Private Practice: The Good and the Bad

In this series premiere of Practice Matters, Payal Kohli, MD, founder of Cherry Creek Heart in Denver, and the 9News/Daily Blast Live medical expert, discusses the pros and cons of owning a private practice, and what questions you should ask yourself before starting.

The following is a transcript of her remarks:

Hello everyone, and welcome to "Practice Matters." My name is Dr. Payal Kohli. I'm a non-invasive and preventive cardiologist, and I run my own private practice, Cherry Creek Heart, which I started in 2020 in Denver, Colorado.

Today I'm going to talk to you about the benefits and the challenges of owning a private practice and really what goes into the decision to start your own practice, which was probably the biggest decision of my entire medical career. So, let's get started.

The most common question I get is: what made me go into private practice? When I finished my fellowship, I really had two roads in front of me, like most of us think we do. One was hospital employment and the other was academics. Many fellows and residents who finished training feel that they have to choose one of these two roads.

For me, of course, employment was the easier path because everything's all set up for you. It's almost like continuing your fellowship. You just show up, you do the work, you see your patients, collect your paycheck, and you go home.

But what you don't understand is that you give up a lot when you pick that employment road. It was only after a few years of being employed that I started to realize what I was giving up by being employed and not being my own boss.

You know, it's funny, when I wasn't in private practice, I really thought that private practice was a mountain that I could never climb. I thought it was too expensive, too time consuming, I thought it meant that I would really have to work day and night and couldn't have a work-life balance. Most importantly, I worried. I worried that I needed to have a strong business background, that I needed to be somebody who either had formal business training or accounting training in order to run a successful private practice.

But really over time, as I spent time exploring and researching private practice, I realized it's not a mountain that I can't climb. In fact, private practice can really become anything that you want it to become, and that's really the beauty of it. Private practice is not one-size-fits-all. It's actually a way to create the career that you want to have. It's a way to create medicine the way that you want to practice it.

There are so many benefits to having a private practice, but there are really three that I want to focus on:

• The financial goals and benefits

• The personalized medicine

• The control and autonomy

Let's start with the financial goals and benefits financially. Now, private practice allows you to have an extremely steep financial trajectory, whereas in an employed model, your trajectory looks more like this [flat] because you may get a sign-on bonus and then you're sort of getting the same salary with a little bit of a raise. But in private practice, it can look like this [steep incline] depending on what type of service lines you want to create, what you want to do, and how you want to set up your practice. It really allows you to make a lot of money and to do it in a way that aligns with your financial goals and objectives.

The second benefit is the opportunity to really spend time with patients and practice medicine with your own personality, focusing on the things that are important to you. Whereas in an employment model, a lot of it is you're told only 15-minute appointments for follow-ups, 30 minutes for news [new patients], these are the types of patients you'll see, this is the pair mix.

In private practice, it's a blank slate. You can really decide how you want your schedule to look, how much time you want with your patients, what types of patients you want to focus on, and you can take the chance to go beyond just the medicine and actually develop those relationships with patients.

Now that I've been in practice for a few years, it's so fulfilling to see my patients coming back and see their life progress; [they're] getting married, they're having kids, and it's just an incredibly rewarding experience.

Then the final benefit is the control and the autonomy, which I think is tremendous, and being your own boss. That's really something I don't think I could ever look back on in those other two roads of employment or academic medicine, because private practice allows you to have this immense amount of control, not just on your schedule, on your day-to-day life, but on every aspect of how we practice medicine. The staff that you have, the culture that you create, the types of patients that you see, whether you're working 4 days a week, 5 days a week, weekends, not working weekends, if you need to have time off -- really so many different things that you have control over.

You even forget sometimes how many things you gave up when you went into that employment model or into that academic medicine that private practice really puts back in your hands. It allows you as the captain of the team to be in charge of all of the decisions of how your patients are seen and what sorts of things you're doing in your office.

No position is without its challenges. As much as the benefits of private practice are tremendous, you have to be aware of the challenges as well so that you're going into this with your eyes wide open. I'm going to talk about a few different challenges.

The first is that private practice is really like having a baby. Just like the decision to have a baby is obviously a life-changing decision, but so rewarding, private practice is the same. It's a commitment that you make, and when the baby is young, you're having those sleepless nights, you're working around the clock, staying up all night, working weekends and working nights, and then when they become a teenager you can really allow them to spread their wings and fly and you get some of your own life back.

I would say private practice is very much the same. In its infancy when it's first starting out, it's labor intensive. You are going to be working nights and weekends; you are going to be spending a lot of time making a lot of those administrative decisions after hours so that you can see your patients during the day. But really once that practice becomes a little bit mature -- and it doesn't take long for it to mature, it doesn't take as long as it does for a teenager -- it's only a few years.

I'm only about 3 years into my private practice, but I already feel like there's a tremendous amount of freedom. Now it's a lot more in that autopilot mode where, yes, I'm there during the day, I'm making clinical decisions, I'm making administrative decisions, but I can get the right team around me and really start to delegate some work to others and get some of my evenings and weekends back.

The second challenge of private practice is that we're so good at medicine, we've learned medicine, we've been trained for it all of our careers, we know how to do it, but when it comes to running a business, that's a bit of a black box. It's not something that we've been told about; it's not something we've been trained on. So we do have to sort of hit the ground running, really learn that new skill set, whether it comes to budgeting, accounting, purchasing, practice management, how to negotiate contracts with insurance companies, all of the different things that go into running a private practice. We have to learn on the fly.

I like to say that the first few years of a private practice are kind of like your medical internship, but I like to call it a "practice internship" or a "practice residency," because you're really learning on the job.

The final challenge of private practice is that the buck always stops with you. As the founder, the medical director, the leader, of this private practice, if anything goes wrong from A to Z, whether it's a patient's clinical care, whether it's an administrative issue, whether it's an HR issue, anything at all, the responsibility falls on your shoulders. You have to be willing to accept that responsibility.

But I would say in exchange for that responsibility, you do get all of those benefits that we discussed.

So if you're considering going into private practice, I want to congratulate and applaud you and I want to encourage you, because it is that mountain that you can climb and it can really change your career for the better.

But some things to think about before you make that decision are: whether or not you're in a financial position where you could spend a few months or perhaps even a year or two without necessarily drawing an income, if you're in a financial position where you may actually be able to invest some capital to get the practice started, are you going to go solo, are you going to have a partner? This will be important not just, of course, for the decisions that you make in the practice, but also for coverage of your patients.

And then, of course, keep in mind that starting this practice is like having that baby. It's not a short-term decision. It's definitely a 5- or 10-year goal when you're thinking about how this practice plays out.

I want to thank you so much for watching "Practice Matters" today, and I really encourage you to join me on this journey, to follow along with us as we talk about all the different topics that relate to private practice, how to start it, and how you can make this dream a reality for you.

Join us next time as we talk about setting realistic expectations for yourself and your practice in the first few years.

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