Doctor Careers: Managing Conflicting Desires When Starting a Private Practice

Transitioning from an employed role in the healthcare industry to starting your own Direct Care practice can be daunting, filled with psychological barriers and uncertainties.

To help us navigate these complex questions, and conflicting fears, we sat down with Dr. Daniel Hochman, a board-certified psychiatrist based in Austin, TX. Dr. Hochman has a private practice specializing in the treatment of mood disorders such as depression, anxiety, substance abuse, and PTSD. He is also the founder of Self Recovery, an innovative online addiction recovery program.

Doctor Careers: Conflicting Desires When Considering Starting a Private Practice

In this insightful interview, Dr. Hochman will explore the psychological and emotional challenges that often prevent physicians from taking the leap to start their own practice, offering valuable strategies and understanding to pursue your true aspirations.

First of all, we would love to hear your story, Dr. Hochman! Tell us more about your own journey to a private practice.

Now I'm a psychiatrist, and I only see patients who want to come for therapy. So I do therapy or therapy combined with medication, but not just med management. I've created a private practice that I really enjoy every day, but I had no idea that I'd end up here.

It's probably a long and convoluted story, but to keep it brief, I had to keep following what I was curious about. Longevity was also a factor, and so during my time meandering through college, I thought I was going to pursue emergency medicine. I really liked that pace. I had done some volunteer firefighting, and I just liked the whole atmosphere.

It took a little while for me to realize that I actually enjoy understanding exactly how things work, how they evolve, and where they started. Those kinds of questions are not satisfying in the ER, where it's mostly about patching up patients and ensuring they're stable before sending them to the next place. So, the short story is, I followed what I thought were my deepest interests.

In your opinion, why might doctors not start their own practices, even though they want to?

It's funny because I think it occurred to me more and more that psychiatrists do have an easier time setting up a practice due to less overhead and fewer things to juggle. In mental health, you can usually get away with Direct Care, like not having insurance involved. So, because of the current state of US healthcare, it's fairly easy to, as we say, "hang a shingle" as a psychiatrist in the US. 

Still, I've found that I have a lot of colleagues, people I graduated with, who want to do this but don't. And that started to catch my attention. It's like, well, there aren't necessarily big practical barriers, yet people still don't do it. It's easy to come up with excuses for why, say, a Primary Care doctor doesn't want to start a practice. 

There are even more reasons for a surgeon, who needs an entire infrastructure with an OR and credentialing requirements to have an ER - that's a major operation. So, it's easy to understand why some doctors feel the need to plug into a larger system. 

But when you distill it down, even a psychiatrist who just needs to rent a room and get malpractice insurance can still be afraid to do it. It is more than just the practicalities; there's a psychological aspect that prevents people from deciding to take the plunge and start their own thing.

How can clinicians identify and overcome conflicting desires when deciding to start a Direct Care practice? Example: “I want to start a practice, do something for the first time, but I also want security.”

That's a big question. So let's start meandering through it. People often take a common route: you graduate and then go work somewhere because you've got loans and want security. You need to figure out whether you're moving or renting a medical office, and so you need some stability. People start out doing that. And, we don't need to go into detail today, but hopefully, people will understand. 

"I mean, just practicing medicine as it is today is challenging. There are just way too many things wrong in healthcare, with patient demands, charting, insurance, and practice management utilization. It makes practicing so far from what you expected it to be." 

So we're kind of all real go-getters, wanting to help the world, and then you get out there, and there's just endless things to do that aren't about taking care of the patient in front of you. And so, that wears on people pretty quickly, just because of how much there is and how many hours it takes. It wears on you very fast. 

So, a lot of people are still pretty young in their careers when they start noticing, "Wait, there's no good longevity in this. It's a bad contract, a bad workplace. I'm not seeing exactly the kinds of patients I enjoy," and so on. So it's a common route to say, "Well, what else is there for me? Is there a way for me to maneuver so that I can have a practice or a career that I want?" 

And probably anyone listening is experiencing some derivative of that. Are there doctors who take a good job that pays well, see the kinds of patients they want, and get some autonomy? Of course, those jobs are out there. But, most people don't experience that. So, you get to that point. 

And then you encounter a backdrop of cultural things, too. And what I mean by that is, there's this idea of, "Hey, pull yourself up by your bootstraps. Go get a loan or some seed money to start, you know, take a risk, start a practice." And that's the American way: create a business. Don't trade your time for money, but build something. Build an asset, generational wealth, a company—something that can earn you money when you're not there. 

So, there's an American dream of building some kind of empire, and that's when you've made it. That's going to earn your status, prestige, or just financial security. And I think that is still available in this country, but it's also quite an elusive idea because it's really hard to start any business and do well. It's always a hustle, and there's a harder and darker side to all of that. 

So, I think what we're talking about is if that were easier and less risky, everyone would be doing it, and it would always work. But it is risky, and it's very hard to make work. And even if you knew there wasn't risk and that it would work, there'd still be so much work involved. There'd still be a question: "Do you really want to do it?" But then you reach this point, and it's like, "OK, I know I don't like plugging into corporate medicine." But the other side of it is not this slam dunk, easy decision either. And so it's a very difficult place to be in.

How can physicians better understand their true motivations and align them with their professional goals?

So I'll start with what I think people do that doesn't necessarily provide a complete answer. It's usually easy to say, "I don't like corporate medicine," and then decide to join or start something else. I'd call that a reflexive decision because it's reacting to what you don't like, but it doesn't necessarily mean you're moving toward what's best suited for you. Does that make sense? 

It's like if you're breaking up with someone, you might know you don't like them, but you don't necessarily know if the next person will be great or wonderful for you. So, you first just know what you don't like, but that doesn't mean you should do the opposite. And so, that's one thing to be cautious about: understanding what you're getting into. That's one part of it.

Then, I'll explain what I mean by it's not just an automatic, easy decision to start your own practice and think you'll ride off into the sunset. It's a lot of work. I'll just name a few points. You need to figure out how to get legal documents in order, decide who to hire on day one versus later. Where will you get your funding from? Are you going to lease an office? Are you going to buy a place? Are you going to buy an equipment? Do you start out of the gates doing that, or do you add these services over time? Do you bring on a partner? There are a lot of unknowns and a lot of risk. It's very difficult, and because of that, it is not suited for everyone. That's the point. Just because you don't like corporate medicine doesn't mean you're automatically the right fit for doing all these other things.

And when you start doing those other things, you might be Googling, looking on blogs, or talking to colleagues, and it's like, "Oh, look, Sally did this. Sally started her practice. Now she gets to charge a lot, see the patients she wants, and work half-time or three-quarters time. See, you can do it." And then you ask her, "Can you really do it?" And she says, "Oh, it was hard, but here are the resources. I took this class, read this book, talked to this person." And it's true that I believe most anyone who can graduate from medical school or become an NP, if you're smart and organized enough to do all that, you can probably figure out a way to make a practice work in general. So it's not impossible, and you don't have to be some business expert. 

But there are still temperament and character factors that come into play, and this is something I explore with patients. To do all that takes a certain kind of person. So, I'll start with just the most basic of them: Do you even have the time to do that? Maybe Sally could do it because she's, let's say, 33 and doesn't have kids yet. Maybe she's in a good situation, financially stable, or has wealthy parents who helped out a bit. So, you don't necessarily know what exactly helped get that person off the ground. You need to have reliable income and the time to make that happen. Can you do it on a loan? Can you do it on nights and weekends? Of course, those stories are out there, but it's a lot of uphill work. So, that's one thing—those practical considerations. If you're not the primary breadwinner and have a lot of time, it's way easier, right? OK, but let's pretend that's not the case.

"Even then, dealing with legal documents and incorporating a business is very different from practicing medicine. Not only is it a different skill, but it's also a different kind of person. There's a certain kind of person who wants to sit in a room and help people who are hurting. It's another kind of person who wants to build something and deal with administrative and business questions."

Similarly, there's a different kind of person who handles risk well. Just as in medicine, we have different fields, and it takes a certain kind of person to be a surgeon. It's not just about liking to use your hands and deal with medical situations. Being a surgeon requires a certain kind of person who is comfortable with having a life in front of them on a table, figuring things out, and getting it right—or the patient might not make it. If you can't sleep at night doing that, then it's probably not for you. That's what I mean by a certain kind of person, not just skill.

So, could anyone learn the skills to set up a business? Yeah, but it takes a certain kind of person to work in the evening, take financial risks, and be intrigued or interested in the business side. Just because you know you don't like corporate medicine doesn't mean you're automatically the right kind of person to start and grow a practice.

Let's say clinicians reading this interview have decided that, despite the challenges, they still want to start a Direct Care practice. What's next? How can they embrace their new entrepreneurial role and build confidence in their decision?

I'll start with this concept: the earlier you understand that everything is a trade-off, the better. OK, so think of it as a trade-off rather than, "OK, I've decided to do this. I'm starting it, OK, I'm going in," and then you reach all these very difficult roadblocks and obstacles. You feel like either giving up or it's just miserable. 

Instead, when you can recognize each choice you're making as a trade-off, it's a lot healthier emotionally to deal with. Let me explain what I mean. Say the first step is you're trying to incorporate a business and figure out how to structure it well. Then you get frustrated or uncertain. Instead of experiencing that emotionally as, "Damn it, it's not," you know, kind of complaining and hating it, realize from the start that this is the trade-off to working in corporate medicine. You realize you're actually just trading one problem for another. And I don't mean that in a cynical way, like, "Wow, so what's it worth? You're just going to be trading one issue for another." No, it just means what it means. 

You may be trading for a much better option, right? You get to build a practice, do something beautiful in the community, practice how you want, and help people better. It may be more beautiful, but recognize that it is a trade-off. You could have gone to work one more day in that corporate office, knowing that you saw whatever, 20 patients, and helped at least some of them. And that felt decent enough. The trade-off, then, to go start your own thing is you may not see patients for months, depending on the case. Well, that's a trade-off. And if you can recognize that this was your chosen trade-off, you decided it. It's not the comptroller, your accountant, or anybody else, including the lawyer, making your life difficult. You've come to them ready and made this trade, and now you have to deal with it. But it was a trade you made.

"You have to really believe not just in creating this clinic that is awesome and helps people, but also in where you are going to be in it. Not just financially, but in believing that you will be a happier, healthier, better parent if you can create this, so that you can, for example, finish at 4:00 PM. You have to know what this means for you, or else it becomes a mess and difficult, and you'll give up. It has to be attached to something personal, preferably not just financial or material. It has to be attached to something that you see yourself growing into—a person you are going to be proud of."

Whether that's being proud that you made it, that you could rise to the challenge, proud of what you provide to patients, or proud of who you are as a parent or in balancing your time, you have to be proud of who you are going to become in that endeavor. And then these things are trade-offs, and you're happy with the trade-offs because they're facilitating you becoming the kind of person you want to be.

Do you have any final messages for those who are starting their journey as a solo practitioner?

I'll maybe go to something harder and deeper rather than too light or easy. As you do that, don't be afraid. I'm a psychiatrist, so I have that perspective of wanting to ensure that if you're starting something and then notice, "I'm terrified about this" or "Oh, I feel so insecure when I should feel fine," it's normal. We're always facing our own demons, our own self-doubt. That could come from being picked on when you were young, growing up poor and no one knowing, or experiencing abuse. There are reasons we've become the people we are.

As you try to push yourself, those doubts will come up. It's very comfortable to work for someone else, even if you hate your job, because it doesn't challenge you as much personally. But as we test ourselves to see if we have the perseverance, the intelligence to figure things out, all our doubts and fears come up, and our defenses rise. We don't want to fail; we want to do well in everything. So, those doubts will always come up. Rather than let them take over or pretend they don't exist, address them. You're going to learn something about yourself.

"I've never met an entrepreneur who didn't discover things about themselves as they faced these challenges. That personal journey goes well beyond just figuring out things about your practice or how you want to practice with patients. It teaches you things about yourself that you'll learn from and carry with you forever."

So, the message would be: if you start this and you're super successful, great. But most people have a very hard time at different points. Different things are challenging in different ways, so everyone gets challenged by different aspects of it. Be ready for that. When you encounter it, don't just cower; figure out what it means for you. Sometimes it means facing a demon and getting through it, but also being respectful enough to recognize if something comes up that makes you realize, "This isn't actually for me." So you have to be ready and honestly assess what's coming up for you.

I'm glad to cover a topic like this because I think it's really important. The practical stuff, you know, there are books for that. But a lot of people aren't prepared for the psychological part of it. So thanks for making the time for it.