To the Editor::

In this era of rampant cynicism within our profession, it is encouraging to see the energy and creativity of many of our younger colleagues. Dr. Gordon Moore’s latest offering, “Creating a Vital, Burnout-Proof Practice” [September 2003, page 51], is another heartening example and provides a useful compass for those physicians trying to reinvent themselves and their practices. As a family physician who has been around for most of the modern history of family medicine, I applaud his fresh, optimistic perspectives. I particularly like his eschewing of the “hamsterwheel,” production-based approach so characteristic of most salary formulas. As a veteran of several practices and business models, I offer the following comments on the piece:

1. “How much would you like to work?” I would add, “How much do I have to work to meet basic needs?” This amount is usually less than most overachievers think, but it is invariably more than it used to be as the costs of practicing have escalated (regardless of the practice model) and the reimbursement for professional services has failed to keep pace.

2. “What is your ideal scope of practice?” I’ve found it useful to evaluate the demographics, competition and particularly the needs of the practice population as well as personal preferences when determining scope of practice. Many physicians are disappointed to find that what they want to do is not needed. In short, find the place that fits your desired scope.

3. “Where would you like to work?” Besides distance from home and type of facility, consider your proximity to a hospital and ancillary services when choosing where to work. Also consider what type of community would best fit your family’s lifestyle. Perhaps the most important location-related consideration should be the local professional and community cultures. Without any hard data, my gut tells me that cultural issues, both professional and personal, account for many cases of dissatisfaction and burnout for physicians and their families. I am fond of saying, “When you’ve seen one practice, you’ve seen one practice.” Remember that there are many different environments.

4. “How would you like to work?” In addition to compensation, another fundamental issue is whether the practice views and rewards care-delivery as a team activity or merely as the work of the provider. I have a strong bias that today’s fragmented system of care and reimbursement mandates a team approach.

Finally, I applaud Dr. Moore’s commitment to same-day appointments and appropriate time management of patient visits. These precepts have been shown to increase patient satisfaction in numerous studies. However, after 35 years of practice (eight years solo, rural), I must differ with his conclusion about the importance of personal availability. I know of very few folks who can sustain this commitment in the long term. Most patients understand what is realistic for one physician to handle. If they understand the office operates as a team, with all members capable and willing to help, usually patients’ needs can be met without risking burnout from well-intended overcommitment.