Transitioning from fellowship to practice

You have nearly finished the formal part of your training. Until now, each step has been clear: finish college, attend medical school, apply for residency, and then apply for and complete a fellowship. Given the competitive nature of each of these steps, most people do not choose their paths; each of us is chosen. This final step, the transition from fellowship to practice, is the least discussed step, but it is your opportunity to make some important choices.

This article discusses 6 steps that can help structure your job search and provide some tools and tips to help you understand the process. It also discusses trends that define the market.

Two important legislative health care bills were passed during your fellowship: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. Although the legislative portion was passed, the lines of federal regulations have yet to be defined. Despite their implications for your job search, their major effect is to create uncertainty regarding the ultimate law and the day-to-day ramifications of the regulations. Regardless, although there are many potential areas of impact on gastrointestinal (GI) practices, the law has changed the job search in several ways.

• 1.
  

  Uncertainty may lead to reticence in expanding a GI practice for many groups. Many GI practices are small businesses and, in this time of economic uncertainty and increased unemployment, some patients are losing their coverage or putting off preventive services. This slowdown and the continued uncertainty makes further investments in expansion seem more dangerous. Thus, practices that may have been considering hiring are waiting to see when the economy is going to improve. Furthermore, the current controversy regarding health care reform is increasing the level of uncertainty in the market. Actively growing a practice based on a health care reform act that may be partially or fully repealed in 2 years has been giving many physicians pause and encouraging a wait-and-see attitude.

  
  
• 2.
  

  Consolidation of practices will accelerate and there will be fewer solo practitioners and small groups. The push toward consolidation is in response to the increasing challenges of insurance company negotiations and the restriction of the capital market to make investments in ambulatory surgery centers and radiology services, and to seek greater economies of scale. This trend has even extended to more rural areas with larger practices expanding geographically to ensure a steady income stream.

  
  
• 3.
  

  Accountable care organizations (ACOs) may begin to define practice patterns (this is a caveat of issue number 2). The ACO is being positioned as a way to track the use of health care resources. One of the most significant impacts may be a change in the traditional fee-for-service model to a bundled payment system for care of disease conditions. The relationship of specialists to these organizations is not yet well defined, and every practice should have an active strategy regarding their participation in ACOs. However, changes will occur that will necessitate a change in the design and operation of the GI practice.

  
  
• 4.
  

  An electronic medical record (EMR) is essential, not an option. In many ways, the EMR used to be a nice addition to a practice, but this is no longer true. The EMR is close to the heart of health care reforms, and practices should either have or be actively transitioning to an EMR. This transition represents a substantial financial as well as strategic commitment that will pose a challenge to many practices, especially smaller ones. After 2015, penalties for not participating in the EMR requirements start at 1% of Medicare fees, rising each year to a maximum of 5%.