Employment vs. private practice: 7 orthopedic leaders weigh in

Orthopedic

From less independence to higher pay, physicians often have to make several tradeoffs when deciding between employment and private practice. 

Seven orthopedic and spine specialists told Becker's some of the pros and cons of physician employment versus private practice in 2025. 

Shehzad Choudry, MD. Director for Interventional Spine and Pain at Orlando (Fla.) Health Interventional Spine Pain Department: The biggest benefit is that I don't have to worry about operations of the practice. I focus on providing the best clinical care for my patients. When I worked in private practice, I spent at least 10 hours a week, addressing all sorts of issues- staffing issues, compliance, as well as making sure we had enough hand soap and toilet paper. You cannot compare the two types of practices as they are so different. The grass is not always greener. But being employed works for me and it does let me focus on the best care for my patients.

Harel Deutsch, MD. Co-Director of Rush Spine Center (Chicago): Overall, I think that private practice is important for the future of the medical profession. Once you are an employee, you lose autonomy and control of your environment to a great degree. Working as an employed physician, there are some advantages such as the ability to work in a large organization with more resources. Physicians are more able to concentrate on just patient care and they can have a more predictable work schedule.

Brian Gantwerker, MD. Neurosurgeon at the Craniospinal Center of Los Angeles: Working as an independent neurosurgeon has been an extremely fulfilling part of my life. If anything, at the beginning, I didn't know how to properly balance family time and work time. I found myself doing charting late at night and not paying attention to my family.

I've learned to balance things much better now while maintaining an independent private practice. Being able to manage my own schedule I can make sure I'm getting enough family time and that I can go on hikes with my son and go on day trips with my wife when he is away at camp. You can set your schedule, see the cases you'd like to see, and collaborate with people outside of your group.

As opposed to an employed physician, you were locked into a system and rarely can go outside of it. Your choices for specialists to collaborate with are very limited and oftentimes may not be the right fit for the patient. In addition, employed physicians end up costing the economy, more in terms of money as you were in fewer private practice people who live outside of the virtual bubble. My hope is that we will discover the value and virtues of private practice in order to control costs rather than just reap more rewards and profits for the hospital systems and insurance companies. The point being, we get one trip in this life and it's very important to carefully consider your career choices to maximize your chances of enjoying that trip with the ones you love. 

Joseph O'Brien, MD. Medical Director of Minimally Invasive Orthopaedic Spine Surgery at Virginia Hospital Center (Arlington): In markets where physician ownership is preserved, private practice can be quite desirable for orthopedic surgeons. For instance, the ancillaries generated from durable medical equipment, physical therapy and surgery center ownership can rival the actual professional fees that the doctors generate. The main drawback for higher producers is variable overhead assigned on collections. This feature can harm spine surgeons who are partners with general orthopaedic surgeons.   

In markets like [the District of Columbia], physician ownership of ASCs, PT and the practice has plummeted. Private equity, [management services organizations]/collective bargaining and other trends in the D.C. market have seized physician ownership of ancillaries and created the concept of "unlimited" overhead — where compensation is strictly based on a percentage of collections. The more you collect, the more overhead you pay. Additionally, the surgery center fees are divided among two to three entities in the D.C. market, making ASCs undesirable in the D.C. market. In this sort of market, employment can be a boon. Where the hospital can tune overhead to less than 30% for some specialities. This trend makes hospital employment much more desirable moving forward in markets such as D.C. 

Finally, employment is a good feature for docs over 50. In a setting where a base salary is not guaranteed, illness or injury can reduce compensation significantly. A private practice doctor that has a major illness and is out of work for three to six months will lose a huge amount of compensation. In comparison, a high base salary guarantee from hospital employment can be much more safe for doctors with chronic or acute health conditions. 

Peter Passias, MD. Orthopedic Spine Surgeon at NYU Langone Health (New York City): There are certainly upsides to both situations and [are] dependent highly on the individual circumstances. Some of the unique advantages of being an employed physician are the collaboration with larger institutions which have strength in numbers. This reaps benefits with regards to enhanced referral patterns, allowance for sub-specialization of practice and superior bargaining power with payers, and bulk discounts for capital purchasing. One item that requires critical attention in generally larger employed physician models is attention to the needs of the individual, as well as the incentivization of productivity.

John Prunskis, MD. Medical Director and Principal at DxTx Pain & Spine (Chicago): The question needs clarity as there are many subsets of employment such as employment by a hospital, employment by a clinic not affiliated with the hospital, employment by a group owned by private equity, employment by a group owned by a family office, employment by a small group of physicians, et cetera. In 2025, most specialties are not a minimal to a solo practitioner hanging out a shingle.

It depends on the specialty and the group situation that one is joining. The No. 1 criteria is excellent patient care followed by respect for physicians. Extremely important is compliant billing and data driven medical practice. Once a physician finds that a practice situation meets those criteria then the physician can choose what is best for what is best for them given their specialty.

Unfortunately, without a nondisclosure agreement signed by the practice, which will never occur in a physician injury situation it's virtually impossible to really understand what they're getting involved with unless they are showing that the practice is extremely thorough and careful and its relationships. In my specialty as an interventional pain physician, the best model I have seen is one in a multi-state, single-specialty group with the highest ethical standards, respect for physicians and sound business practices. Being in strong practice having locations in multiple states provides advantages.

Mark Testaiuti, MD. Spinal Neurosurgeon, Partner and Vice President at Coastal Spine (Mount Laurel, N.J.): Having been employed for the first 10 years of my career and then having been in private practice for the next 20, I believe the decision to be employed versus being in private practice is a personal one that revolves around lifestyle and responsibility aversion considerations.

This has been a common conundrum contemplated by physicians over the decades, but more recently in our present time of lifestyle choices over cumbersome responsibility. As the benefits of private practice might be seen as waning with diminishing reimbursement, greater documentation responsibilities, et cetera, the return on investment might not be as attractive for some physicians as it once was.

First, if the goal of being a physician is to enjoy your craft, but not be burdened by all of the administrative and managerial responsibilities, then hospital employment may be more for you. This is particularly true of younger physicians that still feel they need to explore the world while still becoming academically or professionally successful early in their career and may not want or appreciate the value of early equity one gains by being privately employed, if properly managed.

Additionally, working at a prestigious university hospital teaching residents and publishing papers during the workday and then being "off" completely may be enough sweat equity for them, versus slowly gaining monetary equity through private practice employment, building ownership and growth of their personal practice value. This is how my early career was structured. However, more and more I have noticed the trend of younger graduating physicians choosing the "9-to-5" approach and not wanting to be tied down as much to a practice that they own, and need to be responsible for. It is a delicate balance between working to live versus living to work. Some highly regarded hospital employed physicians have figured out how to fill the void of private equity growth private practice affords by growing relationships with industry, having lucrative consulting and speaking engagements, patenting inventions, being involved in research and other intellectual property pursuits. Although this is somewhat off topic, it is definitely a delicate and ethically charged consideration employed physicians face.

Older physicians that are towards the end of their careers may consider this a good option for retirement If they have done less well for themselves or even if they have sold off their practice at a smart profit but feel that they can still produce for another few years after having shed the burden of private practice management for a more straightforward employment option. Perhaps giving back by teaching trainees and staff may be further rewarding for them before they retire. This choice can allow them to slowly transition into retirement with additional 401(k) and lifestyle perks that they might not have enjoyed as a solo practitioner or a in small group.

As for private practice, if one gets through the initial start up and early years of uncertainty, growth and little lifestyle enjoyment, it can become extremely rewarding. Having built something that you own, including real estate and multiple practice locations and using that equity as a means to invest against, can become very profitable, depending on the business acumen of the practitioner.  However, steady stream income may vary year to year, depending on the prevailing overhead, and it requires fiscal diligence and oversight to avoid expenses overtaking profit in lean years. There is also the responsibility of risk management HR and insurability. With the risk of lawsuits ever looming, these considerations can be burdensome and frightening enough to avoid private practice depending on the specialty.

As a perk, private practice does allow more flexibility when there may be cancellations etc. with the latitude to do what you like for the day versus needing to “show up at work“ because you are employed. There are other tax benefits to being in private practice, including expense accounts, tax write offs through property ownership, etc. and taking out personal loans for business growth and investment. 

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