After a few weeks in Family Medicine, I find myself being asked that question with increasing frequency. So, I thought I’d answer it here, knowing that my answer will probably continue to evolve over the next two weeks. Before I get into it, I think it’s important to divide out the thought into two separate strands.
1. What do I think about having / running a private medical practice?
Man, what a tough way to eke out a living. You have to really enjoy being an entrepreneur and all of the challenges that entails. On the plus side, you get to have everything “just so”: hire your own staff, rent or buy your own office space, and pick every detail down to the toilet paper. On the minus side, you have to manage everything to the same level of detail, down to the toilet paper. If your staff orders too many boxes of gowns because they stock Room #7 with all of the supplies and then forget to restock the other rooms, resulting in triplicate supply orders, you have to deal with it. If your employees embezzle, falsify time sheets, or are being unproductive, you have to deal with it. Welcome to the world of Chart audits, tax audits, ceiling leaks and HVAC repairs. Oh, and did I mention that you have to actually see patients?
Furthermore, as in any entrepreneurial endeavor, no one teaches you the ropes. You have to figure it out yourself. Unlike most entrepreneurs, who spent their early formative years (18-28) trying out their ideas and seeing what works, you were in Medical School and Residency, working 80 hour weeks and getting zero practical experience. There is no medical school class in toilet paper ordering, billing, coding or managing receptionists.
Lastly, financially, you are facing some pretty dominant interests who want to keep you from making money whenever possible (Hi Managed Care!). As a result, I’ve seen or heard of several unfortunate consequences:
1. Creative billing and coding that changes charting. Did that patient have a history of anemia? Well then they must have had fatigue, right? So we’ll just add that to their list of billing codes …
2. Reimbursement drives medical decisionmaking in unpredictable ways. So you need to document nine points for your review of systems, or two medical problems? OK, so you ask more questions than you would have, or you adjust your management of the patient so that you can bill for it.
3. Rarely, one could imagine that there would be actual bad actors out there. These folks might do things like unnecessary testing using in-house equipment (procedures are more reimbursable than cognitive / patient-facing time), they might order less-than-necessary tests at affiliated/associated facilities, etc.
4. Litigation sensitivity is very high. You have no hospital covering your butt (and paying your premiums) if you get sued. No partners to see your patients while you are indisposed.
5. Your relationship with patients (a.k.a. your volume) determines your salary. One angry/dis-satisfied customer will tell more friends about you than three happy customers. This puts a new spin on “patient centered” medicine and a new strain on situations where you should say no to a patient’s request based on medical evidence.
6. Unequal partnerships are difficult to maintain in practice. When one partner sees more patients but makes less money, or when some physicians are salaried but not partners, situations can become complicated.
7. MOST DAMNINGLY, practicing medicine in the community can be an isolating experience. You work with your hand-picked staff and partners, and those are the only faces you see day-in and day-out, year-in and year-out. There’s little time or energy to discuss, teach and learn. I got the distinct feeling that I would feel very isolated and mentally lonely in a small or solo practice. Certainly grand rounds and case conferences can seem like a chore, and there’s a definite rise in “Powerpoint Rangers” in academia. But they also serve an important purpose by providing a constant reminder for all physicians to carve out time to stop, think and learn, whether they may be the greenest ‘tern or the most grizzled eminence on the faculty.
In conclusion, community physicians face many pressures that are more severe than those faced by hospital or academically-affiliated physicians. This can potentially affect the way they practice medicine and their happiness. I think the last two months have reinforced my desire to work in an academic setting and I feel confident in restricting my residency application choices to stronger, more academic programs.
In part 2: What I think about practicing Family Medicine (i.e. not affiliated with a hospital or academic center)