​​Getting Ahead in Private Practice Neonatology

Expanded Newborn Care

The one-year of fellowship allocated for clinical training is intensive-care focused in almost all training programs. Neonatal training programs do an excellent job of preparing fellows for the care of the small critical care baby or the very sick term infant with cardiac or congenital anomalies, severe asphyxia, metabolic disease, or infection. Nevertheless, clinical activities involving non intensive care patients (normal newborn nursery, Level II coverage, follow up clinics, etc.) is becoming more pervasive among neonatal practices. This expanded scope of care by neonatology is seen also at the University level, but often this care is assumed by clinical staff physicians (sometimes neonatologists, sometimes pediatricians) and often is not included in fellows' responsibilities. In the past, general pediatric newborn training was more extensive than now, and general pediatricians assumed care of convalescent preterm or sick infants, larger premature, and late-preterm infants in addition to the normal nursery population. Now, general pediatric training in newborn medicine is less comprehensive and general pediatric practices often wish to accept new newborns only after their inpatient neonatal management has been done by the neonatology service. Although the expanded scope of practice impacts academia as well, demands for total newborn care may impact private practices more profoundly.

Private practices need to determine how the expanded scope of practice is to be met. Exclusive assignments to intensive care duties may be desired by some neonatologists. Realistically, the intensive care demand in most settings is insufficient to restrict neonatologists' attention solely to Level III care and also secure enough total practice compensation to be able to add the number of colleagues required to allow for time off, a reasonable call schedule, attention to other mandatory practice responsibilities, and the like. Responding to the pediatricians' desires to relinquish newborn care and the institutional and/or obstetrical desires for universal availability of neonatologists, especially at high-risk or operative deliveries, many private practices have assumed responsibility for the whole range of newborn care. How these needs are met varies: in some, practices have secured general pediatricians to oversee the expanded scope; some have incorporated advance practice nursing or physicians' assistants; and, others now expect neonatologist colleagues to assume these duties. Data do not define the balance (and time spent) required for one's intensive care involvement to be sufficient to maintain proficiency, although data are available demonstrating an association of improved outcome and numbers of (high risk) patients treated annually in a NICU. On the other hand, some clinical duties of general pediatrics are unlikely components of neonatal fellowship (eg, transitional care, circumcisions, assessment of breast feeding in the term infant, maternal counseling regarding cord separation [not all cords are cut off; some actually come off on their own!], diaper rashes, bathing, etc) but require knowledge and experience to evaluate, perform, manage, or provide counsel to the family.

Practices with an expanded scope of care need to define the expectations and limitations in their unique situation and proactively structure the practice. This demands ongoing growth that will be determined both by practice needs and values and the individual goals of each physician. Every member of the practice should be aware of the full scope of work that needs to be accomplished. It is not necessary to have each group member participate equally in every phase of this work (see section on "Collegiality"); it is necessary to share this workload equitably, or to be compensated for appropriately for any inequalities. Trade-offs can work. For example, because of his or her interests one group member, , may devote more time doing outreach education than others but less time in follow up clinic, formal teaching, or administrative duties. Practices having a diversity of activities should establish a plan for workload distribution as part of the preparing to recruit process. Potential new group members should be interviewed with this plan in mind and be asked to voice their interests so as to determine if his/her career interests can fit into the mission of the practice.

The first year out of fellowship, many new members will devote a greater share of their time to clinical care in the NICU. Out of a sense of fairness, and consistent with the expectations of the generation X or Y individuals now entering practice, wise practices will transparently disclose the time and effort contributed by all practice members. It should be expected, however, that each year there will be a greater involvement in some of the non-intensive care activities in which younger colleagues demonstrate interest. In some arenas, such as administration, mentoring can be an effective tool to incorporate new associates.

How smoothly this transformation occurs will help determine both personal satisfaction and success in reaching the goals of the practice. Some questions to think about:

• What are the non intensive care activities of the practice I am joining and how are they valued within the practice?
• Which of these activities fit into my personal goals for a satisfying career?
• What is the plan of the practice for incorporating me into these activities?
• Who will be my mentor for these activities?
• How will new ideas that I may bring related to non-intensive care activities be accepted by the practice?

Maintaining Clinical Quality

Everyone will agree that provision of high quality medical care is essential if we are going to find satisfaction with our careers. For most physicians starting into private practice, it is the first time they will be practicing outside of a very structured academic environment. However, this does not mean that continual learning and ongoing personal educational growth does not occur outside of the academic world (despite some myths to the contrary!)

Challenges in some private practice venues that may make this personal growth more difficult:

• Fewer organized opportunities to attend lectures, seminars and journal club than there are in the academic community
• Lack of the continual stimulation of fellows, residents, or medical students who challenge you to provide scientific reasons for your practice patterns
• Rounding often more individual than group based, decreasing exchange with colleagues at the bedside
• Greater degree of personal responsibility in assuring ongoing learning
• Complacency with the status quo

Opportunities for growth can be created and be found.

• Maintenance of Certification should be supported by each practice. Initial certification requirements often are stated in the interview process and included in employment contracts. Although some senior colleagues may have "lifetime" certification, the ABP will confirm maintenance of certification only for those certified neonatologists actively participating in MOC. Institutional privileges, insurance credentials, and potentially state licensure may be dependant on MOC participation. Practices should support MOC participation, including commitment to part 4 (practice outcomes analysis and quality assurance) completion and part 3 (examination) preparation.

• ​Commitment from the practice to remain on the cutting edge of new ideas and technologies through an evidence-informed process of evaluation and introduction of new ideas.

• Multidisciplinary care models. Most nurseries that do not have pediatric residents rely heavily on both NNPs and staff nurses who take on a greater clinical role. This provides a great opportunity to learn a collaborative care model that enhances overall patient and family outcomes.

• Keeping abreast of change. Practice policy should support educational activities. Keeping up with current literature and best practices must remain a top priority for each individual physician as well as the practice as a whole.

• At least one member will attend the major neonatal conferences and share their ideas with other group members and the rest of the NICU staff.

• Regular journal clubs

• Regular review of any quality indicators gleaned from participation in national databases. Programs developed or assimilated to address outcomes and change should be considered for qualification by the ABP for part 4 MOC credit.

In addition, private practices seeking new associates and fellows considering a private environment should consider answers to such questions as:

• What opportunities do I have within my practice to grow professionally?
• Does my unit participate in a national database? If so, how do we utilize the data we receive to improve care practices and facilitate MCO?
• Does the practice facilitate me to structure structure time to stay abreast of new literature, research and best practices?

Learning the Business of Practice Management

It is very unlikely that any new member of a private practice group will be given initial responsibilities in the financial or business aspects of the practice. This does not mean, however, that new members should avoid becoming proficient in this very important aspect of private practice. In the interviewing process, it is reasonable to discern the legal structure of the practice. Solo practice, partnerships, and professional corporations have different structures for financial management, but in the end practice associates are ultimately responsible. Although one enters as an employee, often employment leads to shared ownership and direct financial responsibility. You will likely find that practices do not want to initially "open the books" to new group members very early in their career, but smart practices will realize that it is important to begin grooming members to take on this role relatively early. In fact, it is an area that can almost guarantee long-term success in a practice, since most groups have one (or maybe two) physicians designated to handle most of the "business" questions. On the other hand, practice associates in partnerships, professional corporations, or practice plans should receive periodic reports of the business' health and having proactive audit and review activities is helpful to avert inappropriate diversion of practice resources (eg, embezzlement).

In the interviewing process, inquire how the practice exists as a business entity. The business aspects may be assumed by an associate as discussed above, or the practice may contract for these services. If hospital employed, determine what department of the hospital will be responsible for the practice's business and how business matters are communicated with the practice. Spending time with the practice's business leader, or with an office manager, business manager or billing personnel can provide valuable education about proper coding, typical reimbursements, how contracts vary among different insurers, and the overall costs involved with running a practice, including office space rental, utilities, staff, etc. Even without disclosure of specific figures, you should be able to discuss the sources of practice income (patient billing, administrative directorship stipend, faculty stipends, grants, non-clinical work reimbursement) and general financial procedures of the practice. The business aspect of the practice should be rigorous, reviewed regularly, audited periodically, and adjusted to conform to regulations.

There is a direct relationship between coding and reimbursement, and physicians are responsible for assuring that codes assigned are appropriate for the care actually provided and that the record so documents the care. The Section on Perinatal Pediatrics has an active coding committee and presents regular educational sessions for neonatologists. Rigorous attention to coding and documentation is essential. The practice that ignores or abuses its coding is at great risk at time of audit.

It is vital for both your future and the future of the practice to stay proficient in this area. Some questions to consider:

• Are the senior colleagues open to discussions and willing to let me learn the business aspects of the practice? If so, when?
• Who will be my mentors in this learning process?
• How are the books reviewed and audited?
• ​What opportunities do I have outside the practice to learn proper coding and documentation (e.g., Perinatal Section and other AAP resources)

Practice Organizational Structure and Governance »​​