Preserving the solo physician

After a two-year hiatus, I returned to Kansas City to give a workshop on practice management at the AAFP’s national conference of family medicine residents and medical students. The first time I gave this workshop, I listed 10 reasons to be self-employed, all of which came down to the same bottom line: In independent practice we are in control and can take care of our patients the way we feel is best. This year I thought of an eleventh reason, the most important one of all.

According to the AAFP, what separates us from other specialties is that family physicians really know their patients, listen to them and help them make the right health care decisions. Our most precious resource in delivering this patient-centered care is our time. What determines the amount of time we can spend with our patients? It’s the number of patients we see per day, which is dictated by our practice overhead. Independent practice is the only model that let us truly control our costs. In all other models, we are working not only to pay ourselves but also the operating expenses of the group we are working for. For example, in private practice, I pay only the salary of an office manager; in corporate medicine, physicians have to work to pay the salaries of administrators, midlevel managers, nurses and technicians (and in some cases, to add to the profits of stockholders). How many more patients do we have to see each day to do this?

Knowing from experience that a physician in private practice can earn $1,000 per day from seeing 15 or so patients and that entry-level, employed family physicians are paid about $120,000 per year to see at least 30 patients per day, I reasoned that the independent physician would be earning twice as much seeing half as many patients. The lower the overhead, the more the independent physician would get to keep. Conversely, the salaried physician is working twice as hard for half the income, with only half to a third as much time to spend with each patient. Ergo, I’m convinced that independent practice is the only model compatible with comprehensive, personalized care – our raison d’etre. Why then, aren’t we all doing it? One compelling reason is that residents get almost no practice management training in their programs and they enter the medical marketplace woefully ignorant of what it takes to run an office.

Independent practice is not only good for the patient; it’s good for the doctor as well. If you have to see more than 30 patients a day, you really aren’t “seeing” anyone. The infrequent times I had to see that many patients, I left my office feeling beaten up, dissatisfied and insufficient. There simply was not enough time to listen and give my patients enough of my attention. It was not the kind of medicine I wanted to practice on a daily basis.

We need to teach practice management as a core competency in our family medicine residencies so our young doctors don’t have to work to support a superstructure that renders undeliverable the kind of care that should be our signature.

The vampire

“You’re good at that,” my patient, Carolyn, remarked after I had drawn some blood. “At the lab, they usually have to stick me three or four times. You always get it the first time.”

“Thanks,” I said, “But you weren’t a challenge today. Sometimes I have to go into the wrists and ankles to get a draw. Other times, I use hot compresses. On really tough patients, I use extra long needles and go intracardiac.”

My patients usually appreciate my sense of humor, as it eases their anxiety. If they say, “I can’t watch,” I say, “Neither can I. Let’s look the other way.” If I have to stick them a second time, I promise them a free physical if I miss again. I always ask new patients if they want to lie down, especially men. Women, who are used to seeing blood every month, are seldom queasy, but I hate holding up big guys with one hand while trying to get my specimens with the other. But it’s never more trouble than it’s worth; patients welcome the convenience of one-stop shopping.

Most doctors don’t do their own draws because of time constraints and because they weren’t trained in venipuncture. But I went to medical school in an era when many medical students worked in labs to earn extra income. I worked in a small community hospital doing presurgical blood work. Not only did I draw hundreds of patients; I also learned how to use every instrument in the laboratory. I was trained on the job, and before it was over I could type, cross match and do complete blood counts, serum chemistries, pregnancy tests and urinalyses. That, and not killing anyone who required a transfusion, made me feel more like a doctor than anything I ever did in medical school.

“You missed,” said Russ, a patient I always have a hard time drawing. “It’s OK. I’m a tough case. Sometimes I go through three or four techs.”

“Give me your other arm, and make a fist,” I said.

“There’s a good one, doc, ” Russ said, looking at a blue line by his elbow.

“I’ll tell you a secret, Russ. You don’t look for veins, you feel for them,” I said. “Are you ready? Double or nothing.”