do them, that's very frustrating. So I've grouped these into four main categories of what your practice might be able to look like. So you can choose a primarily academic career, and that is maybe research and teaching. Very appealing, actually, to be in that type of a situation. You can work for a hospital or a healthcare system. There's a lot of overlap, actually, between academic medical centers and hospital and healthcare systems these days, as hospital systems continue to consolidate around the country. Traditional private practice is what is under threat. Depending on the specialty, it's under dramatic threat. You can be independent. You can be in solo practice or group practice. You can be multi-specialty or single specialty. Those local models are going away. It depends on what part of the country, the local situation, but it has become very difficult to keep a small practice healthy in many markets. If you have a niche, a geographic niche, a specialty niche, it can be a little bit easier, but it's definitely an issue. What I'm calling advanced independent practices, which is what you're seeing is the organization of medical groups into regional powerhouses, so they have clout with insurance companies and clout with hospital systems, and then into national powerhouses, where they have clout on a national scale to allow us to develop new lines of business, encompass care of our patients, participate in things like value-based care, data initiatives, and things that can actually improve the care of our patients nationally. I look at private practice, and I sort of boil it down into three terms that I like to use. I'll give you examples of each one of them, but autonomy, opportunity, and ownership. Let's talk about autonomy. Autonomy means if you're in a little group of five or ten, you're a small business person. You're running a business, so you can't just put your nose to the grindstone and see patients. You have to pay attention to how your office is working. You have to make sure that you know that your staff is treating people well on the way in and on the way out, that the billing is done appropriately. That's important to patients. It might not be as important to you, but it's important to them. You have to pay attention to all those things in your practice that make you a small business owner. You know, when you go to a restaurant and the owner's on site, the food's always better. Same thing for medical practices. If the owner is in the building, the office is likely going to run better, okay? So that's autonomy. Then opportunity. So think about this. If you are in a practice, and you decide that you want to specialize in IBD, you can do that. Asking anyone for permission. If you're in a group of 20, and you say, you know, we have a nice big office. We have a satellite on the west side of town, but you know, a lot of our patients are coming from the east side of town. It's a 25, 30-minute drive at least. Population out there is growing. Should we open a satellite out there and make life easier for our patients and maybe make more convenient for ourselves too? Good for our practice, good for our patients. You don't actually have to ask permission from anybody to do that. You talk to your partner and say, hey guys, do you think it'd be a good idea to open a satellite office? And they say yes, then you go find some space, and you open an office, and you bring some staff out there, and you start seeing your patients out there, and you've just done a service to the community, and you probably helped your practice in the meantime. So that's opportunity. And you can take that to any level that you like, because you're in charge of your practice. So the third is ownership, right? So think about this. When you go to work for an employer, you're on salary. You're an employee. You get a salary. It might be a nice salary. You finish working for them. You walk out the door. You get to take your 401k with you, and that's what you get. And then you're done. If you spend a career building a practice, starting with a few people, and ending up with a lot of people, and it's a successful practice, and you've decided that you've got your office, and you've built an endoscopy center, and you've got a sedation company to help with your CRNA and your anesthesia, and you've built a path lab, and you have a nice pathologist, that's a business. And you, being one of the builders of that business, own part of that business. That has value. That has real value. And a lot of physicians really appreciate having that ownership responsibility, because it dramatically increases your professional satisfaction, your sense of ownership, your feeling that you built something, you have part of it, and you did a good job for your practice and your patients at the same time. So I'm going to not talk for a whole lot longer, but I do want to have you guys look at this. This is your homework. And you can take a look at this and tell me what you think, but when you're thinking about a job, and you're deciding where to go, I can only speak to the two on the right, because those are the ones that I've been in, so I actually filled in the blanks for you on that. So I can't do it for academia or healthcare system, but you can figure that one out yourself or talk to people that you know about. What I can tell you, the traditional private practice was great, and that's what I was in for the first part of my career, but it became increasingly difficult to maintain that level of professional satisfaction and an upward trajectory. So we became much bigger, and finally, about four or five years ago, we became what's called independent private practice. We joined other groups in Texas and Illinois and became the GI Alliance and actually have grown dramatically since that time. Other groups around the country have done that with other private equity partners. But what I can tell you is that that does have likely the best chance at maintaining physician independence, autonomy, and opportunity for the future of medicine. And so there you go. I'm going to let you guys take a picture of that. You can decide what you want as far as filling the blanks in, and I'll turn it over to other speakers.

practice settings

physicians

healthcare trends

private practice

physician independence