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Crash course on everything - is it possible?

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  • 1.  Crash course on everything - is it possible?

    Posted 09-27-2018 11:49
    Dear group,

    I am 5+ yrs out of residency now doing full spectrum osteopathic FM + non operative OB at a rural FM residency. I had planned on working here for 10 yrs (federal loan foregiveness) and then opening a micro practice in my hippy WV town 2 hrs from DC. Unfortunately our little hospital has been subject to some poor management decisions over the past few years which have made my current practice situation absolutely untenable. I came out on medical leave last week after they refused to let me cut back to outpatient only in a desperate attempt
    to salvage myself.

    So I'm now on a crash course back into the details of micro practices and wondering just how fast I can make this happen (ie how much longer I need to subject myself to the abuse). I have an overflow of outpatients and am the only real osteopath within a 40mi radius, I am FP and Integrative Medicine board certified and have functional medicine courses under my belt. I practice good osteopathic primary care and would plan to continue that in a micro practice. There are two other part time docs with micro practices in my town and both have full patient panels.

    I have no doubt I can make a successful practice work, but what is the fastest I could reasonably do this? In some ways I feel I could hang a shingle out next week so long as I can get the malpractice set up. But I do have a 1 year 20mi noncompete. Not sure what to do about that. I wouldn't want to set up anywhere but the town I live in.

    How fast can this be done (to a reasonable level of quality)? Are noncompetes really enforceable (all the hospital really wants is my downstream revenue anyway)?

    Thanks for any and all of your advice!


    PS - Jean - I was one of your residents at MDFMR.


  • 2.  RE: Crash course on everything - is it possible?

    Posted 09-28-2018 07:30

    Hey Doc,


    Congratulations on taking care of your self and leaving an abuse system / employer.


    When you say micropractice – are you planning on accepting insurance? Or doing insurance free / direct primary care?


    We've been in a direct care practice 8+ years and have helped over 500 docs convert to this model in the last few years.


    All of our consulting is always free and most of our info for new direct care clinics is online at


    Some doctors are able to get out of their non-competes b/c hospital owned / insurance practice à solo insurance free can be argued as too different to be competition.  Also, often docs will have non-competes in states where they are not enforceable.


    But also, the direct care practice allows for a lot of telemedicine so your 20 mile buffer may not bother many patients when they can call/text/email/video chat.  Also you can do labs anywhere (quest, labcorp draw centers etc).  And you can stock wholesale meds in house and mail them to patients.


    We've helped open docs in as fast as 10 days (crazy but worked) but usually recommend 1-3 months once you have a location.  Finding a location is the hardest (then negotiating the lease, signing, cleaning / construction).  The rest (marketing, website, facebook, clia, etc) can all be done very quickly.


    Feel free to contact me directly anytime either by email or cell. and C 316.734.8096

  • 3.  RE: Crash course on everything - is it possible?
    Best Answer

    Posted 09-29-2018 09:39

    The other approach you can consider is to negotiate. If the town is that small (and there is at least some choice in where downstream referrals go), as well as a very limited supply of docs, your leaving is going to cost them a lot. You may consider having a negotiation with them along the lines of, “I stick around 3 months, you waive the non-compete, and we part ways cordially,” vs. “I give you two weeks, you have a huge problem, and I’m never sending a patient to any of your ancillary services.”

    You would have to figure out the details, as well as what you are willing to negotiate, your best alternative to a negotiated settlement, etc., but its something to consider. If they don’t go for it, you are probably not in a worse position. If you give them 3 months (for example) and they waive the non-compete, several of your problems are solved.

    You know the politics better than I do, but something to consider.


  • 4.  RE: Crash course on everything - is it possible?

    Posted 09-28-2018 08:23
    Hi   I remember you- you went to Bryn Mawr yes?
    1 I am sorry you ever signed a non compete clause   I have seen docs destroyed by them
    2  I t   may be that you resign  soon then  work at your same place as an independent contractor( never forget that  they need you  you are not easily replaceable)  for a year or someplace else somehow then open.
     If you are doing OB you need coverage -can that work out?
    3  you need space and an emr and some stuff:) Space  is 500 sq feet? max      get a room inside a practice where  you share waiting room and bathroom unless you are young and ,,well you are, and if you are going to stay-- you could buy a building In the long run its a good idea but renting is easier often and  renting inside of another office gets you business
     so you can start up in  a few months but the noncompete must be respected I have  seen docs  lose their shirt
    what else?:)
     can we  know what happened that it is hurting docs so bad? I am sorry to hear all this!

    Jean Antonucci

  • 5.  RE: Crash course on everything - is it possible?

    Posted 09-28-2018 16:08
    How fast you can start your own shop depends partly on how you plan to make money at it.  If you want to take insurance, you will have to be credentialed with the plans you will accept and that may take from 1-6 months, depending on the insurer, medicare traditionally taking the longest, though I didn't have that experience with them.  If you plan to be cash-only or some other DPC not accepting insurance, you could do it as soon as you have your tax ID and a corporate structure.  You will also have to disenroll formally from Medicare and Medicaid.  Whether you decide to be a sole proprietor, S-Corp PC or LLC filing as an S-Corp depends on how much business risk you wish to mitigate with a corporate proxy (they won't protect you from malpractice claims) and your personal tax and asset picture.  Talk with your accountant and if you decide to incorporate, invest in a good business attorney experienced in healthcare corporate law.  The attorney will be expensive, but you will only need her for a short time.  You will also need to shop for malpractice insurance to cover yourself and your corporate entity.

    Restrictive covenants have often been struck down in court but not always.  You might be able to persuade your employer to void the restrictive covenant if you can convince them that your referral patterns will remain the same and, as you note, the downstream revenue will still end up in their pockets.  Don't hold your breath.  And don't think they won't sue you for breach of contract if you violate the covenant.  If you prevail in court, it will be after more months in limbo and more than a few thousand dollars in legal fees.  You might consider, if your life so permits, working elsewhere as a locum tenens for a year while you get your next act together in a more deliberate way, especially if it allows you to bankroll a cushion to carry your business through the first year.

    Now, presuming a triumphal return after the Year In The Wilderness, do you really know that your hippy West Virginia town wants a third micropractice, especially if you don't plan to take insurance?  You will be surprised at who follows you and who doesn't.  Most, or nearly most, will stay with your current overlord, especially if it will cost them more out of pocket to see you.  When HMO's first entered the scene 30-some years ago and employers started to force their employees to sign on to them, often at the cost of leaving their longtime but non-participating doctors, it turned out, in a couple of studies I recall, that the price point of the enduring patient-physician bond was about 12 dollars extra per month:  if patients had to pay more than that to stay with their doctor, they left their doctor for the cheaper alternative.

    About working and living in the same hippy town:  you and your family will be in a fishbowl.    Since you seem to have swum in that fishbowl already for 5+ years, maybe it feels normal and comfortable.  In 10 or 15 years, you may be ready for a new start in the Federal Witness Protection Program.  I cannot recommend highly enough living at least a town over from where you work.  I also cannot urge you strongly enough to take the chance and open your own practice--just slow down and plan much, much more before you leap.  Good luck!

    Vahe Keukjian
    Your Family Doc PC
    Ghent NY

  • 6.  RE: Crash course on everything - is it possible?

    Posted 01-12-2019 05:37
    Would love an update.

    A word on non-competes. ...   While I have tried to avoid signing them in general - they are ubiquitous.   HOWEVER, often hospitals significantly if not altogether abandon them for an extra 2-3 months service to allow them to appear to have a smooth transition.   The fact is - - in many states physician non-competes are going by the wayside and often doctors prevail. . . . Many hospitals WANT TO AVOID ANY such CASE as once decided in a court, there is precidence (spelling?)  sent and then they are "screwed". . . .they can no longer threaten their doctors with the fear of the non-compete....

    probably too little too late but wishing you luck. My mom went to Bryn Mawr (class '61).  You got great advice on the forum already and hope you are doing well.
    Deborah Lathrop, MD

    D Lathrop

  • 7.  RE: Crash course on everything - is it possible?

    Posted 01-13-2019 23:46
    Wow, sorry to hear you are so unhappy in current situation.

    My 2 cents - Apply now for some Urgent Care work or hospitalist work that you will need to do for a year.  When that seems ready to go, put in your notice with your current employer.  You will also be in a much better negotiation position with your current employer if you know you will have a steady income.   You will likely also need to moonlight for a couple of years until your practice is thriving.

    You will have a year to decide what type of practice you want to have - ie DPC or traditional insurance, learn how to bill, set up office, etc.   Discuss with an accountant, etc.

    Also, you are probably already credentialed with most insurances in your region.  But the money is going to your employer.   If you accept insurqance, you will likely be able to switch those plans to your own Tax ID number, when you have set it up.

    Michael S. MD

  • 8.  RE: Crash course on everything - is it possible?

    Posted 01-14-2019 03:35
    You've got some good advise here. The over arching news I see is you are in charge and courageous to make these steps and reach out. The fundamentals of md self care are: sleep, relaxation and creativity, connection to family and friends, nutrition and exercise and then professionalism and sustainability.

    You describe having some burnout; which to me means these basics can't be lost in the complex retooling. Actually I don't think retooling will be hard; but the basics actually can be hard because we have been trained to ignor our own needs through the rigor of training. If you're crispy fried then identify and connect with friends/colleagues/ professionals who got your back; could be docs who run their own micros or hired allies like an attorney/accountant/banker and consider strongly a therapist; get a routine once a week or every other face time so they can see your situation and make sure you're carrying for your self ahead of your business plan. Once that group is solid and functional the steps others have suggested can start building your exit from the hostil environment and bridge to your future of self direction.

    Adam Schwarz