Thriving in Private Practice
Diving right in from residency to private practice
Jul 21, 2022
Featured topic and speakers
In this episode of AMA Thriving in Private Practice, guest Carolynn Francavilla Brown, MD, of Green Mountain Partners for Health, discusses the steps she took to start their private practice shortly after residency and how other residents can prepare themselves for private practice setting in the future.
Speaker
- Carolynn Francavilla Brown, MD, private practice physician, Green Mountain Partners for Health
Host
- Carol Vargo, director, physician practice sustainability, American Medical Association
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Transcript
Vargo: Hello and welcome back to AMA Thriving in Private Practice, a ten-episode series exploring the unique needs of physicians in private practice settings. In our show, we’ll talk about efficiency solutions and how to transition into the world of private practice. We also will focus on other tips to free-up time so you can focus on your patients. I'm your host, Carol Vargo, director of physician practice sustainability at the American Medical Association. Today, I'm joined by Dr. Carolynn Francavilla. We will hear about her personal journey starting a private practice following residency. Welcome, Dr. Francavilla.
Dr. Francavilla: Thank you so much for having me. I'm excited to talk about this today.
Vargo: Great. Thank you so much for joining us. We know you're very busy. But could you start us off for our audience, a little bit with background on yourself? Where did you grow up? What drew you to medicine? Where did you train?
Dr. Francavilla: Yeah. So, I am now a family physician and an obesity medicine specialist, and I practice in the Denver, Colorado area. And that's actually where I'm from. I think most physicians will find it unique that I actually stayed here for my entire training. So, I went to college here, medical school at the University of Colorado and did my family medicine residency here, too. So, I have been Colorado through and through. And I think my story of my interest in medicine is kind of the classic one. I really liked science; biology was my favorite subject. I actually had some interest in advocacy and I found that bench work, that sort of science, really wasn't for me. But I loved talking to people. And so, medicine seemed like the perfect marriage of my desire to converse with people, talk with people but also get to use that biology and science to my advantage.
Vargo: And what drew you to family practice in particular?
Dr. Francavilla: I think as we have this conversation about private practice, that will kind of mirror itself. But family medicine, we get to do a little bit of everything. And so that's kind of the same when you have your own practice, you get to have your hands in a lot of different pots. And I liked everything, I always wanted to be the sort of doctor that could answer the basic question. Like, if someone had pink eye, I wanted to be the one who could answer that solution. I liked long-term relationships with my patients and I always have this really big interest in prevention, health, wellness, nutrition. And so family medicine really, I think for me, lended itself best to that preventive care, that focus on nutrition and this obesity focus that I've later gone on to have.
Vargo: So, tell our listeners how you became interested in private practice because I know you joined or created a practice right after your residency, which I think is atypical these days, I would gather. So where did it start for you?
Dr. Francavilla: I think it's a little hard to say. I think I actually went into medicine because I liked the idea of having a job and not having my own business. I'm from a somewhat entrepreneurial family. I watched my dad in the restaurant business and to be honest, it didn't appeal to me at all until I kind of got through most of my medical training and realized that if I wanted to practice medicine on my own terms, that private practice really was the only route for that.
So, I actually was employed by a small private practice for my first year out of residency. They were really flexible with me and let me pursue my interests, and I learned a lot there. But even in residency, I was sort of starting to think, "Okay, what would my own practice look like?" And I got a little overwhelmed with the idea of starting one, found a small practice that seemed like it would be a good fit. And then pretty quickly realized that I really wanted to be in charge of my own destiny, wanted to have patient care on my own terms and that the best way for me to serve my patients, was through my own practice.
Vargo: Were you exposed to the private practice model as part of your training, or did you specifically seek it out when you were in residency?
Dr. Francavilla: I was lucky that I really was exposed to a fantastic private practice as a medical student. At the University of Colorado, they have this longitudinal preceptor experience. And so, as a first-year medical student, you start working with, usually, a primary care physician. And I got matched up with a young pediatrician, Dr. Noah Makovsky, who had just started actually, his practice. And I really got to see what that looked like, how happy he was and how connected to his patients he was. And I continued working with him once a week or so throughout all of medical school. So that definitely made an impression on me. And I remember him at one point asking, "Do you think you'd ever start your own practice?" And I said, "Absolutely not. I have no interest in that." And so, he was certainly one of the first people I emailed when I decided to start my own practice and let him know that he was a big inspiration to me.
And that seeing what private practice can look like and how that really allows for the patient and physician relationship, was a huge part of inspiration that, that could be done. So that was the medical experience. But I was at the University of Colorado, big academic institution. So aside from lucking out with that preceptorship, almost all the rest of my training was very academic, big hospital, where you had this giant academic team on your service. So, I know that not everyone at my school got that exposure. I kind of lucked out at my program getting to see a small private practice and seeing it just starting out.
Vargo: That is really interesting because that is something we hear regularly that there is just no exposure, particularly in residency, which I think makes sense. But your undergraduate experience is really fascinating. And I think there are efforts by the AMA to try to better expose medical school students to the private practice model because it does seem like your program was not typical. And I think it will be really interesting to see how that might spread throughout other medical schools, recognizing that you guys are so overwhelmed with so many other things to learn in medical school.
Dr. Francavilla: Yeah. In my residency, I had a little bit more exposure in my family medicine residency because I think the nature of being in the community-based program ... My residency program was through the University of Colorado but it was at a community hospital and so we did work with a lot of private practices in our residency. And so that also gave me additional exposure and really, actually helped me when I started my practice. Because since I stayed in the area where I had done residency, I had some connections to private practice physicians. And this may not be answering the question right now but one of the things in terms of connections that helped me is I had gone to medical school in the Denver area and residency, and I had been involved in my state medical society since day one.
And so, I had a lot of support from the medical community, a lot of connections that I had really been building since day one of medical school. Which doesn't mean if you haven't started at day one, that you can't do this. But that community, that networking is definitely very important in private practice. And for me, my local and state medical society were tremendous resources not just starting my practice but as I've continued to grow my practice. So just kind of a plug there, that that's a great resource in a lot of areas to help start a practice, support a practice, find resources.
Vargo: I think that is a great point. And it's good to know how helpful that was to you. I think often, I say this as someone who works in organized medicine, people just say simply, "I don't have time to get involved." Which is, of course, 100% understandable. But it's great to hear that you found it so rewarding to be interacting with your state and local medical societies, and now the AMA. So, that is great. So, this sort of ... This conversation has led to my next question or thought, is for other residents that are out there, who might be listening to this, how can they dip their toes into private practice? For example, based on your experience, where can they start or get exposure to the model?
Dr. Francavilla: Yeah, I think the vast majority of us have electives as part of our residency training. And so, when you're looking at your elective experiences, thinking about what are opportunities you may not have later and that you may not be able to learn another way. And I think seeing practice models is one of those things that is harder to do. You can always go read articles, go to conferences and all the science is out there but seeing how medicine is practicing, watching a physician, watching how systems work may not be something that is as easy to do. So, while you have that chance as a student or a resident, look for unique opportunities in terms of setting. So that may be in family medicine, we have this focus on rural. We always make sure our residents in Colorado get exposed to what it looks like to work in a rural setting but that also may be looking at private practices, looking at a solo practice.
What might it look like if you were the only doctor? What does it look like to be part of a private practice that maybe has a dozen or 100 doctors but it's an independent practice? So, I think exposing yourself to a variety of settings and locations, when possible, with those electives, is really powerful too. One of my limitations, I think, as a physician, is I have done all my training in Colorado. And so, I sometimes have this little bit of a narrow view because I have no idea what being a doctor in Florida or Texas or Washington might be like because I've really only ever seen the health care system here. So, I think there's lots of different things we need to be exposed to beyond just the science, to be really comprehensive clinicians.
Vargo: And I think you raise a good point, that so much of it, particularly in private practice, can be market specific. Is it the right place to start a private practice? What is the community? What is the mix of patients? Who are the payers? I think those are all factors that go into it. And let's move a little bit more into your current state of private practice. And you mentioned, I believe you said you were employed but in a small private practice and then went out on your own. So, what were the key challenges you experienced when you were setting up and running your own private practice?
Dr. Francavilla: I think the biggest challenge and actually the thing that probably kept me from doing it right out of residency was in family medicine, there's a lot of different things we need, a lot of different supplies and I actually got really overwhelmed just trying to figure out what supplies I need for the clinic. And it's funny looking back because it seems so simple now but I specifically remember thinking about, "Okay, if I'm going to take a urine sample, I know there's a wipe someone has to use before giving the urine sample. And I have no idea what that wipe is called. I have no idea what's in it, I have no idea where you get it." And all those little questions of the supplies overwhelmed me and as luck would have it, as I was starting my practice, I moved into a new home and my next-door neighbor was a rep for a big medical supply company and made my life easy peasy, and helped me come up with a list of everything I needed.
And I think the lesson from that, is there is a resource for every question you have. So just like in medicine, in family medicine, I use resources all the time. If a cardiology case gets to a place where I can no longer manage it, I'm going to consult with a cardiologist, right? And the same thing when we're starting our private practices—if there is a legal question, if there is a HIPAA question, if there is a supply question, if there's a technology question, there is someone out there that has that answer. And so that may be hiring someone, that may be networking and finding that person. But there is an answer to every question you have when starting a private practice.
Vargo: Yeah. It sounds overwhelming to me just as you have described it but I think now, even particularly ... And you had mentioned this earlier about having that entrepreneurial spirit. I feel as if technology has enabled a lot of traditional small businesses to even become more appealing. And I think that might carry over to medical practice as well, just because you have access to so many things now through the internet and other technologies. We've heard of other private practice physicians getting a lot of their management tips and networking, not only from organized medicine but say Instagram, what do you think of that? Where do you go for information from your peers?
Dr. Francavilla: Absolutely. Yeah, I'm sort of a Facebook person. So, there is a Facebook group with a lot of private practice physicians and some with some family physicians and has been a tremendous resource for me. Sometimes, we even separate out based on which EMR we use. And yeah, those Facebook groups for me have been a great way to share resources, ask questions and get ideas.
Vargo: One big challenge that we've heard consistently across many private practices is contracting. Payer contracts, negotiations. How do you handle that? It sounds like you have multiple payers that you contract with. I know you mentioned you have a Medicaid population as well as Medicare but on the commercial side as well.
Dr. Francavilla: Yeah. I think that is kind of overwhelming and can be kind of a roadblock for some people. So again, there's a person who can answer every question you have, right? I think having that mindset, you're there to be the doctor and run the ship and figure out how you want to practice that works for you and for your patients. And then you find the person who answers the questions. So, in my case, we had found a credentialer who did billing, who was in our community. She's actually right down the street from me.
So sometimes, I even walked to her house to drop off or pick up paperwork. And she had been in the business for years and she helped us get those contracts and negotiate them. And she had done it a while, so she knew what was reasonable and fair rates. And so, we relied on her expertise. And she's in the process of renegotiating those contracts for me right now. But yeah, I think again, there's someone out there, and networking in your community and with physicians in your area is often how you can find that person. But we couldn't have replaced her community experience with something else, right? I don't think that was something I would've wanted to navigate on my own, and so really, deferred to sort of an expert for that.
Vargo: Right. That community is so important.
Dr. Francavilla: I think another consideration is that there's lots of models. So, most of us are exposed to this model of an insurance-based sort of fee for service, where there's a rate and we're submitting super bills for reimbursement. But there is growing movements of different relationships between payers and physicians, and sometimes excluding those payers. And so, there are whole direct models, the biggest of which is the direct primary care model, which is a low-cost membership that really, completely excludes insurance. There's different models where people will use sort of a concierge model. So, they might take the lower rate from an insurance contract but then supplement that with a membership fee. So, there's lots of models out there that really, I think we should be open to. And with the mindset of what serves my patients, like what allows me to provide care best to my patients. And sometimes, that means not going through the insurance process.
Vargo: Is that the way your practice is set up currently or are you exploring moving in that context?
Dr. Francavilla: Yeah, so that's something I have been exploring and actually just launched this year. So, I have actually three physicians who now work for me and they are sticking with the traditional insurance-based model. And I have just launched a membership model and it's going amazingly well. I'm really excited about it.
Vargo: That's really good to hear and we would love to obviously follow you on your journey about how that goes. I think to your point, we are getting here at the AMA, more inquiries on that and I know there are a variety of resources out there to explore that model. So would love to follow you as this goes on. I think that leads into my next thought, which is when we've done our research, qualitative research with private practice physicians, one of the joys that they love about it is this sense of nimbleness that I think I hear from you and your conversation. That if it isn't working, they feel like there's not a lot of bureaucracy around them to be able to make a change. Although, there's clearly some challenges with being your own boss. But do you find that you have that nimbleness and how does that translate into you having, I think more of a balance around the hours you work? Because we hear so much about burnout, pajama time, tell us a little bit about how that lives in your daily experience.
Dr. Francavilla: Absolutely. And I think that is the biggest reason that I would recommend private practice for someone, is that autonomy, that control over not just your relationship with your patients but also your personal life and the way you do that. So for me, I was actually seven months pregnant when I started my practice. So, I started this practice in this, this really small setting, and then immediately had a baby and had to take a little bit of time off. And I was able to go back to work just two days a week for a while, and I had complete control over what that schedule was. So that's been immensely powerful for me as a mom and a physician to be able to say like, "These are the hours I'm going to work and this is what works for my family." And sometimes, that's not working Saturdays because that's what worked for my family.
And sometimes, that means I'm done at 1:00 P.M. for the day because that's what my family needs. So, that flexibility is huge. I think the nimbleness in terms of professional obligations is really key, too. So, the COVID pandemic affected everyone in different ways. And for my practice, I felt very safe and empowered compared to what I saw with a lot of my colleagues who didn't have the PPE they needed to feel safe and didn't have any sort of protection from what was going on in the world around them. In my office, we were able to work as a team and figure out what we needed to do to keep the business going but also make sure that we, as clinicians, were safe and that our patients were safe.
And we didn't have a lot of red tape or someone who was worried about the bottom line in a way that wasn't about patient safety. So, we didn't have, I guess, conflicting interests like a lot of employed physicians had in that time. And that was a really powerful experience. And I think I've seen a lot more people interested in private practice in the last couple years. I think partly because of that, they saw that when you're employed, that can actually even put you in a dangerous situation at times.
Vargo: Interesting. So, you obviously have really taken to this model and you seem extremely happy with it. But I think that there are probably some unique skill sets that are required to really succeed in private practice. What do you think the key skills are needed for our audience out there who are potentially thinking of jumping into this model of practice? What do you think these key skills are that they need to succeed?
Dr. Francavilla: I think you have to be a little introspective and be able to take that step back and step away from structure and be creative and think about what really is going to serve your need and your patients’ need. And so, a lot of times, when people ask me about my model when I was first starting out, they kind of were just shocked that I was making it work. But I really started with very little structure. I just started with what I needed to do to be a good physician and make enough money to pay myself. And with that really basic principle in mind, was able to sort of creatively grow this little private practice. So, I think you have to have some creativity, some ingenuity to be able to do this. And I think using your resources, which I think as physicians, we do every single day. Like I said, there's an answer to every question you're going to have as a private practice physician.
And so not being afraid to use lawyers, not being afraid to use someone to make your website, not being afraid to meet with multiple suppliers and figure out who's a good fit for your business. So, you definitely have to be able to do some of that groundwork. But the trade-off of doing some of that admin is that you have complete control. You're getting supplies that you want. You're never having to argue with an administrator about why need the more expensive hemostat or something. So, for someone who really likes making choices themselves and is not afraid to do some of that research and do some of that groundwork, I think it really can set you up to be a lot happier. And I think that these are skills physicians have. I think we've been and sort of let astray thinking that we can't run a business. I really can't imagine anything that's much harder than going through medical school and residency. And I just want to spread the message to physicians that if you can do those things, I promise you can run a business.
Vargo: That's great advice. I just have a question on an infrastructure issue because obviously, there's been an explosion of growth in telehealth. Many used it prior to the pandemic but of course, that overnight made telehealth almost an essential tool, particularly in primary care. Do you use telehealth?
Dr. Francavilla: Yes, yes. I was using telehealth before the pandemic, and I actually made some resources when the pandemic hit to help other physicians get started with it. But telehealth is such a tremendous opportunity, and it really allows you to be usually much more efficient, much more cost-efficient. We added a fourth physician in our office. And I don't think without the extensive use of telehealth in our practice, that we would do that. We don't have room for four physicians in our space but because one of us does a day of telehealth each day, we can now fit one more physician in the same space. So, our rent hasn't gone up at all to have that additional physician but we're able to expand our capacity for patients and for another physician to work in this environment by utilizing telehealth. So, such a huge asset I think, to private practice right now.
Vargo: Absolutely. I agree. And I think that many people ... You were using it obviously before the pandemic but I think the pandemic did show people that they could readily adopt it and it could work. Do you find your patients are enjoying it as well?
Dr. Francavilla: Oh, yeah. They love it. There are certainly people it's not a good fit for. We have some older patients, some lower-income patients that just don't have the technology for it. There will be some things that are always a struggle by telehealth. Abdominal pain, I usually like to see in person. But there's so much flexibility in it and oftentimes, we'll find ourselves doing something by telehealth and then the patient can stop by at their convenience to say, get their vital signs taken by us if they need that or stop by at a different time of day for that abdominal exam but we've already done the majority of the work by the telehealth appointment. So, there's lots of ways to creatively incorporate that. And I actually, personally, I'm already looking at the next thing and I think the next thing is a lot more asynchronous communication with our patients. Meaning, a lot more services by text, by surveys, by email for follow-up conditions that maybe don't need this traditional fee-for-service office visit to provide good care.
Vargo: We'd love to follow you on that journey as well. Agreed. We are hearing of these trends emerging. Absolutely. I have one more quick question for you because I know you are part of the governing council of the AMA's Private Practice Physician Section. Do you want to talk a little bit about the section and your involvement?
Dr. Francavilla: Oh, absolutely. So, the PPPS is one of the newest sections of the AMA. So, our mission really is around making sure that we preserve private practice and that we can make sure newer generations of physicians feel that they can go into private practice, as well as continuing to protect private practice for physicians who are in it. So one of my big missions on the governing council is to reach out to students and residents and let them know that this is a real opportunity. So that's a little bit about the PPPS. And again, we're a new section, so definitely a great place where we need some up-and-coming leadership and need some involvement. We are very open to different things right now as a newer section of the AMA.
Vargo: Before we wrap up or just ... And I know you've given a lot of great I think, fundamental bottom line advice, which if I could summarize, might be "just do it" perhaps. But are there any other final thoughts or comments that you would like to share with our listeners today?
Dr. Francavilla: The advice I always give in terms of just starting a business in general but particularly for my physician colleagues is, as I said before, you can do this. You've already done the hard part of becoming to doctor. If you think about all the small businesses that are out there, the liquor stores, the dry cleaners, all these different small businesses that you might interact with, they often are started by someone who may not have a college or even a high school degree. If they can start a business, you can too.
And there's really just two rules to starting a business. People have made it seem like as physicians, we can't run businesses, that it needs a really special skill set but there's just two rules. The first rule is you need to make more money than the business costs to run. So that's basic business rule number one. And basic business rule number two is don't break any laws in the process. And that may feel like an oversimplification but I think if we take things back to like that is literally the root of what you're trying to do with your private practice, that you can build everything from there.
Vargo: That is great. And to help you not break some of those laws, the AMA often has a lot of great advice and resources. Because I do know there's a lot of regulations out there but I love how you just simply break it down and take a step back. So, Dr. Francavilla, thank you so much for sharing your personal journey on starting your private practice right out of residency. And thank you again so much for your insights and for joining me today.
Dr. Francavilla: Thanks for having me.
Vargo: For more information about some of the AMA resources that I mentioned, please visit [the AMA website]. I'm Carol Vargo. And until next time, this has been Thriving in Private Practice. Thank you so much for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
