Private Practice Has Its Rewards, Challenges
Editor's note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the first in an occasional series of blogs that will look at the different roles family physicians can play.
When I made the decision in medical school to become a family physician, I pictured myself working in a rural private practice. In my mind's eye, this looked something like a Norman Rockwell painting. As my residency and fellowship training drew to a close and I began the job search in earnest, my idealism was met with a stark reality: Private practice seemed to be vanishing.
|Peter Rippey, M.D.
During the past 25 years, the number of active AAFP members who identified themselves as employed physicians increased from 29 percent to 63 percent. During the same time, the ranks of solo practitioners decreased by 27 percent. Many of the positions I considered in rural areas were hospital owned.
I eventually found a position as the seventh physician in a rural private practice. But practicing in a rural area has not insulated me from the changes occurring in our country. The uncertainty of the health care landscape as the Patient Protection and Affordable Care Act continues to be implemented -- along with the challenges related to payment, electronic health records (EHRs), meaningful use and ICD-10 looming on the horizon -- seems to have spurred a mass exodus from private practice to employed positions.
In my area, I have seen a few older physicians retire instead of dealing with the latest round of health care upheaval. Other practices have been absorbed by hospital systems or merged with larger physician organizations. Those who are struggling to stay in private practice have seen their overhead increase and their payments cut.
At a time when everyone is clamoring about the high cost of health care, forcing physicians out of private practice seems foolish. Payment rates for private outpatient clinics are less than those for hospital clinics for the same service provided.Many clinics can provide urgent care services (suturing, fracture care, etc.) at a fraction of the cost of the local ER. It would seem in many ways that a well-run private practice could provide quality patient care at less cost.
At a time when the United States spends more money on health care as a percentage of gross domestic product than any other industrialized nation and has some of the worst health outcomes, is the extinction of private practice really a step forward?
Private practices are a vital means for health care access, especially in rural areas where the next closest option may be more than an hour away. As these practices disappear, medical students and residents will have even less exposure to private practice; fewer and fewer may consider it a viable option. This could lead to further decline in the future of private practice.
That's a shame, because I have found private practice to be extremely rewarding. I am providing high quality, efficient care for my patients. In private practice, I also get to decide what hours I work, what procedural services I provide, what my scope of practice is, when I take vacation and who I have assist me.
In contrast to some employed settings, there us less pressure to see a certain number of patients a day. I can make that decision based on how many patients I think I can manage appropriately. If I want to take a vacation or time for CME, there is no schedule to coordinate with , no need to give significant advance notice and no need to ask for permission. I simply block my clinic schedule.
I think one of the most important benefits of private practice is that all the decisions affecting the practice are made by clinicians, those who understand what it means to be a physician and what it takes to provide care to patients.
In medical school and residency, I was taught that as physicians we are stewards of the health care system. In my practice, I provide the care patients deserve while helping to control costs. But the future seems murky. My practice has had to make many stressful decisions regarding EHRs and is trying to lower overhead due to payment cuts. As a father trying to support a family and pay off a mountain of medical school debt, this uncertainty has often put an extra furrow in my brow.
I understand all too well the reasons many have flocked to employed positions, but do all these changes really mean the demise of private practice? Or is this simply a pendulum, sure to swing the other way in time? To quote the wisdom of The Clash, "Should I stay or should I go now?"
Peter Rippey, M.D., is a board-certified family physician who practices in private practice in rural Missouri. He enjoys a full spectrum practice with a focus on community and collegiate athletic coverage.
Caring for Patients With Addiction Problems Takes Practice
It's a Friday afternoon. I walk into the exam room and meet Carl (not his real name) for the first time. Sitting in a chair with his cane next to him, I see that he is middle-aged and morbidly obese.
After we exchange a few pleasantries, he begins to tell me why he is here: His primary care physician recently moved to a new practice, and he does not like the way he is being treated there. He says it is difficult to get an appointment with his physician. Although his diabetes and hypertension have been well controlled, he worries that the care he is getting will negatively impact his health.
After several minutes of discussing his situation, he begins to tell me about his mother recently passing away. With tears streaming down his face, he admits that he has been depressed lately and does not know what to do anymore. His low back pain is severe, he says, and it makes everything about his situation worse.
| Margaux Lazarin, D.O., M.P.H.
A quick check with our state prescription monitoring program and a call to his previous physician's clinic confirm my suspicion that this patient has a history of prescription drug misuse. The clinic warns me that during his most recent visits, he became aggressive when he wasn't given the medications he requested.
We have all had patients who come in with sad and distracting stories that can conceal the red flags indicating that they're attempting to obtain controlled substance prescriptions. As a resident with Friday afternoon clinics, I became accustomed to recognizing these red flags, which include the discovery that the "doctor just moved" (or "passed away"), the alleged allergies to ibuprofen and contrast dye, the tearful story of a loved one who recently died, the bullet that prevents them from being able to get an MRI, the history of a seizure disorder and, of course, the urgency associated with a Friday afternoon appointment. ("But it's the weekend! The clinic will be closed, and I just took my last pill!")
Patient encounters of this sort often make physicians feel frustrated and even angry. Why? Some of the reasons are obvious. These patients can be manipulative and argumentative. At a minimum, these challenging sessions are time-consuming and require a great deal of emotional effort to prevent the possibility of aggression from becoming a reality.
Moreover, inappropriate dispensation of controlled substances threatens our newly acquired medical licenses. On a deeper level, the need to search beyond the chief complaint for ulterior motives, such as diversion and addiction, can cause any physician to become more cynical as time passes. These patients can erode the core of why we became doctors -- to help people. At the end of an emotional visit, when we have told the patient that we will not give him or her the prescription he or she is demanding, it is difficult to feel as though we have helped that patient.
I have found that there are two tactics that help me better manage both these patients and my feelings about them. First, we can reframe our mindset. These patients still need what our original dedication to medicine was all about -- they still need help. They are in our office for medical problems, although their stated problem is typically different from our diagnosis. If we can recognize their addiction, understand their social circumstances and comprehend their psychological needs, we will realize that a family physician is exactly what they need. We can offer to care for all of their medical needs.
As family physicians, this is an area in which we excel. When we are able to see past patients' manipulation, it becomes clear that this attitude has nothing to do with us personally and everything to do with their disease.
The second tactic is to use our support. In residency, we rely on the attending to play "bad cop" with these patients. And although it can feel as though we're are on our own after residency, none of us practices medicine in a vacuum. We can still rely on our clinic's protocols, our medical director and our state laws. Patients cannot argue with "My hands are tied; I am simply not allowed to give you this prescription because of … " And we can impress upon patients that we want to be their primary care physician and that we are committed to being champions for their health.
If your clinic doesn't have a specific protocol for controlled substances, you can help develop one. These protocols typically involve pain contracts, which clearly delineate rules about random drug screens, restrict patients to obtaining a controlled substance from one physician only and allow no early refills.
To better understand the issues involved in balancing appropriate pain management with helping to combat the public health crisis of misuse and diversion of opioid analgesics, review the AAFP's position paper on pain management and opioid abuse.
In light of the growing trend for pain management clinics to "fire" patients with substance abuse issues, these patients likely will be turning to the primary care setting. State prescription monitoring programs can significantly improve our ability to objectively identify these patients while strengthening our rationale for declining to prescribe controlled substances, thus lowering the tension surrounding these visits.
Ultimately, successfully caring for these patients takes practice. It can be helpful to view these visits as an opportunity for creative negotiation. It's important to remember that these patients have a legitimate medical problem, often substance abuse combined with difficult psychosocial circumstances, and, as family physicians, we have been trained to help them.
Margaux Lazarin, D.O., M.P.H., provides
comprehensive family health services, including osteopathic manipulation, at a
community health center in the Bronx, N.Y. She is actively involved in teaching
residents and medical students to deliver evidenced-based care to underserved
It's OK to Ask for Help
Completing residency was one of the greatest accomplishments of my life. I had survived the grueling uncertainty of my pre-med years, finding any opportunity to make myself stand out among my peers. I had made it through medical school, with all its classroom endeavors and constant grilling from higher-ups. And now I had endured residency, with all its long hours, seemingly never-ending call and all the lessons those experiences entail.
I could no longer be viewed by others as a "pretend doctor." I now had a real job, and I had made it.
Along with this euphoric accomplishment came a certain confidence that I could do anything. Look what I had been through. I had mastered this, and now it was my turn to use my intelligence and training to heal, without a supervisor continuously looking over my shoulder.
Here I am listening to a patient. After 11 years of education and training, I still wondered if I knew everything I needed to know when I completed residency.
But it also came with the exact opposite feelings.
Did I really know enough to care for my patients?
Would they trust me?
Should they trust me?
What if I didn't know the answer to a diagnosis, what test to order or what treatment route to take? Eleven years was a lot of education and training, but was it enough? I wanted my new colleagues to be confident that they had hired the right person. I knew they didn't expect me to be perfect, but they did expect me to be competent.
In my final weeks of residency, an attending I had always admired offered some advice.
"Hey, I didn't feel fully comfortable with what I was doing until probably three or four years into practice," he said. "If you have any questions, you can always call me, even just for some reassurance. This is something we all go through, but it's not a weakness to ask for help."
I appreciated the sentiment. It came in handy with my patient Roger (not his real name). He was in his 50s and had some intellectual disabilities that would frequently impede our ability to properly communicate. Like many of the developmentally disabled patients I see, constipation was a significant issue for Roger. He had been hospitalized in the past for bowel obstructions, and he faced many social impediments due to this condition. I thought I could handle this problem with Roger and others. How hard could it be?
As it turns out, constipation can be fairly complicated. I tried a few things, stumbling around with treatment options, but I was not quite sure what I was doing. Despite feeling a bit silly for needing some help with this, I asked one of my colleagues who had more experience with this population. He gave me some pointers on which medications to try and how to use them effectively. Based on his advice, we were able to come up with a workable treatment plan for Roger that has kept him out of the hospital.
Not only has the experience not worsened the respect or relationship with my colleagues, it actually enhanced it. I was worried this might undermine my credibility, but it has done nothing of the sort. It seems that the more questions I ask or cases I run by my colleagues, the more they are willing to do the same. We have prevented many potential errors, and we have created better plans than what I otherwise would have come up with on my own.
No matter how many years of experience we have had in medicine, we have all seen different cases. I often ask residents about their experiences with certain cases, which has proven useful. None of us should feel self-conscious or hesitant asking for help, no matter how much or how little experience we have had.
I really appreciated that thought being shared with me as I began practice, and I've since found that it in no way tempers the accomplishment of my many years of medical training. In fact, it seems to more than justify it.
Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.
Finding Balance at Home, Practice Makes it All Worth the Effort
At the end of last school year, my son's first-grade teacher asked each child in the class what they wanted to be when they grow up. Then she took a photo of each student holding a small chalkboard with his or her answer written on it.
My son's chalkboard said "doctor."
As a full-time family physician and mother of four, sometimes I ask myself if the crazy balancing act our lives have become is all worth it. Would my family be better off if I worked part-time -- or not at all?
| Helen Gray, M.D., pictured here with her family, says scheduling and multitasking are key to finding the right balance between home and work.
Little moments like that one let me know I'm doing the right thing. My son has spent time at my practice. He understands that my job -- helping people -- is important, and he sees me as a positive role model.
Of course, there are days when figuring out this work-life puzzle isn't easy. How do you juggle being a mom, wife and physician -- not to mention friend, daughter and more? It's a learning process every day. But at the end of the day, it's manageable.
Our children are 7 years old, 4 1/2 years old, 22 months and 5 months. My timing hasn't always been impeccable. Our first baby arrived during my third year of medical school, and our second was born during my intern year. No. 3 was born during my first year in practice. Baby No. 4, who was a surprise, was born last year during this, my third year of practice.
Although all newborns require some adjustments for families, the arrival of our third child was the most stressful for me. I found out I was pregnant in July, the month before I was supposed to start my job.
I worried about how my employer and new colleagues would react to the new physician who needed extended time off less than a year after being hired.
I worried if I was spending enough time physically at work, seeing my patients, building my practice and being focused on medicine, charts, billing, etc.
I worried about going on leave, away from my new patients, after spending several months building my practice and getting to know those patients.
And I worried if I would have enough time to be a good mom to my three children. The arrival of baby No. 3 gave us a newborn at home, one child in school and one in preschool. And the two older children have full slates of activities: piano, soccer, basketball and swimming for my son and gymnastics and dance for my daughter.
How do I get all my work done and make it to my kids' games, recitals and other events? It's not easy, but I'm not afraid to ask for help. Fortunately, my parents live in town and are willing to help. And my husband, who is a mortgage banker, has a flexible work schedule.
We look at our calendar each week and figure out what has to be done and by whom. You have to know your limits, and sometimes you have to say no -- at work and at home.
That first year out of residency wasn't as crazy as I had feared. My pregnancy went smoothly. I went to my physician frequently, and being on the other side of the patient-physician relationship reminded me what it's like to be the patient. That helped improve my bedside manner. Likewise, my experience as a mom has helped me with my own pediatric patients and in working with new parents. I can relate to different stages of life because of my own experiences, and that has made me a better family physician.
Now with four kids, our days are definitely full. But we all have same 24 hours in a day, so how do you maximize that time? Multi-tasking helps. For example, I plan to breastfeed my youngest child for at least a year. I set aside time to pump every day at work, but I also chart while I pump. And I'm available to staff to answer questions during that time.
There definitely have been moments when I've questioned myself about work -- usually when there is a family event I can't make it to -- but I've never come close to walking away. I'm too invested in medicine. After a rough day, there's always the next day and new opportunities. More often than not, my schedule goes as planned -- or close to it -- and I make it to my kids' activities.
At the end of one particularly hectic day recently, I scrambled across town to get to my son's school program, just in time to see him searching the audience to see if his family was there. The smile on his face when he saw me walk in made it all worth it.
How do you balance your responsibilities to work and home?
Helen Gray, M.D., is an employed family physician in Reno, Nev., working in a hospital-based setting. She also is adjunct faculty with the University of Nevada School of Medicine. You can follow her on Twitter @helengraymd.
Changing the Trajectory of Burnout in Medicine
Medicine is my second career; my first was musical theater. Like medicine, that career sounds intriguing, glamorous and even sexy. And like medicine, in reality it is all-consuming, gritty and even dirty.
I left my performing career completely burnt out -- emotionally exhausted and detached with a low sense of personal achievement. I'm trying to prevent that in my second career, but it isn't always easy.
| Heidi Meyer, M.D.
Although the concept of burnout is appreciated by most, its prevalence, definition and impact are not. It is not a diagnosis found in the Diagnostic and Statistical Manual 4 or 5, but it has a specific criteria and even a validated inventory, much like depression. The Maslach Burnout Inventory has actually been given to hundreds of medical students, residents and physicians in what is a considerable body of research.
The data is overwhelming: medicine, as a career, has a singularly high level of burnout -- much higher than other high-stress careers, such as teaching or being a first responder. And it starts early. One study found 76 percent of medical residents have symptoms of burnout. It may be that many physicians start their careers in a state that traditionally would make someone end a career.
This, of course, leads to more part-time health care professionals, a shorter career span, and, quite clearly, higher costs and more medical errors. Yet despite this epidemic of burnout and its negative effect on workforce and patient care, the conversation on this issue has barely begun.
Some may suggest that the revised resident work hours that went into effect in 2003 (has it really been that long?) was the beginning of that conversation, but I would argue otherwise.
Although work hour reforms were spurred by a patient death, preventing burnout was not the goal of limiting hours. The primary goal was to protect patients. The call for shorter work hours was not a new one, but it was only heard when the daughter of an influential person died because of a medical error made by a tired resident.
However, looking at the Institute of Medicine (IOM) report that spurred and informed duty hour reforms, the term "burnout" is used more than 50 times, suggesting that the IOM acknowledged it as a major contributor to patient morbidity and mortality.
What is burnout exactly? Maslach defines it as a high level of emotional exhaustion, a low sense of personal achievement and detachment. Two of the three do not seem to apply to family physicians -- and if they did, most everyone would be burnt out. It's that middle trait -- the low sense of achievement -- that is so ironic.
You are telling me a physician can have a low sense of personal achievement? He or she is a physician for goodness sakes. What more does one need to feel achievement?
But as we all know, we have a job that can feel more like Sisyphus than Galen, and the rock rolls right back down the hill at the end of the day. The perception of achievement is subjective, and it turns out, certain people have traits that make them more likely to burn out when under stress.
A lot of those traits are ones we find in physicians. Yep. Not only are we training our physicians in a way that is likely to burn them out, we select for those traits in medical school admissions. We literally mine for a high-risk pool, expose them to that risk and set them free. It's a bit like giving the opioid risk tool to a bunch of patients, then giving oxycodone to only the highest scorers for seven to 14 years, and then being shocked that you end up with a bunch of addicts.
So what can we do? First of all, we can start looking at the type of students we admit; we already know admissions criteria skew in a way that those most likely to be drawn to -- and be good at --primary care don't even get in the door. But do the criteria skew in a way that selects for burnout?
Ironically, one of the biggest predictors is a high level of empathy. Sad, isn't it? Those who are most invested are the individuals most likely to lose that connection, and in doing so, become likely to leave medicine. Family docs are empathetic -- we have to be. So are we doomed to burn out?
Should med schools look for those with primary care personalities when those traits are a set up to leave the field early?
That brings us to the last point about burnout: it's preventable and reversible. Empathy is predictive, but resiliency is protective and can be learned. Resiliency -- a set of skills that allow us to navigate change with grace -- is something we can teach. Eureka! A solution!
Now all we have to do is require medical schools to add one more course to the already large stack -- one on resilience -- and we will save money, lives and careers.
Anybody know anyone at the Accreditation Council for Graduate Medical Education?
Heidi Meyer, M.D., is an employed integrative family physician at Kaiser Permanente, San Diego. She enjoys yoga; dark chocolate; weekends in Vegas; bonding with her ferocious 9-pound daschund, Bella; and plotting a drastic overthrow of the house of medicine. You can follow her on Twitter @tweetyturt.
Our Specialty, Our Future: Make Your Voice Heard
In 2002, the family of family medicine organizations saw a need to devise a framework for propelling the specialty into the 21st century, so they launched the Future of Family Medicine (FFM) project.
During that project, the Family Medicine Working Party -- the AAFP, AAFP Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Medicine Residency Directors, North American Primary Care Research Group and Society of Teachers of Family Medicine -- came together to create a report that included recommendations to guide the growth of the specialty.
|Gerry Tolbert, M.D.
As a medical student at the time, I eagerly applauded the lofty goals of this endeavor, including a patient-centered team approach, elimination of barriers to access, electronic health records, a focus on quality and outcomes, and enhanced practice finances. Laudable goals, all, and focused more on the care of the patient than on economics.
The final report was published in 2004. Fast forward 10 years. Although many of the goals and objectives of the FFM project have become reality, we still have to work to maintain the relevance of family medicine as a specialty. To that end, the Working Party initiated Family Medicine for America's Health: Future of Family Medicine 2.0 (FFM 2.0) last fall as the next step in planning the specialty's course.
The newest goals set forth include defining the role of the 21st-century family physician (both in terms of scope and nature of practice) and ensuring family medicine can deliver the workforce to care for a growing -- and aging -- population.
As new physicians practicing in the current environment with innovation inspired and directly created by the original FFM project, we have a unique perspective that can impact the direction of FFM 2.0.
Choices about scope of practice, location, lifestyle and a whole host of other environmental concerns dictate most of our decisions, not to mention the patient education and patient care decisions we make every day.
Decisions about work/life balance influence our choice of scope, but the mission all family physicians share is superb patient care. This new FFM report will offer us a chance to define our roles as new physicians and practicing family doctors in the much larger scope of a health care system in flux.
The FFM 2.0 project also will serve to direct the efforts of the AAFP and the other family medicine organizations in areas of concern for members and will help dictate where resources will be allocated for things such as workforce research and reform.
Being in the trenches seeing patients each day, as well as on the cutting edge of technology and innovation, new physicians can offer a unique perspective. We have the advantage of growing up with computers and tech that some of our more veteran colleagues have had to adapt to over time. That's not to say we have it all figured out. FFM 2.0 also allows our more experienced colleagues to pass on the wisdom of years of practice, especially if we as new physicians ask the right questions to get the advice we need.
But in order to get the questions answered or the topics addressed, we have to ask and give input. If you think an issue impacts the specialty (or even subgroups of the specialty), or piques your curiosity, now is the time to take those questions to the highest levels of decision-making because the research and planning phase of the project is scheduled to be completed by April.
Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.
Fresh Perspectives Offers Platform for New-to-Practice Physicians
During my first few weeks in practice after completing residency, it was odd to not have anyone looking over my shoulder. When I wrote a prescription, there was no one to question, "Are you sure that's what you want to do?" When I ordered a test, it was up to me to follow up.
Although the other physicians in my practice were supportive, I had the sense that it really was just me now. I was a real doctor, and I had to make my own decisions. It's a new, different feeling when you don't have to have someone else checking your chart. It was overwhelming and a little bit scary.
|Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.|
On the other hand, I knew I was well trained. And after a few weeks, my confidence started to grow. Each time I saw one of my patients getting better, there was reassurance that I was doing something right. Certainly, there were times when I questioned my judgment -- in fact, I still have those days -- but that keeps me motivated to continue learning and improving my skills to be able to provide the best possible care for my patients.
In residency, I learned that you have to know where to go when you don't know the answers. That could mean asking colleagues for advice or consulting the AAFP's website and journals or other sources.
Starting today, new physicians have one more resource available from the Academy. This new blog -- Fresh Perspectives: News Docs in Practice -- will be written by a group of new physicians who were selected based on recommendations from AAFP leaders and members as well as Academy staff who work directly with our membership segment.
The blog will give new physicians a platform to offer our own fresh perspectives on the challenges and issues we face and also to share our successes. Through the comments field, our new physician peers -- many of whom likely are dealing with similar issues -- also can join the dialogue and offer their own stories and suggestions. We hope that our more experienced family physician colleagues will provide their own knowledge and insights as well.
The new physicians we will be hearing from -- all of whom completed residency in the past three years -- represent different parts of the country and different practice types and have diverse backgrounds and interests. The blog will offer an opportunity for members to find, and talk to, other members who are in similar practice types and also to hear different perspectives on the issues we face.
Here are the new physicians who will be contributing to the blog:
- Michael Brackman, D.O., Fort Hood, Texas;
- Helen Gray, M.D., Reno, Nev.;
- Megan Guffey, M.D., M.P.H., Tacoma, Wash.;
- Kyle Jones, M.D., Salt Lake City;
- Margaux Lazarin, D.O., M.P.H., Bronx, N.Y.;
- Beth Loney Oller, M.D., Stockton, Kan.;
- Amy McIntyre, M.D., M.P.H., Butte, Mont.;
- Heidi Meyer, M.D., San Diego;
- Peter Rippey, M.D., Marshall, Mo.;
- Gerry Tolbert, M.D., Burlington, Ky.;
- Jennifer Trieu, M.D., Seattle; and
- Meshia Waleh, M.D., Columbia, S.C.
You can receive notifications when new blogs are posted by providing your email address under the "sign up" header in the right-hand column of the blog's home page. In the coming weeks, we will address a variety of topics, including the growing percentage of family physicians who are employed, the challenge of starting a new practice, avoiding physician burnout, finding work/life balance and more. What topics would you like to see addressed in this forum?
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
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