So, how does a ‘new’ Doctor establish himself/herself and open a practice? After all his/her training, internship, and completion of the residency in his/her chosen specialty, now what? Are there Doctor want ads?
Yes, there are doctor want ads for “positions available or wanted”. Look in the back of many medical journals (e.g. the New England Journal of Medicine)
However, you are a doctor when you finish medical school. You can get a general license after a one year internship. Residency is more targeted and is part of the qualification for board certification in a specialty (though not all practicing specialists are board certified)
[Most first-year residents aren’t interns anymore. Their programs don’t start with the kind of broad-ranging exposure with specific periods of responsibility in various fields that can properly be called an internship. They generally get that exposure over the years anyway. However, in my state, anyway, residents usually apply for they their full license after completing their first year of residency and part III of the NBME exam. In their first year, they practice under a limited license, meaning they are only licenced to practice under the supervision and direction of the hospital staff]
I should also say that establishing oneself in private practice is no small challenge.
Many residencies tend to give very little training in the business aspects of running and setting up a practice. If I were looking at a residency program, and planning to go into private or small office practice, I’d definitely ask about the business training.
Many young physicians buy into [i.e. some sort of partnership arrangement] an existing practice, or find some sort of employee position. There are as many possible arrangements as there are practices. Buying an established practice outright can be quite expensive, because of the revenue stream and equipment costs – we’re talking six or seven figures. And you thought your med school debt was bad.
In much of the USA, the movement is for primary care doctors (Family Practitioners, Internists, and Pediatricians) to forego the rigors of trying to run their own practice, and become employees of large medical groups. One good friend of mine fought the good fight for nearly 20 years, staying independent, but the last round of Malpractice insurance hikes did him in, and he sold his practice to a corporation, and will now work for a salary rather than for himself.
My attitude was always: I trained for years and years to do medicine, not business. So I’ve been an employee of someone else for ages. They mind the business, I stay current in medicine. I’ve been lucky, it’s worked out ok. Of course now I work for the State, but the principle’s still the same.
And as KP said, the specialty journals are full of ads. Back when I graduated residency, there was a big primary care shortage and every Family Practice resident coming out had about 20 jobs to choose from. So we didn’t have to look very hard. Whenever I changed jobs, I’d pick up my state medical society journal and my state specialty journal, and voila, lots of ads in my area.
I didn’t know that. I always thought you had to endure a residency before you could practice. What exactly can you do with this “general license”, as opposed to board certification? Given what I hear about the rigors of residency, why don’t more doctors choose to go that route?
The following is just my impromptu summary. It’s not something you think about much after you finish your training. Some details may be outdated, incorrect, or colored by hospital scuttlebutt. Also, I may be a moron. Never discount that.
At the end your second year of medical school (when you dcomplete your classroom-only instruction), you take an exam, “Part One of the Boards” (NBMLE Pt I). While it’s legal to go on to the second part of medical school, “he clinical years”, without passing MBME Pt I, most schools will push you to retake and pass it ASAP, and some may not let you start working on the wards until you do. At the end of two more years of medical school, you take NBME Pt II, and some schools require that you pass it for graduation.
When you finish medical school, you can get a limited license to practice under [at least] the supervision and direction of a hospital accredited for such purpose. I don’t know the details of that accreditation – or even if there is any special qualification. (it would vary by state, anyway)
It’s possible that it’s still legal to do your internship under a single physician in some states, as was fairly common at one time – but I imagine that it would involve more of the old-style personal Licensing board review, too, rather than the fairly automatic approval of those who sucessfully complete a preapproved internship program. If that’s still aloowed anywhere, it’d probably depend on the reputation of the doctor who offered to train you, the strength of their evaluation, and many other factors. This is based entirely on my interpretation of the boilerplate language of some older forms (which probably preserves older traditions) and not any actual investigation.
After internship, you take the NMBLE Pt III, and most -possibly all- states require you to have passed all three NBMLE exams (or the equivalent exams given to foreign medical grads) withing the past 7 years in order to qualify for a general license.
Once you have your general license, that’s it, as far as the state is concerned. That’s the only license to practice you’ll ever get or need. There is no higher license. Technically, you can practice any aspect of medicine.
In fact (from what my surgical resident friends told me, back in the day), the general license was a factor in whether you were allowed to do major surgery (as opposed to minor surgery, like superficial excisions) unattended inside your residency [You start assisting in those procedures in the third year of medical school]. Of course, that’s a fairly minimal standard, and most residencies today are much stricter. Often it seems that many residents want to get their general license ASAP solely because it’s a professional landmark and allows them to moonlight outside their residency for extra cash.
Some programs require you to finish an internship first, and enter the program as a PGY-2 (Second year postgraduate trainee). Others [I’ve heard] almost dicourage you from seeking general licensure at the end of PGY-1, because they don’t want you to moonlight. [Others simply try to prohibit you from moonlighting, with varying effect: they can threaten to throw you out of the program, but aside from that, moonlighting is your right as a duly licensed professional. This may vary by state]
Once you have your general license, you can hang up your shingle as a General Practitioner (GP), but very few people choose that path anymore, even if they intend to practice “generalist medicine”. Typically, generalists and primary care physicians today are trained in a specialty residency, like family practice, internal medicine, or sometimes OB/GYN or pediatrics. Frankly, there’s just too much to learn and see nowadays. Finishing an internship just indicates that you are (presumably) no longer an educated medical menace.
I didn’t know too many people who felt they were fully competent to strike out on their own, without a net, at the end of their internship or PGY-1–and some of the ones who did feel that way were definitely the wrong ones.
Board certification is an optional specialty certification by a non-governmental “professional association” of specialists in that field. Each has its own requirements about the length and rigor of training, examinations, and (my favorite) recertification.
Recertification has been a part of family practice every since the specialty was founded in 1975. It was a big reason (though by no means the only one) why I chose FP, rather than internal medicine. Internal Medicine finally decide to require recertification in ca. the mid-90s, but they grandfathered in all then-certified internists and residents, so AFAIK not a single internist has been recertified to date, while every board certified FP has been recertified every seven years. I really liked that requirement. I didn’t feel my “best intentions” were enough. YMMV.
I may be wrong. it’s possible that the first batch of young internists reached the 7-year recertification mark last year. I never checked. Still, unless they have tightened the requirements, it will be decades before the majority of practicing internists fall under a re-certification requirement, and most specialties still don’t require it at all. That may be fine - it’s how medicine has always been practiced. I just happen to like the backstop of being forced to review thoroughly and pass an exam every 7 years. If I assert that I’d keep current anyway, being asked to prove it is not much of an additional burden.
Though requirements vary by area and hospital, accredited hospitals are hesitant to grant you privileges for specific kinds of practice unless you are specifically board-certified in that area. For example, Family Practitioners are specifically trained in routine surgery, but in some parts of the country (e.g. Boston, where there is an ample or even over- supply of BC surgeons), hospitals are hesitant to give FPs surgical privileges. For that matter, I know a lot of well-experienced board certified general surgeons who have been pushed to give up their privileges for “specialty” surgery (which in some Boston area hospitals can include suturing hands and other common procedures that even students do elsewhere)
At some point it becomes as much a matter of politics as professionalism, and I’m sure you don’t have any interest in my personal opinions - which often change, especially when I am as tired as I am right now.
Suffice it to say: you can never learn too much and you can never know it all. You can only do the best you can, knowing that someone, somewhere, would do it better, but you’re the one holding the responsibility here and now. It can be a real burden, but I find it oddly exhillarating, if humbling.
In Canada, a family practice physician graduates from medical school and does a 2 year residency (there are no internships in Canada anymore). At my medical school, the youngest person we’ve accepted to our 3 year program has been 19 (and we’ve accepted a few). That means they were finished all their training, and practicing medicine at the age of 24. BTW - a general licence is the same as board certification.
The reason more folks don’t go this route is that there is much more $$ to be made in specialities. I remember a few years ago I compiled some research into dermatologists and their salary breakdown was over $500,000 and under $500,000 - this suggests that their median salary is $500,000. A Canadian GP can expect to make between $80,000 and $100,000 per year.
Now the numbers will be different (higher) in the US, but the ratio will be about the same.
I neglected to mention that state licensing boards DO take serious note of your training, even though board certification is a non-governmental function. It may be technically legal to run off and start doing heart transplants after you get your general license, but I wouldn’t expect to hang onto your license long, if you did. You wouldn’t be qualified for that, and you’d be expected to know that. Overreaching is a mark of deficient medical judgement.