Is the grass greener? Life as an ID physician working in private practice

Paul Sax: [00:00:11] Hello, this is Paul Sax and I'm editor-in-chief of Clinical Infectious Diseases. And welcome to the next Let's Talk ID podcast. Joining me today is Dr. Alice Han. She is a senior partner at Metro Infectious Disease Consultants. And this is the largest private practice ID group in the country with over 100 physicians based in multiple states, including Illinois, Michigan, Georgia, Alabama, Arizona, Missouri, Kansas and California. Alice, did I forget any?

Alice Han: [00:00:38] No, I don't think so.

Paul Sax: [00:00:40] Okay. Anyway, I've invited her on because the I think the proverbial elephant in the room, to use that cliche about clinical practice and about ID fellowship, is compensation or lack thereof. And one thing that Dr. Han has expressed some optimism about on social media is ways to actually overcome these barriers. And so I wanted her to just start us off. Alice, tell us a little bit about yourself. Anything. Where you grew up, how did you become a doctor? All those things.

Alice Han: [00:01:08] So a little bit about myself. I grew up in Michigan. I spent probably eight years in Ann Arbor, Michigan, doing my undergrad and med school there. I feel like I'm similar to a lot of other doctors who, when they were growing up, they just wanted to like help people. So that's why I decided I wanted my life to have some meaning or impact. And I felt like being a doctor was the easiest way to get there.

Paul Sax: [00:01:33] Yeah, that's extremely good reason to become a doctor. And then when you make that doctor decision and then somewhere along the line you say, I want to be an infectious disease doctor. How did you make that decision? And also, were there any other specialties under consideration?

Alice Han: [00:01:47] I kind of went through a lot of different phases in terms of what I was, you know, trying to decide what I wanted to do. I actually even went through like a phase where I thought I wanted to be a surgeon, where I was like in love with being in the operating room. And I loved, like, the intensity of the field. But I had a really good senior resident or chief resident at the time, and he said, Alice, I mean, you'd be a great surgeon, but you know, if there's anything like anything in the world that would make you happier, just just pick that instead. And I'm very grateful that I took that advice. But actually, when I was in medical school, I think this is something that people don't think about that much when they're in training. When we talk about medicine, we want to think about the parts of medicine that actually make you feel good about yourself and what you're doing. For me, actually, I didn't start in ID. I actually had matched into PM&R. I had done a rotation at Stanford in California, and I saw a lot of spinal cord injuries, TBIs, strokes. And I just I loved seeing people get better. You know, they we would start with this traumatic event. You know, you just carry them to their discharge. And I just loved all the work that went into it.

Alice Han: [00:02:56] So it was actually when I became an intern in New York City. It was my prelim year. I was only supposed to be there for one year. When I got there, it was a very, you know, Ann Arbor is a wonderful place to train and I love it so much. But back then, you know, years and years ago, I'm quite old. But back then, you know, it was a very homogeneous community. So I had literally only seen one patient living with HIV. And when I went to New York, I was seeing so much more. I mean, we had two really full services just dedicated to patients with HIV, and I just fell in love with it. I loved the acuity. I loved the science. I loved trying to figure out these, like, complicated, opportunistic infections. And it's kind of similar to PM&R in that I loved seeing them get better. You took a relatively otherwise healthy young person and you totally changed the trajectory of their life. So it was a bit of an ordeal. I had to get out of the match, and then my residency was gracious enough to let me stay, and then I ended up doing ID in Chicago at Rush. But because of this, like getting out of the match, I actually did a gap year where I was a hospitalist for one year.

Paul Sax: [00:04:08] How would you compare the experience of being a hospitalist and being an ID doctor? The reason I ask is because a lot of people who choose to go into hospital medicine say, Why should I do an ID fellowship if I can get paid just as much, if not more, for hospitalists work and not even have to do those extra years of training?

Alice Han: [00:04:24] That's one of the myths, especially if we're talking about private practice, that you're going to make more being a hospitalist than an ID physician. And that's, I think, one of the things that we do need to talk about. But if we're just talking about the work itself, I hated being a hospitalist. It was terrible. So back then you had to apply for ID fellowship during your second year, not your third year.

Paul Sax: [00:04:47] Yep, I remember that.

Alice Han: [00:04:48] And so because I had such an ordeal with the match, I decided, you know, let me just be extra sure. And I had this gap year, so I thought, I'll be a hospitalist for a year until my fellowship starts. And it's a lot of managing different people. And instead of like the actual medicine, you're managing consultants, discharge planning. It's just not really what I wanted to do. The nature of the work wasn't gratifying. I was seven days on, seven days off, which some people in their minds think. You know, when I started I thought, this is going to be great. But the seven days off, I was so exhausted, I didn't have any energy to do anything. And then the seven days on, I was so busy that I didn't have time to see my friends. It was just not the type of work that I would enjoy doing.

Paul Sax: [00:05:35] Yeah I mean there's something I'm not going to say unnatural, but something strange about the seven on seven off and I haven't heard other people articulate it quite that same way. Maybe for some people it works out well, but I sort of get what you mean. So you decide that you're going to do ID. Did people try to talk you out of it or did they say, That's great, you know, you're perfect ID doctor or how did it work out? You know, in residency, it's not cardiology, It's not gastroenterology. It's not, I mean, at least here at this hospital, Hemonc, those are the three most popular specialties in most residency programs. What did your residency program say to you when you said, I want to be an ID doctor?

Alice Han: [00:06:14] Honestly, my assistant program director was an ID physician and a lot of the people in administration were in IDs, so they were all thrilled.

Paul Sax: [00:06:23] Great.

Alice Han: [00:06:23] I mean, they were, I felt massively supported when I made that decision. And I think that back then there was never this talk that, like ID physicians made less than primary care physicians back then. They said, you're actually going to make more money.

Paul Sax: [00:06:41] Got it. Okay. So then you do your ID fellowship and I'm going to shift away from the experience clinically of your ID fellowship and ask you about career counseling and what sort of career counseling did you get during your ID fellowship and what sort do you wish you received?

Alice Han: [00:06:58] I was really fortunate. I trained at Rush and Cook County when Dr. Gordy Trenholm was a program director and I trained under Bob Weinstein, who was the chairman of the Department of Medicine at Cook County. And Dave Schwartz was the head of ID. And the thing that I appreciated so much about them as individuals is they really cared about us as people, and they really cared about us being happy in our careers. And so it was very clear to me early on that I just was not interested in research. I liked doing clinical medicine. I liked seeing patients. And Dr. Trenholm connected me to several different private practice groups in the Chicagoland area, many of whom were prior fellows. He told me MIDC was a really good group of guys, so I ended up interviewing at a few different places.

Paul Sax: [00:07:52] You have to define what MIDC is.

Alice Han: [00:07:54] So MIDC is Metro Infectious Disease Consultants, which is the group that I'm in right now and I've been with for the last, like 12 years.

Paul Sax: [00:08:01] Got it. Thank you. I knew what you meant.

Alice Han: [00:08:04] One piece of advice that really nobody talked to me about is the contract. And when I was doing interviews, it was hard. Everyone's really lovely. They're really nice. They describe their practice. You think this is kind of maybe the lifestyle I would want. I work at one hospital. I work. You know, this is my call schedule, but I think the contract is really important because it's actually your first honest conversation with your employer. When I got my two contracts, my MIDC contract was extremely straightforward. This is your base salary and you are going to make 20% over whatever you collect above a certain amount. And that was how much I was going to make. Whereas my other contract was, you know, if this, then that maybe this, maybe that. And it was so convoluted, I couldn't really understand how I was going to make money, how much money I would make. It was really confusing. And so, you know, one of our founding partners, Dr. Petrak, he always says when you look at a contract, you want to look at how you get in, how do you advance and how do you get out. And it needs to be really clear and straightforward. I didn't need a lawyer to look through my MIDC contract. I mean, I could have, but it was easy and simple enough for me to understand. And I think that's really important. Nobody really taught that to me. But that's your first real honest conversation with your employer.

Paul Sax: [00:09:26] That's a very, very good point. I want to bring up something, which is that IDSA is right now offering fellows a one-on-one physician compensation session in order to address some of these issues. And then pretty soon it's going to be open to the entire IDSA community, including people who are already out of fellowship. I would love to hear if you could tell us a little bit about the position you have, the practicalities of it, you know, where you're practicing, how you split time between hospital and outpatient work, travel clinic, HIV, your patient profile, call schedule, whatever you want to mention.

Alice Han: [00:10:03] So I'm a senior partner at MIDC. I've been with a group for 12 years. I'm part of the MIDC executive committee. And I also manage the north side of Chicago, which is about 15 doctors. I am primarily located in one tertiary care center. I do one half day of clinic a week and I do a half administrative day. And most of my practice is in the hospital. I'm seeing patients mostly doing inpatient consults every day. I do one weekend call a month. My practice has actually changed quite a bit since I first joined the group. In the beginning when I first started. Like I mentioned before, I was really in love with taking care of patients with HIV. And I think it's important for people to understand that our patients are everywhere and sometimes they don't have the capacity to get to maybe the CORE center or Howard Brown, which are our main HIV clinics in the city of Chicago. And so they will go to their local hospital. They take public transportation to the closest clinic. And so I was seeing a lot of patients with HIV on the near west side of Chicago for the first few years of my clinical practice. And then I was doing a lot of infection control, antibiotic stewardship for about five years at Gottlieb Hospital. Over the last 3 to 5 years, they recruited me to develop the infectious disease component of their bone marrow transplant program. So Dr. Julio Rodriguez was doing bone marrow transplants at Loyola for many years, and he was recruited to the advocate health care system. He has been a wonderful mentor for me and has helped me assist in developing that program.

Paul Sax: [00:11:48] So let me ask you some targeted questions. Let's say you're seeing someone in the hospital and they need OD follow up. How do you arrange that? You're in the outpatient setting a half day a week.

Alice Han: [00:11:58] We have an amazing infrastructure for our group and that's one of the things that allows us to be much more productive and efficient. We have an office full of nurses that help us with all of our appointments, as well as following up all our labs for our outpatient infusion patients. And they know. So if I have patients who are on the outpatient side on IV antibiotics, they look through my labs every day. I will check on them myself every week that I'm in clinic, that half day. But if there's anything out of the ordinary, they'll take care of it. So if there's an elevated potassium, they'll let me know and then I can ask them to send those labs to the primary. Or if the LFTs are elevated, I might ask them to stop the antibiotic, repeat the labs, so they'll take care of all of that. I just send them an order, but they'll notify me if there's anything abnormal. We have a whole office dedicated to infusion, so they will set up everything for us. So if I have a patient who needs outpatient IV antibiotics, either when they're in the hospital or if I have them in clinic, they will take care of all of that. If I have a patient who needs a prior authorization for a certain antibiotic, they will take care of all of that. It really improves our efficiency. It helps us with our time. We also work a lot with extenders. We have wonderful PAs and NPS that really help our efficiencies in the hospital. So they'll help us with notes, with orders. We still see the patients that make all the decisions, but I mean it's incredibly valuable and helpful and it helps us kind of focus on the stuff that we really enjoy, which is seeing the patients, you know, solving complicated cases, developing those relationships.

Paul Sax: [00:13:37] And you must have a free standing clinical site.

Alice Han: [00:13:40] Yes. So we have multiple offices throughout the Chicagoland area. We typically will base our clinic closest to the hospital that we're primarily located, but we have clinics spread throughout this whole area just depending on geographically where the most volume is.

Paul Sax: [00:13:57] So let me just put it to you straight. The reason why most ID clinicians don't have that kind of support is because when administrators look at the RVUs we generate, they say, look, you know, this is just not going to cut it. Yes, we appreciate your services, but you're not going to get an army of nurses and PAs to cover your activities and you're not going to get an infusion center for your antimicrobials. Just be joining with the rest of the group and the infusion center we have or whatever it is. So how does it work financially? Is this something that you already knew about when you entered practice, or did someone sit you down and say, this is how the money works?

Alice Han: [00:14:32] Well, I'm blessed because that infrastructure was already built in and we have brilliant minds in our senior management who created the system. But I always find it really arbitrary, this idea of RVUs and how much money is generated by your consultation and how much people are really bringing in. And so that's the thing that is really nice and clear when you're in private practice, at least in my group, is that I know exactly how much money I'm bringing. I'm seeing exactly how much money I am collecting just from my billing, and it is enough to cover for a PA for nursing. I mean, we also, we're a larger group. So we share some of those costs. But if we're looking at especially in infectious disease consultation, which is so detailed and so thorough and so complicated, we need to be billing at those rates and then making sure that we're getting compensated for our time.

Paul Sax: [00:15:27] And that's helpful, some transparency there. So when people say to you, look, I wanted to be a hospitalist because frankly, I had all this debt and I needed to start paying it back and I didn't see any financial advantage to my going into ID, even though I like it more than hospitalist work. So you can counter and say...

Alice Han: [00:15:46] Yes, we looked at that Medscape study where they published, you know, that average ID physicians made about 260 or $270,000 and we ended up doing a survey of our own and it should be hopefully going up soon on pre-pub and published this summer. But we have over 100 doctors in our survey. We ended up interviewing or surveying anonymously 70 doctors in our group. We excluded the ones who were part time, the ones who were founding partners, the people who had maybe just switched from part time to full time, new doctors that we had just hired within six months. But we surveyed 70 doctors and 67 responded. Over 40 were partners. About 25 or so were employees. What we found was that our employees, on average, made about 310, $315,000, and our partners made on average over $610,000. It's the elephant in the room because nobody wants to really talk about how much money we actually make. But being in private practice infectious disease, having total transparency, you can actually make a very good living doing private practice.

Paul Sax: [00:17:06] You know, it's very refreshing to hear you talk about it. And I give you credit for being specific about the numbers because that's one of the strange things about academic medicine in particular, is that these topics are often sort of obscured and the specifics are often obscured. Alice, something that's important to everyone is work life balance. Do you think you have that in your current position?

Alice Han: [00:17:27] Yeah, I do have a very good work life balance. For me, I'm a morning person, so typically my day will usually start with like a run or a walk with my dog and then I try to get to the hospital by 7:30 to 8, and I usually finish work by somewhere between 4 and 5. And I think that what makes it easier for me to accomplish that is I have a really good team that I work with. At my hospital, for example, we have 3 or 4 doctors, two extenders. We can make our schedule more flexible based off of our personal lives. For example, if I have to leave work early for a doctor's appointment, my partners can cover or take the late consults or vice versa. Having an extender there just makes things so much easier. When we talk about work life balance, I think that many people get bogged down by all of the bureaucratic tasks that we have to accomplish. So paperwork, prior authorization, charting, all of those things. So we have that infrastructure in place where you have extenders, clinical nursing staff, all of those people that make our lives a lot easier. Just to reference the comment that you said before about how sometimes departments say that there's not enough funding for those for that staff. Actually, what we found is that having extenders actually increases our profitability because it improves our productivity. So it's been valuable all around.

Paul Sax: [00:19:04] How about vacation?

Alice Han: [00:19:05] So I just got back from vacation. We as employees get four weeks of vacation a year. As a partner, you can take as much vacation as you want, keeping in mind that you eat what you kill. So if you take more time off, then you're going to make less money. The nice thing about our group is that the first three years that you're in practice, they teach you about your financial viability. You're always looking at your profit and losses to see exactly how hard you need to work to make the amount of income that you would like. For example, some of our older partners who are closer to retirement have decided, you know, I don't need to make as much money so they take more vacation time. When you talk about work life balance, that work life balance for each individual person is going to be very different depending on your phase of life. Maybe you're going through some type of health issue or perhaps you just had a baby, or perhaps you're going through a pandemic when you are forced to kind of work a lot harder. And so what makes it balanced for you as an individual is having autonomy, Being able to create your own schedule and make your own decisions about how hard you want to work. Because we have such a good support system that makes it much easier for all of us to do that for ourselves.

Paul Sax: [00:20:27] It sounds like the transparency in your practice is great. Enables people to make decisions that suits them best.

Alice Han: [00:20:34] Yes, absolutely.

Paul Sax: [00:20:35] Let me shift a little bit and focus on something that happened in the last three years or so, and you might know what I'm going to mention, but it's COVID-19, and I'm sure you saw this Medscape recent poll,since you've mentioned Medscape. Looking at happiness, happiness before the pandemic, ID docs were kind of right in the middle of the pack. And then after the pandemic we dropped way to the bottom and our numerical drop was the worst by far. Even though there's flaws to these Medscape surveys. And you could say, Look, it's not representative. I mean, that says something at least. And I want to ask how in private practice you weathered this storm we've just been through and we hope doesn't come back.

Alice Han: [00:21:15] During the pandemic, well before the pandemic, we would have monthly educational conferences. We'd kind of replicate what we do in fellowship, where we present interesting cases. We try to figure out the differential, and then we go through a presentation. But what happened is when the pandemic started, we moved to weekly COVID conferences. We're in multiple states. So we were talking to physicians in Kansas, Alabama, Atlanta, Michigan, and every Thursday morning we get on a phone call. We would talk about what we were seeing. We would go through all the research. We would go through all the therapeutics. We would go through the studies. We would see what were the flaws in the studies, what we think was actually working, what was not working. We go through the vaccine trials. The pandemic was really tough. There were weeks where we were just vent to each other and talk about, Hey, this is really hard. This is the day that I had today and this is what we're going to do to help each other cope through this. So it was actually a wonderful bonding experience for all of us. During that time, we gave 85,000 vaccine doses. We did over 1000 doses of EvoShield. We did over 1800 treatments of monoclonal antibodies. I mean, we did a lot during the pandemic, and it's something I'm really proud of my group for doing.

Alice Han: [00:22:31] The other thing that we did was we were getting, like everybody else, just killed on the weekends because like I said, we work one weekend a month and the hospitals were overwhelmed. Everybody was critically ill during parts of the pandemic. And so the thing that I really appreciate about our group is that they value the people. And so they paid us extra to work extra on weekends. They gave us like $1,000, $2,000 to work an extra week. And we put a lot of money. And it's not that money is everything. Obviously. It's not everything. But the problem is, is that, you know, when you're working really hard and you're are putting in all your effort and you're doing the best that you can, money is a concrete way of saying, we appreciate you, we value you, we know how hard you're working. And so saying it is one thing, but actually putting your money where your mouth is, I mean, it's a totally different thing. It feels different. I think for us as a group, we actually got a lot stronger. And in terms of job satisfaction, career satisfaction in our survey, I mean, over 90% of our employees and partners were very satisfied.

Paul Sax: [00:23:44] Excellent. A good message. You know, the camaraderie of the community during the pandemic was terrific, but the stresses and the controversies were also very hard. So it's good to have that support group. One other specific issue that I think deserves mention is that doctors are often asked to do things for free. You know, the most common is the curbside consult, the Hey, I have a quick question. You know, or I like to call it clinician advice because curbside consult sounds like it's pretty meaningless. And even if they just take a couple of minutes, they're very disruptive and nobody seems to recognize that they have value. So how in private practice do you manage these requests? Because I assume like other doctors, you must get a lot of them clinician advice questions, you know, take a look at this antibiogram and create it for us. Help us with antibiotic stewardship. What's the process by which you turn that into actual recognized effort?

Alice Han: [00:24:42] The one thing about a curbside consult is that I personally am not a huge, like probably most people, not a huge fan of the curbside consult because one, I just don't know if all the information I'm getting is completely accurate and I don't like to give advice without having the full picture. Oftentimes when somebody asks me, Hey, I have a curbside or I have a question, I'll listen and I'll usually say something like, That's interesting or that sounds a little bit more complicated. Do you want me to go see the patient like I don't mind. Or do you want me to see the patient in my clinic? They're usually extremely grateful because they actually do want to ask you for a formal consult or they do want your opinion and advice, but they're, you know, don't want to burden you. And I think it's important for you to be compensated for your time. So, one, you're going to actually give advice based on the whole picture. And then also you're going to get compensated for that. In terms of antibiotic stewardship and infection control, as ID fellows oftentimes were so eager to like prove yourself, do a great job, like volunteer for everything.

Alice Han: [00:25:42] One of the things that Dr. Petrak has always been wonderful about is protecting our time and making sure that we're compensated for our time. When they asked me to do the infection control at Gottlieb Hospital, initially I was taking over for someone who in our group who was retiring, they said, Well, she doesn't really have a lot of experience doing this. You know, I had never done infection control before, so they really gave me like a lower contract amount. And so he was very clear with them and said, okay, we'll do that for one year. But if she does a good job next year, you're going to have to pay her the market rate. And because we have like over 50 contracts in this area, we know what the market rate is the next year. I think I had saved about $40,000 in something really simple like antibiotic dosing. When we negotiate the contract, you know, I made double in terms of my contract negotiation. So I think that's important to have somebody who advocates for you.

Paul Sax: [00:26:39] Great. Good advice. One area where actually defend the clinician advice service has been, at least at our institution, is the outpatient e-consult model, which are non-urgent questions from mostly primary care clinicians, but also other groups. They are not done urgently. You know, they're like, You have 24 hours to respond. I feel like it's a really good service and you don't really need to see patients to answer questions of whether they need a new pneumococcal vaccine. But I think it's tremendously undervalued. I mean, we do get paid a nominal amount for answering them, but it's the amount hasn't been increased in like 15 years and inflation certainly hasn't stopped. Anyway. That's just one area where I think we can, I wish we would think of a way of monetizing that. A couple of last questions. If you were to be asked by a fellow what the keys are to having professional satisfaction in ID, what would you say?

Alice Han: [00:27:37] I think it's interesting just talking about ID as a field, because just going back to when you're deciding what you want to do in life, I think it's really important to look at your own personality. My best friend, he's a neuro-oncologist and most of his patients, when he meets them, they have less than six months to live. And that's a gift that you're able to help somebody transition someone into the end stages of their life. And he really enjoys it. But for me, that's just not my personality. I love seeing patients get better and nothing makes me happier than to see one of my patients with HIV, when I saw them with pneumocystis pneumonia in the ICU and then a couple of years later, they're thriving. They're doing great. They're getting their nursing degree. It's just those things make me so happy. And the nature of the work is really important. We need to start dispelling the myth that you're not able to make money doing it. You know, nobody really wants to talk about money, but we have to we have to talk about it and understand that you can make a very good living doing what you love.

Paul Sax: [00:28:45] And a resident comes to you and says, I'm thinking about ID versus primary care or versus hospitalist medicine. You say to them?

Alice Han: [00:28:54] I mean, ID is the best field. It's so dynamic, it's always changing. Even myself, like I said, I love seeing patients get better, but also I like to be challenged every few years or so. So I started my practice doing a lot of HIV medicine. I did a lot of infection control and antibiotic stewardship. So if you like systems and you like looking at big quality projects, you know, there are so many different facets to ID. Now I'm doing a lot of transplant medicine, which is like changing all the time because there's so many new biologics and different treatments for cancer that affect the immune system in different ways. And so we're seeing different types of infections. I mean, infectious disease will never be boring. It's always going to be mentally challenging. It's always going to be rewarding because for the most part, we've been pretty good about solving these problems for our patients for the most part, get better. So I think it's one of the best fields in the world. The only thing we need to address is that you can make a decent living doing infectious disease.

Paul Sax: [00:29:57] Alice, any final words?

Alice Han: [00:29:59] Thank you so much for having me on this podcast. It's really been a privilege to be here and I think this is a really important conversation. I'm really grateful to have the opportunity to talk about it. If anybody has any questions about private practice ID, you can email me at Ahan@innovativeventures.com or you can find me on Twitter at @DrAliceHan.

Paul Sax: [00:30:23] Alice, It's been great chatting with you. I appreciate your taking the time to be on this podcast. And once again, I've been talking to Dr. Alice Hamm. She's a senior partner at Metro ID Consultants in private practice. And we've been talking about a different view of the finances of the ID specialty. Thanks so much, Alice.

Alice Han: [00:30:40] Thank you.