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Is Rural Solo Family Practice Medicine Still an Option for You?

Is Rural Solo Family Practice Medicine Still an Option for You?

“D octor, have you ever considered opening your own practice?” is a question I’ve heard several times over the years. It came from well-meaning patients who solo-practice physicians or members of small towns come to their program to try to recruit residents and explaintothemthebenefitsofpracticinginasmalltown. Most directors told me that metro-based recruiting sometimes felt the burden of trying to navigate an firms had reached out to them, or that large hospital automated phone system, having to talk to the on-call systems most heavily recruited their residents. So, one doctor who may not know them like I did, or trying to can conclude that most residents do not have rural get triaged by a nurse who may not really understand solo family medicine on their radar as an employment their problem. option when they finish their training. I suspect that

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Lastyear,IattendedaleadershipconferenceinKansas most residents, having loans to repay along with very City held by the AAFP. One discussion with National little training in the business of medicine, would feel Leadership, State Presidents, and President-Elects intimidated even considering this possibilitywhen most involved dialogue on physician workforce shortages, employment opportunities sound much more secure especially in rural and inner-city areas of the country. and attractive; they present the notion that “someone Most suggested that these shortages were related else” will take care of the business aspect of your to reimbursement issues, and proposed increasing practice and all you have to do is “practice medicine.” taxes to help fund these shortage areas. During these Sound familiar? discussions, I wasstruckbythe factthatI didn’tmove to Whatwould happen ifresidentswereexposed tothe rural Missouri for the money. I moved there to practice idea that rural solo family practice is a viable option? I full-scope family medicine, and because I was born and believeitwould presentafeasibleopportunityforfamily raised in rural Missouri and didn’t really like living in the medicine doctors to move to rural Missouri to practice, “big city.” My wife was also from rural Missouri, and especially if they knew that it could be done with little enjoyed being a part of and raising our children in a small more than understanding a few business principles and community. I alsoenjoyed talkingand relatingtopeople workingthrough a coupleofpagesoftechnical “to-dos”. that were like me. Farmers are really cool to talk to One advantage to working as a physician/small becausetheyarenearlyascompulsiveand superstitious business owner is that you really own your own as we doctors are about practicing our trade. They are business, and as such, you can eliminate committees! “real” in that they will tell you exactly what they think You get to make all the decisions, right or wrong, about the subject at hand, whether you like it or not. and live with the consequences. Fortunately for People in rural communities also seem to have a similar me, my office staff enjoys pointing out when I have approach to life as myself. Their belief systems, desire to clearly blundered on something like running out of a be independent and hard-working attitudes are just a particular immunization that I told them I had already fewexamples ofwhyI feel so comfortable here. ordered. Setting up efficient reminder systems in the

Another factor in the workforce shortage became office has helped to eliminate these sorts of issues apparent after asking a few people in the discussion and delegation of certain responsibilities has become room how often directors of residency programs had a learned art form. There are no hour-long meetings

Jamie Ulbrich, MD, FAAFP

to decide what services you will offer, phone system you will use, lab been in an academic training center. As a result, it became possible services to contract with or insurances you will participate with. to transition to a solo practice where my duties centered around full

You can treat yourpatients as you reallyfeel called to. There are no time clinic practice, leaving the hospital work to the hired hospitalist nursemanagerstellingyou thatyou havetoseesomanypatientsa day and procedures to the specialist. I certainly miss that aspect of family or that your salary is based on your RVU’s. You can choose the pace at medicine, but also find great joy in being a small business owner. I do which you see patients. not think it would be realistic to be doing everything I did in my early

Your clinic staff and patients will ultimately become like family to years while simultaneously trying to be the successful business owner you. You will feel the desire to take as good ofcare ofthe people you ofa solo practice. work with as the care you give your patients. When you live in a small Previously, I mentioned some technical “to-dos” for starting a solo community, your patients and staffgo to church with you, participate practice. I am indebted to one ofmyprevious partners forsharing this in sport activities, help each other get to work during snow storms or laundry list ofessential tasks. These range from items like retaining an car troubles, and help solve familial problems. Everyone helps raise and attorney for purposes of establishing an LLC to obtaining a Medicare supporteach otherthrough all lifeeventswhetherphysical, emotional, number and Tax Identification number. Credentialing with your local relational or spiritual. You really get the womb-to-tomb experience hospital, along with NPI numbers, Missouri Licensing, DEA, BNDD are with yourfamilyofpatients and staff. other considerations. Supplies such as office furniture, an autoclave,

Adisadvantageofbeingasolofamilypracticephysicianisthefeeling and an EKG machine are other items that are easier to come by. If of isolation. When you are dealing with a complicated patient, “curbinterested in pursuingthistypeofpractice,knowthatI would bewilling side” consultations are somewhat more difficult than ifyou worked in to share my “cheat sheets” with anyone who desires to follow me in a large practice. You usuallyhave to pickup a phone instead ofwalking this pursuit. down the hall. Another thing to consider is how cellular coverage Maybeyou’realreadyin practiceand startinga solopracticesounds in your area will affect the practice of telemedicine and working likea reallygood idea thatyou havebeen prayingaboutfora longtime, remotely. With the technology available today, I go everywhere with my computer and can set up a mobile hotspot just about everywhere (minus the Grand Canyon a few years ago); I can usually care for my patients remotely. Being able to take a mental holiday is somewhat more challenging. I have found over the years, however, that most of my patients have really learned to respect my time and feel very You need to negotiate your current and future employment contracts to “ apologetic for “bothering of them will usually wait ” me to call at night and on the weekends. me during clinic hours because Most they include a clause that would exempt knowI am doingthison myown. Thisattitudewasprobablyoneofthe most humbling and cool things I did not expect when starting myown practice. Most of the phone calls I used to get when I was in a large practice came from some of my partners ordering protime/inr’s on Fridaynights and gettingculture results called to me, orsome patients phoning in the early morning hours complaining of not being able to as I did prior to stepping out in faith to do this. Perhaps you are just finishingresidencyandarenotsurethisisforyou,butsomewheredown theroad you mightliketohavethisoption available. Toensurethis,you you from a no-compete clause. ” sleep. Yes, really. need to negotiate your current and future employment contracts to

Financial riskis anotherconsideration. When you are on yourown, include a clause that would exempt you from a no-compete clause for one must watch great in- and out-fluxes of money in your operating the purposes of establishing a solo practice in your present place of and payroll accounts every 2 weeks. At first, it can be alarming, but residence. Mosthospitalsareinterested in you remainingin theirtown aftera fewmonths, you realize thatthe bottom line isaboutthe same. and supporting them. Based on my experience, they would not want Certainly, the financial rewards have been greateroverthe last 5 years you to compete against them, but likely would accept you practicing than in previous years when I belonged to a large group practice, family medicine and continuing to refer patients for admission and simply because I can control costs and keep my overhead much more diagnostictesting.Remembereverythinginyourcontractisnegotiable, manageable. OneoftheearliestprinciplesI learned in owningmyown and that both parties just need to agree in principle about what they business was that you have to operate within your means. The sky is want; you do not need to burn any bridges. When you move your notthe limit; rather, yourbudgetis yourlimit. family to a small town, you’re investing as much as the employer has

The last limitation to being in rural solo practice is knowing what invested in bringing you there. you can and cannot realistically do on your own. As I had mentioned In conclusion, I can find no greater joy in the practice of family earlier, when moving to a small town in Missouri, my dream was to medicine right now than being in a rural solo practice. It has been so practice full-scope family medicine. In my early years, this meant much fun over the last 5 years getting to care for the patients I have delivering babies, and performing caesarian sections, post-partum seen for so many years now. I consistently receive positive feedback and elective laparoscopic tubal ligations, breast biopsies, vasectomies, from patients: “You all seem to get along and have so much fun upper and lower scopes, colposcopes, leeps, circs and critical care together!” I can say that this pandemic has tried to get us down, but medicine. As the years have gone by, my family dynamics changed, we have resolved to continue to provide great care for our patients, and I wanted to prioritize attending some of my kids’ sporting and validate theirconcernsand continue to thrive through itall. Greatstaff other school events. In doing so, it became less important to do all the and working within ourmeans have kept us going. Ifanyone would be things I had been trained to do. It was also more difficult to continue interested in discussing this as a grand round at a residency program, toreceivecontinual trainingin all theaboveproceduresasthenumber orislookingatmakingthe transition toa solopractice, I and the MAFP ofprocedureswere hardertoattain in a small town than itwould have would be more than happyto help anywaywe can.

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