Hi, I'm Drew Chambray. I am a therapeutic advanced endoscopist in California, but I have had a variety of career tracks and I could go on and on about, you know, what I've learned and what I haven't learned and what I'm still learning. But I am, I guess, technically in a private practice model that is essentially an employed model in a multi-specialty group in a large integrated hospital system. I'm Colleen Schmidt from Chattanooga, Tennessee, and I'm president of Galen Medical Group there. So this is a multi-specialty group. We have 570 employees, 11 GI HEP, a hospitalist, and 17 different sites with 12 different specialties. We are a productivity-based, physician-led model. I'm Chael Nunn. I'm a retired gastroenterologist. I went into practice in 85 and I joined a multi-specialty group in North Carolina. We did more internal medicine than we did GI. So I was taking care of DKA, I was taking care of MIs. We were giving lidocaine then, you know. They said 50% of what you're taught in medical school is wrong, you just don't know which is wrong, which is right. In about three to five years into a practice, you know, you will start to question what you've done, you'll question the culture, you'll start to become knowledgeable about how the place works, and you'll start to think about what you may want to do. So I lasted about 10 years doing a lot of internal medicine, not pure GI, and I made a career as a chief medical officer at two different health systems. I went complete into leadership and so totally took a different track. I took a 40% cut in pay and started a new career, but then I drifted back to GI later on and so you never have to leave it, but you can do a lot of different things. And I trained at Duke, like a lot of people on this panel, because Klaus Mergener is a Duke guy and he finds us Duke people, and I never wanted to go into academics. I wanted to play baseball and golf and be in a community and stuff, and so that's what I did most of my career, so I had a good work-life balance. So you can, there's a lot of things you can do, and don't limit yourself. Well, thank you for that tour of your life. It was actually really nice to hear. What I'd love to hear before the audience maybe begin to ask questions, it's your opportunity to ask questions, including the virtual audience, would be for your respective practice styles that you work in, could you give me what you consider to be one pro and one con of that practice? Wow, only one of each. Yeah. So. Otherwise, we'll be here all night. Right. So, yeah, I'm a glass half full person, so I'll start with the one pro. Just like John and just like Jason, I love my job. In fact, my daughter's applying to colleges now, and I heard her talking with one of her counselors and said, you know, I really am nervous that I'm not going to find a job where, like my dad, where he really enjoys what he does every day. So the big pro is that every day I get to do really cool stuff. People thank me for it, and I get paid well for it, which is actually a phenomenal kind of a trifecta. What I don't like? Only one thing. I'll give you the option. You can say two. Okay. I would say Epic and Cerner. But no, what I, my big, what I don't like is that, frankly, the rest of the medical community doesn't always see the big picture of getting people well and doing it in a cost effective manner. I think that's very nicely stated. Dr. Schmidt. The big pro for me has been, it won't be too, sorry, Ferga, my partners and being close to my family. That's the reason we went back to Chattanooga, so my kids could grow up near their grandparents. I picked the group because of the people, not because of the location, though. Also I really value the flexibility I have in my schedule because we're a productivity based model. My productivity is my own to create. I think you almost stole my answer, but not quite. The con, this is asking me today, so ask me yesterday or tomorrow, it might be different. The con is a locus of control issue for me personally, and it has to do with controlling behaviors, but Drew just alluded to it, and it's because it's such a focus on value based care. To try to get everybody moving down that path together is a challenge. I think the one pro of being in a multi-specialty group is you never, you maintain your view of a patient as a whole, not just a GI patient. I was always very fastidious of outlining all their problems and thinking about all their problems and not just the GI problem. So I think that multi-specialty kind of approach helped do that, and that's also the setting in which you can influence perhaps the value based course that we're taking rather than independent practice. I would say the con was that you never got a chance to really develop your own GI specialty. I didn't. Advanced endoscopy is in the early days of that, and so you sort of stayed in the general setting. So that would be the pros and cons for me. Can I ask any questions from the audience that you'd like to ask our panelists? Yeah, go ahead. Where do these different practice models exist? It's easy to see where academia is. It's usually big cities that have a big academic medical center. Are there certain markets where one type of practice may predominate, like a rural or suburban setting, a smaller town, a larger city, or do these still exist fairly homogeneously across the United States? Are you going to pitch that to each member or anyone in particular? I guess I don't know if there are specific practice types. Do the same again? Yeah. Drew, if you'd like to go ahead first, maybe? Sure. Like everything else, just like there are more and better restaurants in big cities than Applebee's in a small town, you are limited by geography. In a rural environment, where you have all the wonders of a rural environment, you're usually limited to a few options. As John said, those are often sometimes still solo practices because there are just not that many people and patients are few and far in between. But increasingly, in suburban and urban areas, there is a variety of practice opportunities. John Allen had a nice piece in gastroenterology about 10 years ago, kind of looking at how things had changed in his career. When he started, like when I started, there were basically two avenues. You were either physician, scientist, and academics, or you were on a small private practice. Now, there are all those different semi-employed models, independent models, multi-specialty groups. And now, we started in our group that I run, we have now nine docs. And we have a full-time hospitalist who works seven on, seven off. And he loves it. Locum tenens is now a career option for a lot of people, and everything in between. In urban and suburban areas, there are a lot of opportunities. And there are more employed models and more multi-specialty models than there were before. I think the difference that you'll see across these areas is actually one of resources, and then the other issue that's come up tonight, consolidation. But that really gets back to the resources challenge that some of the smaller practices face. I think you could find any style of practice right now pretty much across the United States. I do think some of that is going to disappear as we see the marketplace consolidate. And I regret that very much, actually. Yeah, I would say, just in my local network in Virginia and North Carolina, I've seen every style that we talked about. I had a friend that was in solo G.I. practice in Greensboro. He did a lot of clinical research. He had a big research. He had a big, big group. I mean, his operation was very large, and he did his endoscopy at a surgery center. My group in Lynchburg, Virginia, we were about seven docs and three nurse practitioners, and we were a typical small-sized group. And then there's large groups like Asheville G.I. that have 20 and 30 docs in the practice. And then in Northern Virginia, there would be friends that would have consolidated practices, bringing groups together and making mega-groups. So I've seen them all, but I think that those smaller independent shops are getting less and less prevalent, and most people are finding they need the capital and leadership, and they have to get bigger to do that. So, Dr. Nunn, can I ask you, you've had such a wide and varied experience with all sorts of different practices. I noticed that you have an advanced degree in medical management. Can I ask you, where do you think that that assisted you throughout your career? And I sort of push that question to the other panelists as well. We're seeing more and more MBAs, executive healthcare degrees. Is this something you anticipate that the next generation of gastroenterologists, irrespective of what practice style they work in, that there's an expectation that they have some sort of extra degree like this? I think that you don't necessarily have to get a full degree. I think if you're going to take a major leadership role, like Joe in running his group, it's a good idea to get an advanced degree. But I think every one of us needs to have some exposure to some management leadership training, whether it's negotiation or organizational dynamics or IT. You need to learn a little bit more about leadership and management, because you're all going to have to do it, no matter what level you are in your organization. I think getting a more advanced degree is for those who want to take on bigger and broader leadership roles. Not all of us are like Klaus, who's got a PhD and MBA and every other degree. I think he's a professional student. I think I got a master's through the American Association of Physicians of Leadership at Carnegie Mellon. It's sort of an MMM. It shows that I'm serious about leadership, and it helps you with looking for jobs and things like that if you want to move more into leadership roles. And if you're in a big group and they want you to be the leader, if you show that I'm willing to take the training to do it so I can do a good job, then it shows that it makes you more credible as a leader to get that degree. Dr. Schmidt, your take on it? I think you've got the best toolkit on the planet right now. I hope you're launching into a career that you just love, because we have, I think, one of the funnest jobs on the planet Earth. We really do. Unless you know right now that you really do want to move into an administrative role, this is just really an area where you might have a personal passion and want to pursue extra training or develop new skill sets. I subscribe to the 10-80-10 rule. In our organization, there's 10 percent that really want to be involved in a high level in decision-making and leadership, and they are the leaders in the group. There's 10 percent that really will kind of balk at anything. Most of us just want to do a good job and let everybody get their job done and try to all achieve this goal of taking great care of patients. That's where you are right now. You're going to go out there and take great care of patients, and if there's something else that you think in the back of your mind you want to pursue, you've got ample time to do it and lots of different kinds of opportunities now, which is really cool. Different paths, they all have an M in front of them for some reason, but there are small bits, big bits, and official degrees, but I hope you're looking forward to the next step. Dr. Shembray, do you have any thoughts, do you think it's a nice-to-have or a need-to-have? So, yeah, the niche idea is a great idea because the generic gastroenterologist is to some degree interchangeable. If somebody to show up in clinic, somebody to do endoscopy, you know, what separates you from everybody else? What makes you really valuable to your group? What makes you valuable if things change in your group? What if you want to go to a different place? How do you differentiate yourself? And that's not just as a marketing pitch, but something that kind of makes the day more interesting. Like, you know, if you have a particular interest in inflammatory bowel disease and you want to do that because, frankly, a lot of people don't. It's expensive, it's time-consuming, but maybe it's really interesting. That makes you uniquely valuable. If you have a business degree, and physicians are terrible business people, we find that again and again, and ask any investment manager, they'll say, you know, don't let physicians make investment decisions. If you learn that extra skill, then you're hugely valuable to your group because a lot of people, especially in GI, where the opportunity costs of not doing endoscopy is expensive. So if you're not doing endoscopy and doing something else, then, you know, you're losing money in some people's mind. And so if you're doing that, you have an advantage and you have a unique skill that's really valuable to your group. So for some reason, Klaus seemed to have invited everybody who is, like, a manager of their group. So you have a bit of a skewed panel. But many of us are, you know, running our groups because we're control freaks and we don't like the job, but we don't want anybody else to do it because they'll do it wrong. So if you have, if you are kind of interested in making things run the way you want them and you don't like other people's suggestions all the time, then you do kind of gravitate toward these positions. But in your career, in a medical career, I mean, you know, 80% of it, 90% of it is the medicine part. But there are these other parts that make it unique and interesting. And pursuing those has real advantages. I can add that a little bit. I had an experience once where I went to network with one of my physicians and visiting, he was an employee with a hospital in Spartanburg, South Carolina, and I was watching colonoscopy one of his partners was doing and he turned to me and said, Chal, I'm envious of you. Why? He says, all I can do is colonoscopy. You can do these other things. So I would advise everybody to put their toe in the water in different things they're interested in. Just don't be a one-trick pony. And you don't have to get a full MMM or MBA. You can take a course in a particular area and use it for CME. You can take a, rather than doing four weeks of, two or three weeks of CME and just GI, do a leadership week, do a course somewhere else, try to develop an interest in something else so you have other avenues of things you can do. That's wonderful. Thank you very much for that. So we've got a few more questions and a few more minutes. So let's try and see if we can put it all into the last four minutes or so. So you go ahead, first of all. I have kind of like a weird question, first of all. I think everyone in the room has probably got experts at what program directors want from a trainee, but I think I struggle with figuring out how a group leader on the other side looks at a future job applicant and how is it just a recruiter who brings you names or do you, how does it happen on your end? Were you able to hear that question? We've done it both ways. So we have had headhunters send us names and that has sometimes been a good resource, but most of the folks that come to us are by word of mouth. Is that, does that answer the question I think you asked? Was there somebody else in the audience? Yep, go ahead. What are some choices or perhaps sacrifices that each of you have made to kind of maximize doing what you want to do and minimize not doing what you don't want to be doing? You mean in general? Within, yeah, your professional career. So I'm sure you know because you've heard it from two beautiful talks that there are going to be tradeoffs that you make. I think the important thing is that you and your partner are able to sit down and think carefully about what your personal values are, what guides you there and what your professional values are. You heard Joe mention that. Those are two critical pieces as you move into these next few years because you're the one that really, you are the ones that will prioritize that for yourself and there will be some tradeoffs. Make sure that you prioritize the things that are most important to you and don't get tangled up in the small stuff. For me, my husband's a musician and so our hours sometimes are overlapping. We had to be very intentional about who was taking Aaron to karate and I was able to have the flexibility in my schedule to do that. So that meant I would have Monday afternoons off, I was losing productivity. That was our decision. Those tradeoffs are mine and you have to think about what you think is most important. Let me jump in because I think you have all already made the biggest tradeoff. Okay, you've given up your 20s to advance training. For me, I still remember being in my 20s, all my buddies from college and high school were every weekend, they were climbing or skiing or biking, doing really cool things and I was on call. The good news is you've made the biggest tradeoff already and now you're at the point where you can actually collect on that investment. It's the marshmallow thing. You let the marshmallow sit on your desk and now you're going to get the second one. You have the ability now because of this education training that even if you work half time, even if you work a quarter time and took big gaps, you're still going to make a lot more money than most of your peers and then you can write the great American novel in that second half of the year. You can pursue that rock star career and also be a gastroenterologist, why not? Or you can find joy in what you're doing that you've committed to do so well. So everything is a tradeoff but again, you've made the biggest tradeoff already and now it's time to collect on that. So Dr. Nunn, we'll give you the final word. I think there's lots of ways to do things. Joe Macari gave a great talk about practice. You could write a book from that outline, what he had. In fact, the book ought to be written by him and using that outline, that would be very good. And you've got to figure out what of all those variables resonate with you, that's the culture and does the values fit with you? And you're going to find it doesn't always fit and the question is, how unhappy enough are you with it to either you take a leadership role to make the change or you're willing to move and go somewhere else? And so I used to think you'd go to a place and you'd stay there forever but that's not the case. Like I said, three to five years, you're going to start to think, am I resonating? Is the values lining up? And you've got to be willing to either jump in and make the change or just accept it or go somewhere else. Wow. Thank you. All right. So I would like to take this opportunity to thank the three panelists, Dr. Nunn, Dr. Schmidt, Dr. Shemry. Thank you for bringing all of your insights and your wisdom to that panel discussion.

panelists

career paths

practice models

gastroenterology

flexibility

opportunities