I don’t have an answer, but interesting questions here. I don’t think I’m very business savvy, but my initial naïve thoughts below.
There are surgeons who do cash only, and direct primary care (DPC) or concierge medicine physicians who could be considered self-bosses in some sense. You could also do locums (rent a doc) but you’d be moving from location to location every month or 3 (but you’d have the option to ride out or cancel your contract within a short time frame.) Be an expert witness for lawsuits (would take some business chops to make a career out of it.) I guess if you could make a reputation as top of your field, you can generally be self-employed. In my line of work (wastewater and water treatment), there are a few individuals who have a reputation and are sought after as expert consultants. One such I know clears a mil every year. But he had to pay decades of time into the system to earn this reputation and thus is only able to do so now, after 20-30 years.
My uncle went solo practice together with his wife, also a doc, after almost 30 years as an employee. I think he might even have 1-2 midlevels in his employ. He also chose to purchase the property and is a business owner, renting more than 50% of the property to other non-medical businesses. I am sure this come with the headaches of facilities management, maintenance, bill collections, cash flow, etc. Not going to be easy to do as a non-trad if you’re already old such that you can’t build up your savings to be able to sustain. Some have managed to do the DPC route a few years out of residency, but I would think that cash flow would be negative for 2-5 years depending on the market. As for scaling, I would imagine that it depends on cash flow. If a traditional practice that accepts insurance, would you be able to carry both the physicians and other ancillary staff such as coders, billers, nurses, office admin, etc, plus facility overhead? If not, you’d be dependent on your creditors, right?
As with any business, I guess it would depend on your business smarts (ability to deliver profitable services without farming them out, etc) and this would be no different in medicine than any other field. Two years ago, I got tired of being a 9-5 employee and wanted to strike out on my own. I quickly realized that I did not have the resources to bear a negative cash flow during startup (I don’t have significant savings and it typically takes 6 months between billing and collecting on top of 2-3 years to establish as a business.) I also did not have any niche skills to sell and have a low tolerance for risk. Thus, I prefer my paycheck-to-paycheck existence to a riskier solo business that might have a chance for better income.
Side note: I’m single. If I had a spouse with a decent income, I’d be more inclined to go solo.