Melissa Young, MD

Throughout my career I’ve had the opportunity to be part of some very different practices. Each one has its merits and I can see how different endocrinologists might gravitate toward one or the other.

During my fellowship training I had four mentors. One was a thyroid expert, another pituitary, and two were specialists in bone and mineral metabolism. I spent a lot of time doing thyroid biopsies, provocative testing and IV bisphosphonate administration. We conducted research and held regular journal club meetings. The majority of our inpatient consults were for pituitary tumors and the occasional thyroid storm. We had maybe one consult a day, but some days none and on a bad day two. We almost never got consulted for inpatient diabetes management, and when we did, my attendings would ask me why. “They are internists. Can’t they manage DKA?”

So, it was quite a culture shock when my first job was primarily inpatient and mostly for diabetes management. I was employed by a university affiliated community hospital and was part of the faculty. We saw few outpatient patients. When I started, on average, we saw 18-20 inpatients in a day and almost exclusively for diabetes management. As the hospital expanded, so did our inpatient consult census so much, that by the time I left, it was not uncommon to have 40 or more patients in the hospital.

In the office, when we weren’t on service, we saw maybe 10-12 patients a day. New patients were seen for an hour, and follow-ups were seen for 30 minutes. As part of the faculty, we were also expected to teach residents and fellows, and we also had to see patients on the general medical service. We were encouraged, but not required, to do research and write papers, but when you are seeing 40 patients a day and teaching, research gets pushed aside. My employers were responsible not only for my salary, but for my benefits including time and funding for continuing medical education, i.e. conferences. I never had to worry about overhead, coverage or vacation time. I also had no control over staffing. It took three years to get an ultrasound machine approved and purchased. It took weeks to get something as simple as a stapler.

Visit Dr.Young's column, "Endocrine Feedback," for more articles that explore the state of private practice.

After being employed for eight years, I decided it was time to venture off on my own. I opened a solo practice which has been primarily an outpatient practice. I spend most of my day seeing patients in the office, and a large number of them (probably the majority) have diabetes.

I had originally scheduled my days so that I could attend endocrine grand rounds at a nearby teaching hospital. Now, when I say nearby, that means in the neighboring county. It didn’t take long for me to realize that it just wasn’t feasible for me to go up there during rush hour, attend grand rounds, and then drive back in time to see patients and do rounds at the hospital. So, I started going to the nearest hospital’s grand rounds. Over time, that too, unfortunately became impossible. So, I spend my days seeing 20-24 patients in the office and two to four in the hospital. I am responsible not only for my own benefits but those of my staff. I have to research and purchase whatever we need for the office-everything from computers to toilet paper. I have to find and fund medical education on my own, and since it’s hard to take time off, I often do it online. 

I know that there are many other types of practices:  Solo, small groups and multi-specialty.  Some endocrinologists choose to focus on either thyroid cancer, or pituitary disease or another niche. There are cash only practices, and concierge and hybrid practices. Each has its own nuances. There is a place for everyone. Right now, I am comfortable where I am. I continue to think about the future and what the next chapter of my career will bring. Will I stay independent?  Will I let a bigger healthcare system buy me out? Will I choose to be employed again? Maybe do inpatient only? Or, maybe start a concierge practice. We will see. Much depends on how the healthcare system changes, where my children eventually end up (they are currently in high school), and what my retirement plans become. For now, I’ve grown accustomed to life as is.

Dr. Young is an endocrinologist in Freehold, N.J.

Articles

In this month's "Endocrine Feedback" column, Dr. Melissa Young explores how her career has evolved over the years and questions what the future may hold.

For now, it’s life as is for this solo endocrinology practice

I can’t believe it’s been 10 years since I left being an employed physician to starting my own practice. It was a difficult decision and I recognize there are perks to being employed, but I am so glad I made the change when I did. However, I will say that a lot has changed since I started out 10 years ago.

In my head, one of the advantages of being a practice owner is that you get to make your own schedule and you can be flexible with your hours. That is partly true. You can create a schedule template any way you’d like. But in a busy practiceâespecially a busy solo practiceâonce that template is full of patients, taking a day or even an afternoon off requires a lot of planning.

I had originally carved out a couple of hours every week so that I could attend endocrine grand rounds at the nearest university hospital. Well, I did that for a few months then realized that driving 20-30 minutes each way was too stressful. I was never able to return to my office with enough time to prepare my charts for the day. And, when I planned my schedule, I failed to take into account the amount of time needed for getting prior authorizations or writing appeal letters (this is probably because this wasn’t as big an issue 10 years ago). Back then, there weren’t as many diabetes drugs to choose from and insurance companies weren’t standing in the way. But today, there isn’t a day that I’m not filling out a form or making a phone call to get drugs or equipment for three to four patients.

I also foolishly thought I could go paperless (or, at least paperless-adjacent). I figured I’d be cutting edge by using an EMR (this was in the early phases of EMR use). But meaningful use with its required visit summaries and EMR-generated patient education plans, actually forced me to use more paper. I created my own templates when I started and have had to revise them over the years. I had to add new medications to the history template. And, now with increasing requirements for documentation for testing and pump supplies, I have had to amend the diabetes notes template. With the advent of a lot of new technology, such as continuous glucose sensors, I’ve had to add templates for the data gathered and make some additions to documentation for the purposes of MIPS.

Staffing has changed, too, over the years. First it was just me and a receptionist. As it got busier, I hired a medical assistant. After my first year, I hired a second physician and another medical assistant. For a brief period, we had a nurse practitioner. Then, my associate left and I couldn’t keep three support staff, which meant I had to let my receptionist go (she’d been with me since the beginning). So now, I’m back to me and two medical assistants.

What will the next 10 years bring? That is to be seen. Retirement? Not any time soon.

A lot has changed over the course of 10 years in solo practice, writes Melissa Young, M.D., in this month's Endocrine Feedback column. Dr. Young describes a decade of changes for the solo endocrinology practitioner. 

Reflecting on 10 Years of Solo Practice

“At first, I was afraid, I was petrified. I kept thinking I could never live without you by my side…” so the song goes. That is sort of how I felt when my associate told me she was leaving.

At the time, she asked me not to be mad. I wasn’t. There was no point in being mad. She also said I was taking it better than she thought I would. I couldn’t be emotional at that point. I couldn’t be upset with her, nor could I wallow in self-pity. My mind immediately turned to the task at hand. How do I make this transition manageable? 

Now, I find myself well into month two of solo practice. The office has been incredibly busy and the schedule is more than full. I see a few more patients each day. I have had to stay later than usual in order to respond to phone calls and paperwork, but I have learned to delegate more and now, my staff makes some of the calls. It really hasn’t been as bad as I thought it would be. With fewer patients and slightly fewer expenses, there is less to supervise (but I have discovered that I probably should have been more diligent with the supervision of documentation). 

I do wish that people would stop talking to me as if I was recently widowed or as if I was a survivor of a horrible tragedy. “Hey, how are you holding up?” “Are you doing OK?” “It must be really hard for you right now.” I really and truly am doing OK and no, I am not looking for another physician to join the practice right now. “But you don’t want to work 365 days a year! You’ll burn out!”  I know, but I have someone to cover for me if I do decide to go away, regardless, I can’t right now. I have kids in school and they usually have activities on the weekends, so it’s not like I’d be jet-setting if I had a partner. The truth is I rarely traveled when I did have an associate. 

My biller is going to look at our current payor contracts to determine if some should be dropped.  Since I am no longer taking new patients (except for hospital patients who follow-up), I figure that over the years, I’ll lose some patients by attrition anyway. It seems as if each week a patient tells me that they are leaving New Jersey for a warmer and less expensive place to live. Maybe then I can start cutting back on hours.

in Endocrinology Network tell me they wouldn’t do it any other way. Some have been in solo practice for 10-15 years. I am hoping that I can continue working as I am for a few more years. Until then, as the song says:  “I will survive.”

“I will survive.” A solo practitioner’s story.

To certify or not to certify, that is the question. There has been much discussion about board certification. It is expensive and time consuming. There is no evidence that it improves patient care. Changes have been made and more are to come, I’m sure. And yet, the question often comes up in my discussions with colleagues. Should we recertify? Should we get additional certifications?

There was a time I would have said yes on both counts. Of course, back then, someone else (my employer) was footing the bill for the necessary CME credits and the fees. Now that I am in private practice, I have to decide whether the expense will translate into better reimbursement and better patient care. 

For now, I am still planning on recertifying in endocrinology. While I do not believe it improves patient care, I think it still matters to payors and patients if I am officially board-certified. I just wish that my state-required 50 hours a year of CME credits would suffice as proof that I am up-to-date in medical education. I have not yet fully decided if I am taking the 10-year assessment or the every two-year assessment, although I am leaning towards the latter.

I have recently decided to no longer recertify in ECNU. The cost of the required CME and the cost of maintaining the equipment coupled with the decrease in reimbursement is making performing ultrasounds in-house a financial losing matter. In addition, the approved CME lectures are often far away, are repetitious and would require me to cancel office hours. There are no online CME opportunities. There is actually a thyroid cancer conference in Boston that I may be able to attend, but it is not ECNU approved. At the moment, only one of my payors requires ECNU certification, and it also requires AIUM certification which I do not have. As such, I have not been performing ultrasounds on those patients, unless they are willing to pay out of pocket.  Some are, because it actually costs them more to have it done in radiology.  So my current plan is to allow my certification to expire and to continue to perform ultrasounds on patients whose insurance will allow it and on those who are willing to pay out of pocket. As one colleague put it, I was doing ultrasounds for 10 years before ECNU was even a thing.  That experience is not enhanced by taking a test and paying a fee.

One colleague recently posed the question of whether it is worth it to get certified in obesity management if she is going to do that part-time. Personally, I don’t see the benefit.  One can always attend the conference and get the necessary education, but unless you intend to use that certification to gain more patients, I don’t see the utility of taking another test or paying more fees.  But then again, my patient panel is full, so there is little benefit to me. 

So, for me, at least, the plan is to cave to ABIMs requirements and recertify in endocrinology (I am letting my certification in internal medicine expire), to allow my ECNU certification to expire and to avoid getting tangled up in any additional specific-CME-requiring, exam-necessitating, time-consuming certifications.  I’ve got patients to see.

Dr. Young is an endocrinologist in Freehold, N.J.

To certify or not to certify, that is the question. There is no evidence that it improves patient care. And yet, the question often comes up in my discussions with colleagues:  Should we recertify? 

Author | Melissa Young, MD

Articles

For now, it’s life as is for this solo endocrinology practice

Reflecting on 10 Years of Solo Practice

“I will survive.” A solo practitioner’s story.

Board Certification in Endocrinology