More Efficiency? More Satisfaction? Private Practice?

Private practice was not Plan A for me and for good reason. During residency, it was impossible not to understand that private practitioners occupied a lower caste. Our training contained nothing about office functioning, design, billing, personnel, or workflow. The future belonged to multispecialty groups and, besides, multispecialty groups looked very similar to the residencies that we were moving on from.

I chose carefully and picked a location and group that I felt met my expectations for my career. After four years, however, I was ready to make a radical change. I had gotten a look at this model and learned what it was and what it was not. It also became clear to me that the majority of my waking hours were spent in my practice and I needed to make the right choices so I could have career satisfaction. My ability to practice and be satisfied with the results required just as much thought and control as would choosing and furnishing a home (where I would spend less of my time at that point). Imagine the difference between choosing the design of your home, furnishing it, and being able to make changes whenever you feel necessary. Then imagine moving into a predesigned house and having little input into the original design, knowing that any changes that you requested needed to pass through an administration with numerous other priorities.

From my perspective, my success in delivering care to my patients was affected by more than my knowledge, skill, and ability to communicate. It depended on everything from how the phones were answered, to the staff job descriptions, workflow, wait times, and my workload. As I became aware of this, I became more interested in seeing how I could improve the details that I had not been taught in residency. I decided to go from one extreme to the other and entered solo practice.

In Obstetrics and Gynecology, your life is dependent on coverage. No coverage, no life outside of practice. Fortunately, I had colleagues in private practice who were willing to exchange coverage and make this move possible. There was quite a learning curve (especially with billing), but hiring the right people made all of the difference. Because my biller had only one priority, our collection ratios soon exceeded those of larger systems. Because decisions were being made by me, the office overhead was considerably lower than was seen in large organizations with layers of administrators. If I wanted to hire a new person, I could. If I wanted new equipment, I got it (if I was willing to pay for it). If I wanted to see fewer patients per hour or change the days and hours that I saw them- voila! Done! I also became interested in office design and, thanks to willing landlords, designed four offices during my career. When I grew interested in technology, I studied electronic medical records in the late 1990s, visiting offices where they were used and getting into the details of workflow and implementation. In 2002, before the large systems in Worcester, we implemented an EHR that we had chosen and altered the workflow to accommodate it. Filing went away, transcription went away, the patients seen did not change and I never took computer work home with me. My objective was not to maximize income, but, rather, to create a workspace that I was proud of.

Today there are significant challenges that were not as extreme when I entered private practice. Vertical integration has been favored by the government and the payers associated with fees that are substantially higher. Large groups can make gaining patients (especially if you are new) more difficult since they have large numbers of doctors that they need to support and internal referral patterns (captured lives) that keep the patients in the building.

Still, while most industries have decentralized and outsourced elements of production to smaller, more nimble businesses, health care has just discovered the factory system with higher overhead and more inertia. This is being supported by a system that sets fees based on bargaining power and disfavors the small guy. Interestingly, if we look at Western European countries such as Germany, Switzerland, and others, they achieve universal coverage with multiple health plan choices, but uniform fees. In these models, there are no huge hospital systems and doctor groups with thousands of doctors. With that bargaining chip gone the average doctor group is five or less.

Private practice is more satisfying for the right doctors and more efficient for the system. In the electronic age, patient information can just as easily travel across town as across the hall. Far from being a relic of the past, it is now an option for the future.

B. Dale Magee, MDPast president MMS, WDMS Curator, WDMS