Are You Ready to Change Your Practice?

Are you thinking about tapering back your surgical practice or retiring from surgery altogether? Are you tired of the electronic medical records (EMRs), insurance denials, and constant administrative changes? Do you worry about malpractice exposure, despite practicing a good standard of medicine? Does the adrenaline no longer surge when you are performing emergency cases? Maybe your overhead continues to climb, but reimbursements do not, and future Medicare reimbursement weighs heavily on your mind? Perhaps you have a health issue that makes surgery more difficult?

These are just a few of the reasons you may be looking for—and need—a change. I decided to make the change at 60 years of age because I had health issues and no longer desired to deal with the heavy workload of a busy office practice. I did not want to leave medicine entirely, but I wanted to slow the pace and eliminate some of the frustrating aspects of my previous practice. That’s when I decided to change my working focus to independent medical examinations (IMEs). For the past four years, I have been doing IMEs throughout the state of Washington. I am also a pilot, and this has given me the opportunity to travel extensively in the state, meeting people from all walks of life and visiting diverse socioeconomic settings.

In this article, I outline some of the issues and fears a physician may face when making this paradigm shift.

Making the change

When contemplating an IME practice, you first have to decide whether you will leave your physician group entirely (i.e., retire from practice) or stay with your group and do IMEs on the side. Will your group let you practice part-time? Do you want to give up all surgery? If you stay with your group, arrangements will have to be made as to how the income stream plays into your overhead. Also, the group members may decide they don’t want IME patients comingled with the practice’s general patient population.


Eugene Pepper Toomey, MD

There are many positive aspects to remaining part of your group. You can stay in the same office with a staff you know and where all administrative tasks such as billing and tax and Health Insurance Portability and Accountability Act (HIPAA) compliance are already done. If you break away from your group, you will have to purchase separate malpractice insurance and devise compliant procedures to handle the extensive paperwork associated with IMEs. I prefer not to deal with paper and store my records electronically with a HIPAA-compliant program called “The Box.” Other options are available.

Depending on the state in which you practice, deciding to go out on your own can be a fundamental change. Do not underestimate the work involved. You can set up a completely independent office, including administrative work, accounting, collections, an information technology department, and dictation and transcription services.

You also can use an exam company to collect records, put together charts, handle collections, and transcribe reports. Such companies specialize in IMEs and can be found easily on the internet. Most IMEs are performed at an office that is owned or rented by an exam company. Your only responsibility is to see the patient and create a report. However, you are not an employee of the exam company. Therefore, you must set up and comply with the rules of forming a business in your state. You also will have to comply with federal tax laws and Medicare withholding.

If you choose to leave your practice and go out on your own to do IMEs, it’s important to remember you are not treating patients—you are only evaluating them and providing your opinions. If you want to continue treating patients, consider a part-time clinical practice, even one that is nonsurgical, or performing part-time charity care. I run an orthopaedic clinic for primary care residents 1.5 days a week and find it very gratifying. The residents bring their enthusiasm, make you think and read, and appreciate your experience and teaching. We see many under­insured patients who are not able to get into other orthopaedic offices. Staying involved in clinical medicine helps you keep current in your field and is a good way to keep your clinical skills sharp.

Making the decision to change your practice can be scary. I do not know the secret to overcoming this fear, but, for me, change was a good decision. If this direction appeals to you, I recommend doing a few IMEs during your clinical practice before you fully commit. It will give you some idea of what to expect. I started doing the occasional exam in 1995 and was familiar with the process when I terminated my surgical practice. Several organizations, such AAOS, American Board of Independent Medical Examiners, and SEAK, offer courses on the subject. The AAOS course “Improving Your IME Reporting” is excellent; the next one is scheduled for Nov. 7.

In summary, just like anything else in medicine, there are advantages and disadvantages to doing IMEs. Advantages include lowered malpractice concerns and therefore lower rates. Your overhead is much less, as your need for staff is minimal, and you don’t have to deal with EMRs or insurance issues. Some may consider the amount of travel required a disadvantage, although this can be limited at your own discretion. In some cases, you may be asked to go to a claimant’s home community for an examination.

The demand is high for physicians who have a good working knowledge base and good clinical skills and who work hard to produce solid, nonbiased IME reports. The main disadvantage is that you only evaluate patients and do not have the opportunity to engage them or get to know them as you do in clinical practice. Do not underestimate the importance of a good IME report and the long-term consequences for a claimant. Often, an IME report is critical to get a claimant back to work or have a claimant declared impaired or even disabled. Similar to your medical practice, the success of your IME practice relies on your own work and effort. My advice is to try a few and see whether you like this type of work. After a half-dozen cases, you’ll know whether this is how you want to channel your medical career as you contemplate leaving orthopaedic surgery.

Eugene Pepper Toomey, MD, is a licensed pilot, and his work often requires him to fly to the far corners of the state of Washington to see patients. He did his orthopaedic training at the Mayo Clinic and practiced general orthopaedics before becoming a foot and ankle specialist in 2000.

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