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Wednesday May 23, 2012

The Joys -- and Advantages -- of Solo Practice

One weekday afternoon when I was sitting on a bleacher watching my daughter play softball, another parent asked me why I wasn't at my office seeing patients. My answer? She's only going to grow up once. I attended every one of my daughter's high school softball games, but I also made plenty of time for patients.

Many physicians struggle with work/life balance, so being your own boss has distinct advantages. I own my own small practice in suburban Boston, and I love being a solo doc -- again.

I started my career as a family physician back in 1990, and I owned my own practice by 1992. Over time, it grew to include two other physicians and a nurse practitioner. But after Harvard Pilgrim Health Care -- one of our region's biggest health plans -- lost more than $200 million and fell into receivership in 1999, things got tough for me as well.

By 2001, I thought I had no choice but to become an employed physician, and I went to work at a hospital-owned practice. It's a decision I regret. After four years, I'd had enough of being an employee and went back to being my own boss.

This time around, there are no partners. The practice includes me, a nurse practitioner, a medical assistant and a front office worker. I also recently hired an office manager to help us achieve meaningful use and to transform the practice into a patient-centered medical home. I'm a better business person this time, understand contracts better and know what it takes financially to run a practice.

So why do I prefer things this way? For one thing, I'm in control. Not only do I set my own schedule, I can fix problems without interference or going through channels.

More importantly, I have a stronger bond with my patients than I did as an employee in a large practice. When a patient seeks care in a group practice, he or she may not see the same physician every time. As a solo family doc, my patients know I am involved in all aspects of their care, even if they see the nurse practitioner.

I know my patients, their families and their stories. It helps that my practice is in Walpole, Mass., a town of about 22,000 people where I grew up.

It sounds pretty good, right? And yet the number of small and solo family practices is in decline. A recent AAFP survey shows that 63 percent of our active members are employed physicians. The figure is even higher among new physicians.

This trend is troubling to me. We can't forget about the small and solo family practices out there because there still are many areas of the country that cannot support large practices.

Part of the problem is that students and residents often are not exposed to the small and solo practice model, though there are exceptions. How can our students and residents develop an interest in something they've never experienced?

We need to find more ways for students and residents to see this kind of practice, but it isn't always easy for small practices and solo docs because having a student or resident for a rotation can slow you down, which hurts productivity and finances.

Small practices often are located far from medical schools and residency programs. Personally, my practice is an hour from my old med school in Boston. It might not be feasible for some small practices and solo docs to have med students or residents in their practices on a regular basis or for those physicians to be regular visitors in educational settings. But there are things we can do in a less formal matter. I have had medical students shadow me in my practice. I have done grand rounds at my alma mater. And I am working with my state chapter to come up with other connections for small, solo practices and medical students and residents.

So for my fellow small practice and solo docs out there, what are you willing to do to expose our future family physicians to our model of care? Our small towns and rural areas cannot afford to lose it.

Laura KnobelM.D., of Walpole, Mass., is a third-year member of the AAFP Board of Directors.


The AAFP needs to do more to promote independent practice, both in their journals and at the annual summer conference for medical students and residents. I presented there twice, in 2001 and 2004, first on empowering yourself through practice management and then on saving the solo practitioner-a threatened species. You're right--there is very limited exposure for medical students to this type of practice, although solo practitioners were the rule when I was growing up. It's too bad because very few solos are unhappy with their practices but employed physicians have considerably more angst. FPs just have to get over the fear of being on their own and and steering the ship. Having more independent role models and mentors will help.

Posted by Sandy Brown on May 24, 2012 at 08:45 AM CDT #

I am a solo family physician who did my residency training at a major academic center. I have always wanted to have my own practice, but found that education and mentoring on financially viable ways to do this is sparse. Two years ago, I took the plunge and while the level of personal satisfaction about my work and the appreciation of my patients is very good, not earning a living at this yet is frightening. It really is a shame that such an important profession where years of sacrifice and training is required usually produces only an employee, with limited ability to decide how they will practice in this noble profession. I have recently become a preceptor for the FM rotation of my alma mater and hope that what the students experience attracts, not repels them from solo practice.

Posted by Safiyya S. on May 24, 2012 at 03:45 PM CDT #

Sandy, you are absolutely right about the lack of education our medical students and residents have regarding how to run a practice. I know I certainly had limited knowledge when I first started. Luckily, my husband was running his own small business at the time and he agreed to take care of the "business side" of the practice while I did the clinical work. In retrospect, I really needed to be involved more in the business side of the practice. This time around I look at my budgets, finances, return on investment and can make much more educated decisions. I didn't take any classes to do this, but really learned "on the job" just by taking more control over the situation. The fear was replaced by knowledge. With regards to residents coming out, many will chose employed positions, be it in large or small groups, and that is fine. My suggestion to them would be to get your feet wet, look at your productivity and expenses, your contracts with insurers and learn how your practice runs. Talk to other physicians in your community who may be in solo practice and find out how they run their practices. Many of us change positions throughout our careers and I hope the solo and small practice scenarios are still available options for our new grads when they feel more comfortable setting out on their own. Thanks for the comments.

Posted by Laura Knobel on May 25, 2012 at 06:33 AM CDT #

Safiyya, thank you for taking the time to be a mentor for the students. That is the first step in exposing them to the joys that you have in practice. I was at a meeting recently where two medical students gave an excellent talk on the importance of social mentoring. They felt medical students really wanted to see how family physicians can do all they do in the office and still have time for their families and outside interests. For those of you who are involved in the clinical mentoring of our students and residents, don't forget to let them see that family physicians do have exciting lives outside of the exam rooms. Keep up the good work!

Posted by Laura Knobel on May 25, 2012 at 06:40 AM CDT #

Bravo to Dr. Knobel for championing solo practice. Unfortunately, I fear this is a losing effort. As government unfunded and unproven mandates (ICD-10, EHRs, ACOs etc.) make it ever more difficult and expensive for a solo family practitioner to comply, the willingness of physicians to start a solo practice will continue to plumet. I agree (but understand why) the AAFP does so little in support of the solo practitioner. We are an endangered species and our concerns and opinions are not shared by the majority.

Posted by KEITH DINKLAGE M.D. on May 25, 2012 at 08:42 AM CDT #

In approximately one year I plan to take the leap of faith in myself to start a solo practice. It is refreshing to hear positive stories from those who have walked this road. I will share my experience and welcome future medical students and residents. Thank you all for sharing.

Posted by Brock on May 26, 2012 at 02:27 AM CDT #

Thank you all for your comments. I would be remiss to not mention TransforMED here. This is a great resource available to help people transform their practices to become more efficient and patient centered, and in the long run, more successful financially with increased personal satisfaction. Delta Exchange is a community of physicians who are in the process of, or thinking about transforming, who share their ideas and experiences on line. It is now free to AAFP members and you can sign up on the home page of the AAFP web site. Many state chapters have projects going with TransforMED, and there is a specific small practice offering available as well. While there is a cost involved, the data show that the improved revenue will more than make up for the initial investment. So if you are thinking of going into a solo or small practice, or transforming into a Patient Centered Medical Home, take a look at the TransforMED web site and give Delta Exchange a try.

Posted by Laura Knobel on May 26, 2012 at 10:45 AM CDT #

Great post, Dr. Knobel. Solo and small practices are the true epicenter of patient-centered care: long may they thrive! However, I do have to question your assertion that "data show that the improved revenue (from becoming a PCMH) will more than make up for the initial investment." Is this true? Practicing physicians have been BEGGING the AAFP to provide accurate information on the financial consequences of taking on the medical home style of practice management. TransforMED, despite much criticism, still refuses to release any financial data on the National Demonstration Project, only saying that many of the practices involved experienced "financial stress." The PCPCC loves to report on improved bottom lines for large insurers, but won't address the issue of fair pay for the doctors doing the work. Shockingly, the most accurate financial information we've received so far on the medical home has come from the recent Wall Street Journal article. The information given there is quite grim, with the family physician profiled stating that he gave up $200,000 in billing because of the work of becoming a PCMH. So, respectfully, is there really data showing that the PCMH is financially viable for solo and small practices? Thank you.

Posted by Donald Brown on May 28, 2012 at 09:01 PM CDT #

Donald, I agree with you that the lack of published data is frustrating. I sit on the Board of Managers of TransforMed as part of my AAFP BOD duties and we have struggled with how to get this information out since many of the TransforMed projects have proprietary data that their customers will not allow TransforMed to publish. I can tell you the data does show significant improvement in average net revenue, decreased overhead, decreased staff costs as well as improved physician salaries and satisfaction. I should emphasize here that we are talking about practices that have truly transformed and did not just check off boxes on an application for PCMH qualification. Both the AAFP and TransforMed are trying to find a way we can publish the data since that will be one of the driving forces to encourage more to go forward with the Patient Centered Medical Home. Capital District Health Plans in Albany has published some of their data with regards to the success of their practice transformations and they have completed two waves of projects. They will be participating in the Comprehensive Primary Care Initiative (CPCI) pilot through Medicare. The CPCI has the potential to significantly impact the bottom line of the practices that will participate. They all must be Patient Centered Medical Homes and will have a care management fee up front and quality bonuses as they go forward. This is very exciting for all of us, since if it does show the improvements we expect, it would be the first large scale financial recognition of the value of Patient Centered Medical Homes. Transforming into a Patient Centered Medical Home clearly involves a lot of work. My staff and I are about to set out to do this and I will let you know how we make out. Thanks for the comment.

Posted by Laura Knobel on May 29, 2012 at 05:17 PM CDT #

Thanks for the reply, Dr. Knobel. Yes, what we need is accurate, analyzable data about the finances of the PCMH model of practice management. The Academy's reliance on anecdotal, feel-good infomercials to make the case for the medical home has been embarrassing to those of us who practice evidence-based medicine. We find it hard to believe that taking on the work of the PCMH would lower overhead and reduce staff costs, but if the Academy has data showing that, we want to see it. Just this week, JAMA published an excellent study showing a direct correlation between providing medical home services and significant increases in overhead. You yourself say that you will have to increase staff to become a PCMH. Honestly, when the AAFP decided to go into business as a vendor selling the PCMH (and now, apparently, the ACO), they lost their credibility as a source of objective information about practice management. Many of us would love to see an AAFP that proudly represents all its members, in their diversity and creativity; instead, we see a semi-regulatory agency that is attempting to micro-manage how we run our practices. Thanks for listening.

Posted by Donald Brown on July 05, 2012 at 07:11 PM CDT #

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