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Family medicine offers a wide array of practice settings. This guide provides an overview of the most common settings to help you determine the perfect practice opportunity for you.

As a family physician, you will have the flexibility to shape your career to take advantage of your knowledge, skills and unique interests. In addition to direct patient care, many opportunities exist in academia, research, public health and administrative careers, to name just a few exciting possibilities.

Academia/Residency Program

Community Clinics & Federally Qualified Health Centers

Group Practice

HMO/Permanente Medical Group

State and Government-Sponsored Practice

Solo Practice

 

Solo Practice

·       Control and autonomy

·       Responsibility for start-up and overhead costs

·       Ability to set own schedule

·       Control over one’s health insurance

·       Significant administrative and managerial responsibilities

 

Christopher Flores, MD | Palm Desert, CA

Why did you choose this practice setting and why is it a good fit for you?

I choose to practice as a solo family physician in private practice because I like being in control of my level of service and medical quality. After finishing residency, I “tried out” (for 10+ years) various types of employment and hospital-based practices, including academic medicine for five years, but I was continually frustrated because I was never fully in control of my schedule, duties, staff and office management. It seemed as if I was constantly being asked to see more patients, supervise more mid-level and ancillary staff and manage a larger panel. The absurd thing was that as the primary care provider and physician leader, I was held accountable for my productivity, medical quality, chart documentation and patient satisfaction. Now in my own small “micro-practice,” following the Ideal Medical Practice (IMP) low-overhead model, I am in full control of my practice and I have never been happier. I see the whole spectrum of family medicine, with hospital work and house calls, and consider myself a traditional, old-fashioned doctor. New physicians who want more information about this style of practice should review Gordon Moore’s articles in Family Practice Management.

 

Group Practice

·       Established patient base

·       Potential income division conflicts

·       Schedule/coverage flexibility

·       Assistance from other physicians in the office

·       Partnership with other physicians

·       Potential ownership opportunities

 

Option 1: Small Group

Craig Endo, MD | Grace Medical Group of the Valley – Pomona, CA

Why did you choose this practice setting and why is it a good fit for you?

My wife and I did our residencies in our home town, so we were very familiar with the physician community and the local hospitals. Staying in our community allowed us to truly have a full spectrum family practice.

Although hospitalist programs in our area have swallowed a large percentage of our admissions, we still do both inpatient and outpatient pediatric and adult medicine. I have had to relinquish my OB privileges due to lower volume and increasing malpractice rates, but my wife still does about 50 deliveries a year and often has to turn away OB patients not to exceed her delivery cap imposed by her malpractice insurance carrier. To get us started, Pomona Valley Hospital provided financial support via an income guarantee for the first two years.

I think we enjoy the autonomy of having our own office the most. We are open Monday through Friday and are located about three miles from home. We knew we did not want to contend with Los Angeles traffic and commute to our jobs. We have more control over our schedules and the types of patients we see, and making changes in the office tends to be easier than wading through a whole bureaucracy. I also enjoy having a greater decision on whom we work with as a practice. After four years of practice, we formed a partnership with family members and were fortunate enough to purchase a medical office building. We have tried to recruit like-minded health care providers because we try to address both the physical and spiritual needs of our patients. Our office encompasses most of the first floor and we lease out the other suites. We saw this as our best bet to help contain office overhead expenses over the long term.

 

Option 2: Multi-Specialty Group

Steve Green, MD | Sharp Rees-Stealy Medical Group – San Diego, CA

Why did you choose this practice setting and why is it a good fit for you?

I’ve practiced with Sharp Rees-Stealy Medical Group since completing residency in 1988. We are a large multi-specialty medical group with 465 physicians and 21 offices throughout San Diego County. It was a challenge making a decision between various practice types. Ultimately I made my decision based on the whether the physicians seemed to be enjoying their practice, and whether the practice seemed stable and able to do well with the changes coming in health care. I chose Sharp Rees-Stealy because they are focused on high quality care, while at the same time, are efficient and convenient.

What do you like about working in this practice setting?

One of the biggest advantages of working at SRSMG is there is a large team supporting the physicians. Besides sharing call, we have a nurse line after hours and weekends to take calls. We have our own hospital team, so we can focus on the office without needing to round or admit patients after hours. Our group is large enough so that most specialties and studies are available internally. This means I seldom need to ask for approval for consultation or getting tests done. We have care management nurses at the office to help with complex patients as well as a large quality department helping us to provide better care and excel at quality metrics, which are becoming increasingly important as the emphasis is shifting from volume to value. Working in a large group does mean physicians need to accept some degree of standardization of how we practice. Fortunately we are physician-run, meaning the people on the committees who decide how we do things are our physicians themselves.

What unique opportunities or challenges does a multi-specialty group offer?

When I started with SRSMG, I had little interest in leadership or management. Within a few years I decided I wanted to contribute more and help shape how things were done. For 20 years I was chair of the family medicine department, and for 10 of those, I chaired our council of department chairs. I’ve been fortunate in the group works to educate leaders from within its ranks and helps with training in these area. Recently, I was chosen to be our new medical director when our current medical director retires in December, so after 26 years I won’t have my own practice, but will be helping with the practices of all the physicians. It’s a big change for me, but I’m really looking forward to the challenge.

What advice would you give to a resident seeking to join this type of practice?

My best advice to a resident choosing a practice is to speak to many people within the practice. Ask themselves whether they can see practicing in that setting, and how well poised the practice seems for the changes which will continue to come in health care.

 

Community Clinics & Federally Qualified Health Centers (FQHC)

·       Work with underserved population

·       Opportunity to give back to the community

·       Ability to partner with other clinics/hospitals

·       May depend on federal and/or public funding

 

Mark Dressner, MD | The Children’s Clinic - Long Beach, CA

Why did you choose this practice setting and why is it a good fit for you?

I practice in Long Beach in a Federally Qualified Health Center (FQHC) called The Children's Clinic. (This is somewhat of a misnomer because there is a thriving section for adults only, which is where I work.)  I have been there for the last 5 years working 32 hours a week after leaving 15 years in academic medicine working 50 to 60 hours a week. With my son starting kindergarten, it became important to me to work part time only in order to be more involved in his school and after school life.

Upon leaving academics I had several opportunities. I could not decide which to choose, so I decided to get back in touch with why I wanted to be a doctor and the essay I wrote for med school. I found that working with primarily Spanish-speaking new immigrants with chronic health issues clearly matched what I was writing about in my essay. Now, I speak Spanish 80 percent of my day. I believe this is a population who is very grateful for anything that I can do to help. It is also gratifying as a physician to help this new population start developing a new life in their new country.

What are some of the challenges of working in this practice setting?

I do mainly chronic care management so a lot of diabetes along with hypertension, hyperlipidemia, and asthma. Frustrations include several issues. Although I can do many different procedures, because of cost and inability to purchase supplies, I mainly do cognitive medicine. Previously, I could take off skin lesions, remove sebaceous cysts, insert IUD's, inject joints, aspirate joints, suture, apply splints, etc., but now have not been able to do any of that. Also, I would love to practice full family medicine but only the pediatricians are permitted to care for children. Obtaining consults and diagnostic tests can be frustrating with incredibly long wait times (rheumatology consults can take two to three years). 

What advice would you give to a resident seeking to join this type of practice?

If looking at a position, especially right after residency when one should ideally continue using all of their skills, I would ask the following questions:

·       Will I need interpreter services for most of my encounters?  If so, are these trained interpreters or just someone who speaks the same language?

·       Do I get to see adults and children? Do I get to do gynecology care?  OB?

·       Do I get to do different procedures? What are the ones I can do?

·       How hard is it to get medications not on formulary if needed?

·       How easy is it to get consultations? Is it even possible?

·       How far can I go with diagnostic work ups? Can I get imaging? Cardiac testing? Sleep studies? Nerve conduction/EMG? EEG's?

·       Is there an EMR and is it well functioning?

·       What is the mix of uninsured with Medi-Cal, Medicare, and other insurance?

·       Is there a hospital affiliation?  Who cares for hospitalized patients? What is the quality of these hospitalizing physicians and do they communicate with the primary care team?

·       How is pay level? Benefits? Vacation? CME? Is there loan repayment possibility (A huge plus working for FQHC!)?

If you are looking for a practice helping with the neediest, usually in a second language, providing essential but limited healthcare services to a very grateful population but with limited ability to practice the full scope of our training—then an FQHC might be the place for you. Also remember, many FQHCs experience a shortage of physicians, so more are willing to allow part-time work and arrange a schedule that fits into your needs in balancing work and family.

 

State and Government-Sponsored Practice

·       Unique experience

·       Broad scope of practice

·       Security or administrative rules may infringe on autonomy

·       Requirement to adhere to government policies and regulations

·       Public service careers often qualify for loan repayment programs

 

Option 1: Prison Health Care Services

Richard N. Gray, Jr., MD | California Correctional Health Care Services (CCHCS) - Sacramento, CA

Why did you choose this practice setting (and why is it a good fit for you)?

A prison doctor . . . me? Never! That’s what I thought, but my experience with CCHCS has been overwhelmingly positive. After 20 years of primary care (solo and small practice) I was doing my second year of urgent care when I was at a CME activity and a participant approached me saying,

“I’ve been impressed with your questions and comments and I think you should get a job with me.” No, I’ve already got a job. What do you do? “ I work for the state prisons.” 

Now I was sure I didn’t want to do that.  I had heard bad things and thought the quality of the prison doctors was inferior to those on the outside.

“No, think about it: being home evenings, weekends, and holidays . . .” Wow, I hadn’t done that in 23 years! “And you get 14 paid holidays annually . . .” If I didn’t go to work there was no revenue stream, this would be amazing!  “Plus paid vacation . . .” Diving in the Caribbean and South Pacific . . . “CME, malpractice, and a retirement plan.”

Like many of you, especially in retirement communities with a majority of patients using Medicare, I had seen overhead costs increasing and revenues decreasing. I didn’t want to be there when those two lines crossed. Also I wasn’t the best business man. So, when I paid my staff, rent, utilities, insurances, supplies, taxes, etc., and took home the rest, there wasn’t that much left to bring home.  I left medical school with $100K in debt, which took me 11 years to pay off, at which point I started putting my kids through college. Like many of my colleagues, I was going to literally die practicing; I would never be able to retire.

Here was something new. And the income was half-again what I was getting in the urgent care, which was half-again what I had been making doing primary care. I had loved my practice, but I hated the business. Here was the practice without worrying about the business, and the pay and benefits, for the amount of responsibility required, far outpacing anything I had seen before. I only wished I had started five years earlier.

What do you like about working in this practice setting?

I am not a line physician, but am in a middle management position, near Sacramento, where my breadth of experience prepared me well for the breadth of responsibilities—mentoring, training, teaching, writing evaluations and reports, assisting with prison physician relief on-site or by telemedicine, serving on committees and debating the standard of care with other physicians as we evaluate the care we see provided to our patients. I enjoy the people I get to work with, and I have fun every day! Yes, much of my time is spent in a cubicle, in front of a computer monitor, but I have my favorite music playing all the time. I am unable to think of any other disadvantage to this practice setting. It’s clean, and I’m not washing my hands all the time.

I have recruited one resident to CCHCS and she has been very happy with this choice, providing her with the opportunity to be of service to an underserved population, yet having all the benefits I just mentioned, getting the same pay I do, and the security of a state government job. Things have changed, and most of the poor-quality doctors have been dealt with. Now we hire only good-quality, board-certified internists and family physicians. We are now converting to an electronic medical record and have other systemic issues to overcome, but that is part of the fun of my job—recognizing problems and finding solutions.

 

Option 2: Military Health System

Matthew Hahn, MD | Yongsan US Military Base Brian Allgood Army Community Hospital - Seoul, South Korea

Why did you choose this practice setting (and why is it a good fit for you)? 

I'm currently practicing in Seoul, South Korea on the US Military base called Yongsan at the 121st Community Support Hospital, or Brian Allgood Army Community Hospital.  I'm employed by Laulima Government Solutions, a government contractor, who has a contract with the US Army Medical Research Institute of Infectious Diseases to support a new Smallpox Vaccine Trial.

What do you like about working in this practice setting?

My presence in Korea is actually the result of my wife's occupation as a Foreign Service officer in the US Department of State. We got here in May 2014, arriving from Tijuana, Mexico, where she had previously been posted. During our time there, I crossed the border and worked at Kaiser Permanente in San Diego.

Working in Korea for a Korean business as a physician requires clearing multiple hurdles related to medical regulations and certifications and most importantly, requires taking a Korean medical licensing exam which is administered in Korean. So, working on the "local economy" was not an option for me.

Instead, I had to explore options at the two major US presences in Korea—the US Embassy and the US Military. Fortunately, the best opportunity that arose was working on a unique research trial that has need for a family physician with a broad set of skills in interpreting tests, evaluating symptoms and managing a patient population.

My position on this clinical research team is unique in that I am serving in a leadership capacity in a way that I hadn't worked previously. We have a team including nurses, lab technicians, data entry specialists and recruiters, which is a very different operation than the traditional clinic setting that I was trained in and worked in since graduating from residency in 2011. I enjoy new challenges and developing new sets of skills that might be applicable to wherever I might end up. 

Are there any disadvantages to working in this practice setting, and if so, what are they?

The major disadvantage to working on this research project is that I'm not seeing patients in a traditional clinical setting and caring for the broad diversity of health issues that a family doctor might get normally get exposed to. Consequently, I'm seeking out volunteering opportunities to maintain those sets of clinical skills. 

How does this practice setting fit into your personal lifestyle?

The research trial is a normal-work-hour type of job, which is outstanding for me in that I can engage in the community through volunteer work and explore the unique cultural learning opportunity that I have been given by living here. I'm studying Korean and traveling as much I can to gain a greater appreciation for the country and the region.

What advice would you give to a resident seeking to join this type of practice?

My current position is obviously a unique opportunity and while this specific position may not be available in the future, it is a testament to opportunities opening up around the world in unique locations. Timing does play a huge role in finding that right job at the right time, but it also takes a person willing to explore and to look at non-traditional paths. 

 

HMO/Permanente Medical Group

·       Established patient base

·       No overhead costs

·       In network/internal physician referrals

·       Coverage and schedule flexibility

·       Limited administrative responsibilities

 

Michelle Quiogue, MD | Kaiser Permanente, Kern County - Bakersfield, CA

Why did you choose this practice setting (and why is it a good fit for you)? 

I trained at KP LAMC. I moved to Kern County to fulfill the National Health Service Corps obligation. I stayed in Kern County after I completed my obligation because I wanted to return to KP and the Kern County leadership made me feel at home. I saw the potential for my personal growth as well as opportunities for leadership and administration. Also, I share the ideal of the Thrive brand as a personal aspiration.

What do you like about working in this practice setting?

The integrated PCMH model is superior for population care management and ancillary support (integrated pharmacy, health education, RN case management, etc). High standards are set for quality measures and evidenced based clinical practice guidelines. I have a patient panel that is a good mix of ages and medical conditions. I see about 20% Spanish speaking patients. I also work on the KP mobile health clinic and volunteer in the community. As Kern County Diversity Physician Champion, I work on improving health equity and I get to lead the Hippocrates Circle Program which is a Southern California KP mentoring program for junior high students interested in medical careers.

Are there any disadvantages to working in this practice setting, and if so, what are they?

In a group practice, there is less autonomy.

How does this practice setting fit into your personal lifestyle?

I do not work on evenings or weekends. I don't worry about coverage for my patients while I'm on vacation. More importantly, this practice fits with my personal values.

What advice would you give to a resident seeking to join this type of practice?

It's important to find an integrated system that encourages and demands interaction with physician colleagues across departments. Relationships with leadership and potential for personal growth are as important as work hours. Also, KP provides unmatched retirement benefits.

 

Nathan Hitzeman | Sutter Medical Group – Sacramento, CA

Why did you choose this practice setting (and why is it a good fit for you)?

I did my residency at same location. It was comfortable to stay on. I was used to the Sutter system, and liked the collegial feel of the program.

What do you like about working in this practice setting?

It is a very friendly and supportive place to work. Family physicians have a strong presence within the medical group.

Are there any disadvantages to working in this practice setting, and if so, what are they?

Whenever you work in a larger group, you can't do whatever it is you want. You have to check with the organization before implementing new workflows or services. Having said that, the organization takes care of a lot of logistical stuff that would eat up a small practice doc's time (like paying the rent, hiring staff, dealing with insurance contracts, and cleaning the toilets at the end of the day).

How does this practice setting fit into your personal lifestyle?

In a larger practice, you have colleagues to watch your patient panel when you are away or off-duty. It's nice to be able to turn off my pager on vacation. In a residency training program, it is wonderful to be able to continue teaching residents and medical students. It keeps medicine exciting for me.

What advice would you give to a resident seeking to join this type of practice?

There are many similarities among health organizations, but each one has their own vibe or energy. You have to try to check out a few places to see what vibe meshes with your own. It's not uncommon for residents to graduate and stay within their health system. It's like a long engagement, and when you finally tie the knot, that's ok.

 

Academia/Residency Program

·       Opportunities to teach and/or mentor

·       Opportunity to mold new generation of family physicians

·       Flexible clinical responsibilities

·       Opportunities to be involved in various projects

·       Innovative research and clinical work

 

Lauren Simon, MD, MPH | Loma Linda University – Loma Linda, CA

Where do you practice (city, name of practice)?

I practice in Loma Linda, California in my faculty practice site at Loma Linda University Health in the Department of Family Medicine. I teach family medicine residents, residents in the combined family medicine and preventive medicine residency program, and medical students.

Additionally, I teach residents at our urban residency clinic site SACHS (Social Action Community Health System) in San Bernardino which is a Federally Qualified Health Center (FQHC) look-alike clinic just a few minutes away from my faculty clinic. Our family medicine residency clinic is part of the not-for-profit religious healthcare corporation called Loma Linda-Inland Empire Consortium for Healthcare Education (LLIECHE).

Why did you choose this practice setting (and why is it a good fit for you)?

By working in an academic setting it challenges me to stay up to date on medical advances as I teach the residents and students. Together we encourage our patients to achieve optimal health. This setting also affords the opportunity to interact with our multidisciplinary specialty colleagues. During residency, I found I really enjoyed teaching, so I chose to go into academic medicine. As part of a large health system I have access to academic resources, such as reference librarians and statisticians, which are useful when I prepare publications and presentations. It is also fun to mentor residents and students on clinical research topics.

Loma Linda is a suburban clinic where my colleagues and I see a wide variety of patients. In our practice group, some of the clinicians do solely outpatient clinic and others do a mixture of inpatient and outpatient care. I care for patients of all ages, do full spectrum care and lots of office procedures, and navigate multiple types of insurance systems. On our teaching faculty, we divide the week such that some of us whose primary practice site is at Loma Linda precept at the residents’ clinic in San Bernardino either half days or some full days per week and other faculty have their own primary practice site at the same location as the residents.

What do you like about working in this practice setting?

I really enjoy working in a group setting with colleagues who share my excitement about keeping current with medical advances and who each have their own area of special interest in Family Medicine. Within our group we always seem to have someone to bounce ideas off of about medical management and share personal experiences about great locales, activities, and adventures to maintain work-life balance. We value our families and working in this type of group practice setting allows us share our workload and still be active parents. Teaching residents and students is energizing and also adds a wonderful variety to the day!

Are there any disadvantages to working in this practice setting, and if so, what are they?

In an academic setting, there is always more work that can be done and more teaching or research to do or papers to write, so one has to maintain some personal boundaries or risk burnout. However, having “more work to do” is not restricted just to an academic setting—it is the reality of being a physician. Navigating multiple types of insurance systems (rather than working in a single-payer practice model) in our large academic health system is sometimes challenging especially due to the variety of medication formularies and referral procedures that we need to be familiar with. The financial remuneration in our family medicine faculty practice is less than those in surrounding private practice. Time off needs to be scheduled way in advance since there are many people and schedules that will be affected by a faculty members’ absence.

How does this practice setting fit into your personal lifestyle?

Regarding my personal lifestyle, I enjoy learning, teaching, spending time with family and friends, exercising, and being active in the community. I also like having variety in my day and the opportunity to interact with many people. Working in academic family medicine promotes these activities that I enjoy and has lifelong learning incorporated into my work on a daily basis.

What advice would you give to a resident seeking to join this type of practice?

Listen to your instincts. If you really enjoy teaching others as a resident and like continued learning opportunities incorporated in your day, then consider a position in an academic setting. Academic medicine is truly emotionally rewarding and inspirational!