AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger discusses what medical students need to know about pursuing careers in private practice with Omar Maniya, MD, MBA—CEO of Maniya Health in Hamilton, New Jersey.

Speaker

  • Omar Z. Maniya, MD, MBA, CEO, Maniya Health

Moving Medicine video series

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today, we're talking with Dr. Omar Maniya, CEO of Maniya Health in Hamilton, New Jersey, about what medical students need to know about pursuing careers in private practice. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Maniya, it's great to see you again. You've had the opportunity to work in both large health systems, and now in your family's private practice. Talk to me a little bit about the considerations that medical students should be thinking about when they're thinking about which path to follow.

Dr. Maniya: I think this is sort of a trip down memory lane, because who talks about private practice anymore? That was what people talked about in the seventies and the eighties. But I think private practice is having a resurgence. It's one of the reason I voted with my feet and I am here. And I think when you look at what the practice of medicine has become, particularly in large hospital systems, you see a tremendous amount of burnout. You see a tremendous amount of frustration. There's a lot of "suits" making the decisions, and a lot of loss of a sense of efficacy on the part of physicians because you see a patient, you know the right way they have to be treated and the way you want to treat them, but you might not necessarily be able to do that. And I think all of those things are flipped on their head in private practice.

Yes, private practice has its own unique challenges and frustrations no doubt, and I'm sure we're going to get into that, but, a lot of the things that I think are driving burnout for physicians as a whole, those aren't there in private practice. In fact, those are strong advantages, and that's one of the reasons I'm sitting here today.

Unger: Tell me a little bit more about that. When we think about the sources of burnout, we know, for instance, administrative burden plays a huge role. Do you feel like that in a different situation now that you're in private practice or not?

Dr. Maniya: I think it's completely a different situation. For example, let's talk about charting. Charting is the bane of most physicians' existence. Scribes have existed for a very, very long time. There is tons of data out there, and it's shocking that they even needed data to prove this. Having someone else write your note saves you time. Duh. And so, yes, everyone has equal access to scribes. Every hospital system could get some for you. Private practice could get some for you. But in a private practice, the person making the decision to get scribes or not is also seeing patients. And so, they know it, they feel it, those problems, your problems are their problems. In a big health system, that might not necessarily be the case.

And so, of course, this is not to detract from all big health systems. There are many health systems that have physicians as CEOs or physicians in leadership positions and value physician input. And so, yes, with that caveat, this is an oversimplification, but I think in private practice, you have this unique system where the person making the decisions is going through the same challenges you have. And so, on the margin, they're going to do things that benefit themselves and you because they're seeing those problems all day every day just like you are.

Unger: I'm curious, when we spoke to you in the kind of height of the pandemic, you were on the front lines as a resident in a large health system in the epicenter of the pandemic. What's been the biggest surprise to you as you've shifted into private practice in terms of these benefits that you're now experiencing? What surprised you?

Dr. Maniya: It's a lot easier to make change than you think it is. I will give you an example. When I was an emergency medicine resident, working in an emergency department, treating COVID patients, I, for nine months, did not know where to get a same-day COVID swab to keep myself, my family and my patients safe. It took nine months to get that figured out. Over here, it took 48 hours. We called up a lab company. We said, "Hey, we got a parking lot. Do you want to set up shop here all day, every day and do drive-through COVID testing for free," because the CARES Act covers it. And they said yes, and 48 hours later, we're doing drive-through COVID tests. That wasn't hard. Now, that was a unique challenge, a unique situation where you had government funding, you had policy support, the regulation supported it, et cetera, et cetera, et cetera. But, there are a lot of things like that in health care that frustrate docs, which you can solve in private practice that you don't even know who to email or how to get started in a bigger organization.

Unger: Do you have a little statue of "The Buck Stops Here" on your desk?

Dr. Maniya: I don't, I don't.

Unger: Because, it sounds like that aspect, a personality of, the chance to be in charge and be more in control, when you think about your nature, the kind of person you are, and the path that you've chosen, does that seem now like a better fit?

Dr. Maniya: I feel like I was born to do this, but I want to just make a distinction. I don't think that "Go run a private practice" is the right career path for every single person, because then society and American health care would be 800,000 or 900,000 individual practices. People have different things that they want out of life, but even if you're not running the place, being in a small organization, particularly in private practice, it's set up so that everyone can take individual leadership roles. "You really care about the COVID swabs? Okay, you lead that and you make that happen." "I really care about the scribes and the charting. I'm going to go do that in my free time." And we can all divide and conquer tasks in a way that's mutually beneficial, where we respect each other and we're all working towards the common good because we're all facing those problems together. And I think that's the really unique thing. When I reflect, you put effort in a small organization, in a private practice, you will see the results and so will everybody else.

Unger: If you were to kind of put yourself in the shoes of today's medical students that are kind of thinking about which path to go forward, how would you counsel them?

Dr. Maniya: I think that's a great, great question and one that I've had to do within the recruiting process. What I see a lot of today, and I understand it, is there is a lot of burnout and fear. People are focused on asking questions about things like, "Am I going to get a lunch break?" "Oh, if I stay 20 extra minutes, am I going to get overtime?" "If an extra patient walks in, what's going to happen?" And I think that's because our whole medical training system is predicated on the fact that stuff flows downhill, and the lowest person in the totem pole gets stuck with all the extra work and they get no extra reward for it. And they can't even complain or give feedback by and large.

Now, many places are more innovative and so this is an oversimplification, but I think the cause of that culture that's been around for decades, when people finally get out of training and they're finally ready to choose their first job where they can actualize themselves and their feelings and their happiness, they're not asking about actualization and happiness and innovation. They're just trying to make sure the abuse that was put on them in training is not going to happen here. And that's unfortunate, because if you're focused that way, you're looking in the rearview mirror, you're not going to be focused on all that you can accomplish. So, when I talked earlier about private practice having lots of challenges, yeah, you have less people, one person calls out sick, that's going to make everyone else's day suck, in a way that at a large organization, that wouldn't happen. But you have all of these other benefits, all these other problems. You see a patient you think they can be treated that way, you can go make that happen.

And so, what my biggest advice would be is don't look in the rearview mirror, being an attending is very different than being a resident or a student, and look forward. How are you going to change the world? How are you going to make the world better for your patients? How are you going to make the health care system better? And how are you going to achieve your personal goals? And sometimes, that may involve being in a big health system but oftentimes, I think people would be really happy in a smaller, private practice setting.

Unger: Well, you mentioned earlier about recruiting physicians. And so, now, with the practice, you're trying to find other physicians for your team. What are you looking for?

Dr. Maniya: I'm looking for someone who will treat this place like their baby. And there's a very different mentality between clock in, clock out on one end of the extreme and treating a place like your baby on the other end of the extreme. Now, if you treated residency like your baby, if you treated med school like your baby, you would probably be a pretty unhappy person because there is no opportunity to graduate earlier by and large, there is no opportunity to get paid more by and large, there's minimal opportunity for recognition. And so, you could put in all the work, but you don't get anything extra for it. Private practice, totally, totally, totally different. The more work you put in, the more you get out of it, on a bunch of different metrics.

And so, what I look for is someone who's in that camp, someone who wants to treat this like their baby, and not saying you've got to be here 24/7, nobody wants to do that, but treat it like your baby in the sense that you care for it, you nurture the practice, you help grow it. And you know that it's a virtuous cycle. It benefits the practice, it benefits everyone in the practice, and so forth. And if I could just make one comment about our profession as a whole, there are a lot of seemingly appealing clock in, clock out types of jobs.

I'll give you an example. There's a practice in our area that recruits primary care docs by saying, "No add-on visits. No sick visits." Now, that sounds pretty great. You come in, you got your schedule. If they don't show up, "Oh yes, I got a free 20 minutes and nobody can be added onto my schedule." And that's very doctor-centric and that's good in the short run. But if you think long run, my view is, how do the patients feel? Patients tries to call their doc, they can't get in. What are they going to do? They're going to suffer at home? They're going to go to the ER? They're going to not take care of their health, et cetera, et cetera, et cetera?

And so, where does that leave us as a profession 10, 20, 30 years from now? I would posit that it would leave us in a much worse situation where docs are treated like shift workers and have even less of a sense of efficacy, even less of feedback, even less leadership in big organizations, and overall would degrade this beautiful profession that we've all chosen for noble reasons. It would degrade the whole thing.

Unger: Well, it's interesting, I mean, because when you're recruiting out there, you're not doing it in a vacuum. You're talking to people who have choices to go work for a place like the one that you just mentioned, or to work in a practice. In terms of the challenges you have, in terms of saying, "My private practice is the right place for you," what are those challenges and how do you address them when you talk to folks?

Dr. Maniya: I've been waxing about the positives of private practice and there are definitely lots of challenges. I think one of the biggest challenges is variability. And I think the other is patient experience and patient service. On the variability standpoint, the less number of people you have, if one of them is sick, one of them, grandparent dies, one of them has car that breaks down, et cetera, that's going to mess up the rest of the day for everybody else, in a way that if you had a thousand people, that would never happen. And so, you're much more prone to these idiosyncratic person-specific events. I think there is a positive in there, which is that if you are that person, you are very glad that everyone else is willing to step up and cover for you and let you take the time that you need and take care of the things you need. But, oftentimes, it can be a negative.

I think the second is in terms of patient experience. Some organizations can just ride on their name because their name just so happened to be around for 150 or 200 years. Everyone knows that name, that brand comes with trust, et cetera. And when you're a small private practice and people have heard of you in your local area but not really, you have to go win people's hearts and minds every, every single day. And so, that's tough. That means that ... I saw a patient on Friday who had a really swollen finger that I thought about all weekend and I was worried about. He had an appointment on Thursday, but I called him on Monday and I said, "Hey, I just wanted to check in. No co-pay for this. This is not a real visit. I just want to know how your finger's doing." And he was so grateful that I did that. And that's the sort of thing that wins hearts and minds.

Now, in the long run, will that lead to success, et cetera? In the long run, does that make for a better physician? Possibly. Does it foster more ownership over patients and potentially better outcomes? I hope so. But, I think those are the two potential negatives that we definitely experience. And we try to alleviate it, but there's definitely a part which is these are just the challenges you have to accept. Every place has pros and cons. These are the things about private practice that you just have to accept and be okay with, and take with a ...

Unger: And embrace.

Dr. Maniya: Yeah.

Unger: So, putting yourself in the shoes of prospective folks looking at your practice, a lot of small practices selecting physicians, obviously, in any organization, one of the most important things you can do is get somebody and get the right fit. It's almost like, I've heard it described by some as a kind of the dynamics of a marriage. This is very close working relationship. How should a medical student be looking to determine if a practice like yours is the right fit for them?

Dr. Maniya: Well, I think exposure is probably the first way. There's a lot of people who have advice on, "Look for this," "Look for that," et cetera. I don't think I'm that smart. The way I know what I like and what I don't like is by going out and doing it. And I have a pretty visceral reaction to, "Wow, I can't stand this," or "I love this. I need more of it." I think at the end of the day, most of these things come down to what your heart feels and not what your brain thinks. And so, I think the key for med students and residents is try to go out and seek out opportunities to experience this different practice model, which is hard because most training programs are at large academic institutions. And so, by the very nature, we are only shown a sub segment of how medicine is practiced.

Unger: How would a student get that experience?

Dr. Maniya: Can we start with residency? I think residency is a little bit easier. You have elective time, you can go seek these out. Ask to go rotate at X, Y, Z clinic. Yes, maybe no one in your program has done it before, but hey, you can ask for it and try to make it happen. As a med student, tactically, it's much harder. In your rotations, these are much more governed and regimented. And so, I think finding gap times, so for example, between first year and second year, you often have a summer off. Most people go and do research. Many people go and do research and maybe they get paid for it, et cetera. And so, that's a great time. Either then or right before starting med school, or maybe in your fourth year when you have some elective or free time, try to go out and literally work at a private practice.

Yes, you could do a rotation, but why not get paid if you're doing work? For example, here, we have four people, one just finished med school who is applying to residency, and we have two who are in their gap period before going to med school, and we have another person who's similar. And so, we have four people who we literally pay to work at the practice and they get to do interesting things. Yeah, they're doing some medical assistant work but they're also are doing some interesting care management, and they're fantastic workers because they're highly motivated and they're really interested in learning because they know that, "I'm not doing this just for three months. This is my career. And I really want to get into it and interact with patients and learn how to work with patients and so forth." I think those are some ways you can get that exposure.

Unger: Well, last question. The last time we talked, you talked about how you feel like primary care is broken, and I'm curious, where do you see the greatest opportunity for private practice, and why does it offer an exciting career path for a young physician?

Dr. Maniya: I still think primary care is very broken. I still think our health care system is very broken overall. And I think the key lies in patients are not cookie cutter, and health care does not have to be a cookie cutter approach to every single person. And in a smaller organization where you have less patients to focus on, where you can really tailor the testing in your office, the add-on services, the nutritionist that you have, et cetera, et cetera, around your patient population, and then even dive into the individual patient ... "Look, this patient doesn't fit into any of these boxes, so I'm going to treat them X, Y, Z way, which I just made up right now because I think it's best for the patient. And yes, we don't have a protocol for it, but we also don't have some online database with 400 protocols that I have to follow because it's a private practice." I think that's where the key is in making our health care system better.

I think there's a lot of overlap with addressing social determinants of health. I think there's a lot of overlaps in personalizing care and delivering more care in the home and more care at the right place at the right time, et cetera. And so, there's some interesting Venn diagrams that I, myself, is still trying to tease out and execute on. But, I think, overall, medicine is not cookie cutter. Patients are not cookie cutter, and being in a private practice, you can start to break down those cookies and start to just break it down the little chips and give the chips where they need to be for each patient.

Unger: Well, we're going to follow that cookie metaphor. This has been amazing in hearing your recipe for a terrific career. Thanks so much for joining us, Dr. Maniya. It's such a pleasure to see you. That's it for today's episode. We'll be back with another Moving Medicine video and podcast soon. Be sure to click Subscribe on AMA's YouTube channel, Apple, Spotify, or wherever you listen to your podcast. And you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us. Please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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