By Emily Margosian, assistant editor
For the average dermatologist 20 years ago, starting a career also meant starting your own practice. Today, however, employed physicians outnumber their independent counterparts. According to AMA survey data, last year nearly half of practicing physicians — 47.4% — were employed, tipping the scales away from practice ownership. While private practice remains a strong and attractive practice option for many dermatologists, some may be choosing employed practice options — such as a larger group, health system, hospital, or academic institution — to avoid the administrative aspects of owning and managing a practice.
To get a first-hand sense of this shift, this month Dermatology World interviewed six dermatologists from different practice settings about their experiences as employed physicians, why they chose their practice model, and what they want other dermatologists to know. Want help making your own practice model choice? Visit the Evaluating Practice Models section of AAD.org.
Practice type: Managed Care Organization
Dermatologist: Arun Pathy, MD, dermatologist at Colorado Permanente Medical Group, Centennial, Colorado
Why did you choose to work for a managed care organization?
Dr. Pathy: I started out my career working in a fee-for-service private practice dermatology group. I was there for 10 years, and honestly the reason for the switch was a move unrelated to the practice itself. However, one of the things I noticed during my time in the private practice model was that the administrative burden of working in that setting was increasing steadily. So, when I had the opportunity to switch to a completely different practice model, it seemed attractive at the time.
What do you like most about your current practice model?
Dr. Pathy: Virtually all of my workday consists of direct, face-to-face patient care. I have minimal administrative responsibilities. It’s all patient care. I don’t have to worry about things like staff management, or marketing my practice, or maintaining compliance with the ever-expanding myriad of regulations — all of that is done behind the scenes by the organization. It leaves me free to focus on patient care.
Are there any drawbacks to practicing as part of a managed care organization? What do you find challenging about it at times?
Dr. Pathy: Occasionally, I’ll miss having that direct control over the hiring or firing of staff that I work with on a daily basis. It’s a double-edged sword; I don’t have to deal with the headaches of staffing issues, but I also miss having some direct control over who is on my patient care team. The other one minor downside that I find with working in a managed care organization is that the formulary of medications that we’re able to prescribe is somewhat restricted. Especially with some of the newer medications coming on the market, it might take some time before we’re able to prescribe them to our patients.
What might a young physician looking into your practice model want to consider?
Dr. Pathy: I think you’d want to work on honing your clinical skills and clinical efficiency, and you can really do that in this type of setting as an employee physician. You don’t have to worry about the distraction of day-to-day practice management and other administrative burdens.
What might other dermatologists find surprising about practicing as part of a managed care organization?
Dr. Pathy: I was a bit leery about becoming an employee of a managed care organization, because my perception was that there would be significant loss of autonomy and that non-clinicians would be dictating how I practice medicine. I came into the situation with those trepidations, but what I’ve found is the exact opposite of that. In most of these organizations, the administration isn’t really interested in micromanaging your clinical practice. In some ways, you have more autonomy than when you’re in a private group partnership setting, where the financial interests of the group may conflict with your ideas of providing good medical care.
How does your current practice model affect your work-life balance?
Dr. Pathy: It’s been much better as an employee physician because I am freed from the burdens of practice management. Again, my workday consists of seeing my patients and then I’m done. That allows me to have a lot more time and energy to devote to my family and my outside interests. It’s been a big difference compared to being in a private group.
What is the most rewarding part of your job?
Dr. Pathy: As is the case for most dermatologists and most physicians in general, I derive the most joy from having a meaningful positive impact on the lives of my patients. As an employee physician I get the chance to experience this daily, and at the same time I’m not burdened by all the hassles of being a small-business owner.
Practice type: Multispecialty
Dermatologist: Alix Charles, MD, dermatologist at DuPage Medical Group, Hinsdale, Illinois
Why did you choose multispecialty practice?
Dr. Charles: Before I joined DuPage Medical Group 12 years ago, I was part of a private practice with just one other dermatologist. I really value the collegiality I have with my colleagues in different specialties and the ease with which I can coordinate a patient’s care when compared to my previous job. I also enjoy a higher level of compensation as well as equity ownership, neither of which was available to me in my previous practice setting. In a physician-led model like ours, I am also directly engaged in problem-solving for achieving greater quality and bending the cost curve.
What do you like most about multispecialty practice?
Dr. Charles: Several things. Our integrated, multidisciplinary approach fosters frequent cross-specialty communication among our providers, and our group’s single EHR system allows for efficient and timely exchange of patient information. From an administrative standpoint, I have clinical autonomy, and our operational partner provides practice management support that reduces my administrative burden and allows me to spend more time focusing on patients.
As a specialist, being part of a multispecialty group also gives me a steady stream of referrals — we are a well-balanced group; roughly half of our physicians are primary care, and half are specialists. Affiliation with DuPage Medical also gives me access to the latest and greatest technologies when they come to market.
Are there any drawbacks to multispecialty practice? What do you find challenging about it at times?
Dr. Charles: I have few complaints. While some may argue that single specialty groups offer greater clinical autonomy, it is still possible to have clinical autonomy in a multispecialty group, along with many other benefits such as care integration, a single EHR system, built-in referrals, less administrative burden, et cetera. For me personally, having access to these benefits isn’t something I would want to miss out on.
What might a young physician looking into multispecialty practice want to consider?
Dr. Charles: Find a physician-led model that’s deferential to younger physicians — they’re the lifeblood of our organization moving forward. An independent, multispecialty group can offer stability, integrated culture, and practice management support without compromising clinical autonomy and work-life balance. It’s important to consider factors like how the group is structured, what the organization’s growth plan is, and what level of administrative and practice support is provided.
What might other dermatologists find surprising about multispecialty practice?
Dr. Charles: Many entrepreneurial-minded dermatologists may think that solo or small practice is the only way to achieve clinical autonomy, but you can still get that with the right multispecialty group.
How does your current practice model affect your work-life balance?
Dr. Charles: I feel like I have great work-life balance! I don’t believe that I work more or less than any other full-time dermatologist. I have partners with whom I can share calls and discuss interesting or difficult cases, so I sleep well at night.
What is the most rewarding part of your job?
Dr. Charles: Feeling like I make a real difference in people’s quality of life every single day. Skin disease and concerns can create a lot of anxiety, embarrassment, and physical discomfort for patients. I find it very gratifying to be able to help clear up someone’s skin problems and improve their life. I also really value the diversity of people and viewpoints that my specialty exposes me to. I learn so much about the world and people in general through interactions with my patients and feel so fortunate to be a part of this vibrant specialty.
Practice type: Veterans Affairs
Dermatologist: Elma Baron, MD, chief of dermatology, VA Medical Center, Cleveland
Why did you choose VA dermatology practice?
Dr. Baron: The VA has always been a part of my career. I first started part time before eventually transitioning to full time. The system as a whole is a healthy, growing, dynamic environment, and patient care is cohesive and coordinated within the system. Being a VA dermatologist allows me to serve those who served, and in that sense alone, it’s not difficult to see the significance of what I’m doing. Significance is an important factor in career satisfaction.
What do you like most about working for the VA?
Dr. Baron: The environment is both challenging and fulfilling. If you’re looking for something easy, the VA is not for you, but the institution is very supportive, and teamwork is highly feasible when you find people who are as committed as you are to doing a good job.
Are there any drawbacks to VA practice? What do you find challenging about it at times?
Dr. Baron: It can feel overwhelming to learn and master the processes and procedures within the institution, and can be particularly challenging to navigate when you are in a leadership position, as I am. If you are a physician who is there for purely clinical practice, then you may not need to interact with so many administrative offices, which can be at times inefficient depending on leadership and management at the office level.
What might a young physician looking into VA dermatology practice want to consider?
Dr. Baron: Consider first if you are ready to give up pediatric and cosmetic dermatology, as you won’t have these if you are employed full time at the VA. However, if you are looking for purely adult medical and surgical dermatology, you will never be bored. Your salary will be less than your peers in private practice but take a good look at your pay slip and see the benefits the VA provides — better than what you get in academia and private practice, at least in my local experience.
What might other dermatologists find surprising about working for the VA?
Dr. Baron: Outside dermatologists may actually be surprised that VA doctors have a great work-life balance, and that most health care providers within the VA are very collaborative. Most doctors I know — whether dermatologists or in another specialty — are quite effective at what they do and happy to be working at the VA.
How does your current practice model affect your work-life balance?
Dr. Baron: Overall, my VA practice makes me less prone to burnout. Productivity is still important, and they (i.e., leadership) do check regularly, but goals are not unreasonable. My work schedule is well defined, and the VA is also generous with vacation days and annual leave. I don’t typically use all of mine because of the volume of patients that need to be seen, but I do get to take time off regularly. It makes me a better person and a better physician.
What is the most rewarding part of your job?
Dr. Baron: As Chief of Service, I get to figure out ways to improve patient access to dermatology, and the VA welcomes creative ideas such as telehealth, video-based encounters, etc. The VA gives me freedom to innovate as long as it benefits the veterans.
Practice type: Large group practice (non-private equity-backed)
Dermatologist: Jeremy Moss, MD, PhD, dermatologist at Brookside Dermatology Associates/Integrated Dermatology of Bridgeport (IDG), Bridgeport, Connecticut
Why did you choose large group practice?
Dr. Moss: During my years of owning a small practice I found the administrative aspects of the business to be overly burdensome, so I explored various options to relieve the burden. I ultimately settled on joining a large group practice.
What do you like most about your current practice model?
Dr. Moss: In truth, it was exactly what I was looking for. As I said, I was not enjoying the administrative tasks associated with owning a practice. I was very happy to give those up and let the group, IDG, perform them. They now handle human resources, arbitrating employee disputes, security, reimbursement, navigating new payment models, medical records, HIPAA, OSHA — I’m sure there are a number more. This has allowed me to focus solely on my clinical responsibilities and providing the highest quality care to my patients.
Are there any drawbacks to practicing as part of a large dermatology group? What do you find challenging about it at times?
Dr. Moss: As with any significant life decision, when I was trying to determine if a change was what I really wanted, I researched the risks and benefits of different practice models in the field of dermatology. I learned about problems other dermatologists were reporting when they joined larger groups. So far, I am not able to report any such problems. I was specifically worried about a loss of autonomy in my medical decision making. I can categorically say that this has not happened in the group I joined. My style of practice has been virtually unchanged since joining IDG, and I feel I have full independence in my ability to make proper medical decisions regarding the care of my patients. I recognize that not all groups manage their physician employees in the same manner and wouldn’t want to invalidate others’ complaints, but I’ve been extremely satisfied since I switched to the large group model in 2018.
What might a young physician looking into large group practice want to consider?
Dr. Moss: As in any business relationship, the key to happiness is negotiating to ensure one’s top priorities will be fulfilled in the relationship while being flexible to compromise on lesser priorities. Thus, I’d want this practitioner to consider what his or her priorities are. For me it was mainly about being free to provide the highest quality care to my patients unimpeded by the administrative demands of practice ownership. However, others may have different key priorities and should negotiate to ensure that these will be fulfilled by a mutually agreeable contract with a prospective employer.
What might other dermatologists find surprising about practicing as part of a large group practice?
Dr. Moss: I can’t believe how much happier and more stress free I am as an employee in a larger group. As a cynical New Yorker by background, after joining IDG I kept waiting for some surprise or trick that would arise and make me regret my decision. I am now part of the group for over a year and can report that no such event has occurred.
How does your current practice model affect your work-life balance?
Dr. Moss: My work-life balance is greatly improved. I’m now focusing solely on what I went into medicine for (medical care of patients) instead of splitting precious time between business tasks and patient care. When the day is over, I’m able to go home, see my family, and leave the office behind. This strongly contrasts with my time as an owner where I would arrive an hour or more before patients came in and sometimes stay hours after they left to handle the business aspects of the practice.
What is the most rewarding part of your job?
Dr. Moss: My favorite part of dermatology is managing especially complex medical cases. I enjoy being able to work my way through a challenging case and help someone who has perhaps failed with other doctors to get their problem resolved. I am an MD PhD with a background in immunology, so I’ve developed a special interest and expertise in managing inflammatory skin diseases. This has included getting involved in clinical trials. Being part of a large group practice has allowed me to do even more of these consultative cases and clinical trials since I have more clinical and less administrative time.
Practice type: Large group practice (private equity-backed)
Dermatologist: Walter Barkey, MD, dermatologist at Pinnacle Dermatology, Flint, Michigan
Why did you choose large group practice?
Dr. Barkey: I didn’t choose them. They found me. I was 64 at the time and looking to probably sell my practice to the Mohs surgeon who was working part time for me. Several private equity firms had contacted me over the past few years and I decided to have two of them evaluate my practice to help me figure out what my practice was worth. I was upfront with them that I was planning on selling to my Mohs surgeon, but they were welcome to come in and give me their pitch. They ended up offering me over three times what my Mohs surgeon could, and my financial advisor told me I couldn’t refuse this.
What do you like most about your current practice model?
Dr. Barkey: After running a solo practice for 34 years with 20 employees and three PAs, I was ready to step back and let someone else do it. I didn’t want to have to try to recruit a new dermatologist (a very difficult thing to do when you are in Flint, Michigan) and I didn’t want to deal with the government and all the new requirements. I had been avoiding implementing an EHR system and was paying the penalties. Pinnacle Dermatology recruited a new dermatologist who was just one year out of his training program and also recruited a new nurse practitioner. My contract allows me to set my hours and the number of patients that I see each day and I can take as much time off as I want.
Are there any drawbacks to practicing as part of a large dermatology group? What do you find challenging about it at times?
Dr. Barkey: I am no longer the “boss” and that has many pros and cons. The cons are that I have to send my dermatopathology to someone else and although they are certainly competent, there is an adjustment when dealing with a new group compared to the one person who I trusted for over 25 years. All my employees were hired and paid the same and my PAs were given contracts that matched mine, but the transition has been painful at times for them. Dealing with “corporate,” which is not on site, is a challenge at times. Although there is no pressure on me (because of my negotiated contract) to change anything about the way I practice, there is pressure on my mid-level providers to increase productivity.
What might a young physician looking into large group practice want to consider?
Dr. Barkey: A more traditional large group practice is not the same as working for a PE group. There is the concern that they will sell to another PE group in three to five years and that new group may put more pressure on you to produce more.
What might other dermatologists find surprising about practicing as part of a large group practice?
Dr. Barkey: I’ve only been with Pinnacle for a year. Like most PE-backed group practices, they are constantly expanding, adding new practices and entirely new locations. They have quite a bit of turnover at all levels of management.
Also, I have three employees who have been with me for over 30 years. In my office, 90% of what is done is done the same way by all the providers. However, now we have new people who have their own way of practicing and I have to “let go” more. It’s not that anyone is doing anything wrong, but over the years I like to think I’ve learned to do things in a way that was most beneficial for me and for patients. Now I see the same problems being handled differently by different providers in the same office.
How does your current practice model affect your work-life balance?
Dr. Barkey: Now I plan all the things I want to do personally (i.e., travel, grandkids) and then I fill in the rest with work. I purposely see about 25% fewer patients a day on the days that I work and spend more time with my patients. I don’t feel that I have to see all the new patients because Pinnacle has brought new providers in to see them.
What is the most rewarding part of your job?
Dr. Barkey: I go to work, see 24 patients a day, and then go home and leave everything at the office. I will be implementing an EHR in the next month, but I have very well-trained MA/scribes so I can spend all my time face to face with patients who have been with me for years.
Dermatology Employment Manual
Check out the Academy’s Dermatology Employment Manual.
Practice type: Academic
Dermatologist: Robert Swerlick, MD, professor and Alicia Leizman Stonecipher chair of dermatology at Emory University School of Medicine, Atlanta
Why did you choose academic practice?
Dr. Swerlick: I’ve been on an academic track since square one, and it’s been 35 years since I made that decision. I don’t entirely remember all the different considerations, but I always knew I wanted to stay in an academic setting after my training. I came out of residency at the University of Virginia and took a two-year stint at the University of Oklahoma as I was figuring out what I wanted to do. There weren’t many academic jobs in the early-to-mid 1980s that were available, but eventually I went to the National Institutes of Health (NIH) for a three-year fellowship. After that, my boss at the NIH took a job as the chairman at Emory. I followed him down here in 1988, and that’s where I’ve been ever since!
What do you like most about academic practice?
Dr. Swerlick: I like challenges, and I like solving puzzles. I also love that I get a new batch of trainees every year, and they bring new perspective and provide energy. They keep you on your toes and ask difficult questions and don’t take pat answers. I think the major benefit is that you get to be in an environment where you are asking questions and being challenged all the time.
Are there any drawbacks to academic practice? What do you find challenging about it at times?
Dr. Swerlick: It takes a lot of energy, and academic systems can be cumbersome and not particularly responsive to dermatology-specific needs. To me, that has been a major challenge, but it’s just one of those problems that I’ve enjoyed taking on.
What might a young physician looking into academic practice want to consider?
Dr. Swerlick: The advantages of academic practice are that you surround yourself with individuals who are interested in asking questions and figuring out how to do things better. That’s why they go into academics — they want to learn and to teach — but you still have to figure out how to make it work.
What might other dermatologists find surprising about academic practice?
Dr. Swerlick: These organizations may be non-profits, but they are certainly financially motivated because you need money to make things work — to pay for the lights, the space, the help, and everything else. So, you still have to figure out how what you do translates into how you pay yourself. I describe it as ‘renting the letterhead.’ There are generally few, if any, deep pockets to underwrite various academic activities. Academic physicians, like physicians in private practice, need to figure out how to pay the bills.
How does your current practice model affect your work-life balance?
Dr. Swerlick: I mean, I work hard. My wife has kept me honest and has made it clear that I need to carve out time for family, so even when I was early in my career and trying to build a research lab, I would take off from work early enough on certain days just to coach my kids in soccer or basketball. You just need to make a commitment to do that.
In academic practice, we are sensitive to the needs of families and women in practice who have children. I think if you have the right leadership, you can make it work. I would say that over time, the pace of work has picked up, but I’m pretty certain that’s not unique to academics. Things like electronic medical records and even cell phones make it more of a challenge to create a balance. When I started practice there were no cell phones; now the phone makes it so you’re essentially working or you’re asleep. I think that cuts across all industries, and we’re still in the midst of grappling with how that feeds into the issue of burnout.
What is the most rewarding part of your job?
Dr. Swerlick: The relationships I’ve built with my trainees over the past 35 years. I get messages from them on a regular basis, reminding me that I’ve had an influence in their lives, and see them at reunions. It’s just great to know that you’ve had that sort of impact on what amounts to be 1% of the dermatology workforce in the country.