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Friday, January 15, 2010

Advice and consulting

Here's a recently posted comment to my Oct. 2 post, "RVU Ramblings":

"I am in my second year of residency with desires to practice OB/FP. I agree with your point about med-peds, however there are so many forces at work. Many of my colleagues go on to practice in urgent care, small town ER’s or Medicare-based practices for a weak salary compared to subspecialists. So how do I help Family Medicine survive (appeal to me and pay off my student loans)? Your setup is essentially what I’d like to be doing. Do you have any advice for a budding family physician who wants to own or partner in an OB/FP practice? Is an OB fellowship worth my time? I’d like to understand how to set up and run a successful practice 6 months prior to graduating. This gives me about a year. Where do I start?"

I wish I knew how to help this young family physician. This blog was intended for folks like him, and I think there is plenty of good advice to sort through. But his letter made me think about the difficulty of making absolute pronouncements in a profession as complex as ours. Part of the problem is that, just as "all politics is local," so is all medical practice. And then there is the issue of personality, and luck.

So here is a hatful of imponderables:

1. How much of my success is due to the fact that my market is dominated by Blue Cross, and that their payment schedules have always been fair to family physicians? 

2. If I had not taken an Army health professions scholarship, which resulted in my finishing residency with no debt and money in the bank, would I have had the freedom to start a solo practice, and do it the way I wanted to?

3. Was it just luck that my residency program offered me unlimited access to patients, thanks to young, recently trained specialist mentors who had every incentive to teach me quickly and let me have just enough rope that I couldn't hang myself, an obstetrics unit amply populated with laboring women 24/7, and a Filipino colonel who introduced vacuum extraction to America? 

4. What if my six years in the ER hadn't enabled me to save enough money to buy a medical building, and convinced me of the need for an urgent care facility running in tandem with my office? And was it luck that I partnered in building ownership with an excellent FP from my residency program who also wanted to go solo, but share coverage?

5. To what extent was my success dependent on a CPA with a deep understanding of medical accounting, who set up my reports in such a way that I could understand them?

6. Is it just luck that I've worked with the same employees for most of my career? Sure, I treat them well, but really – none of their husbands ever transferred to another town!

7. My Army family practice office experience taught me to be lazy. After all, we had one nurse for every 4 doctors, which is pretty much a rate-limiting step, so who cared? My emergency room experience taught me how to move and think fast. And never being on salary in private practice put a big burr under my saddle. Once I learned how to hustle, though, I came to like the stimulation. Just luck?

8. I started exercising regularly halfway through my life, at age 30. In the beginning, it was because I thought I should, and I wanted to practice what I preached. In the end, I came to love it. The benefit is that I never experience dead-dog fatigue. I depart the office with as much energy as when I arrived, leaving plenty of reserve for family and hobbies. Is that commitment teachable, or inborn?

9. At times I think I am a very selfish person. (There is also evidence that I am a very generous person; it is possible to be both at the same time.) From the beginning of my practice, I was determined not to be overwhelmed by its demands. So I set parameters. I scheduled my day, and I finished on time. I decided how much vacation I wanted, and I took it. I taught my patients what I expected, and they responded. Was that selfish, or just good sense? If it is good sense, can it be taught? 

So who do I think I am to give specific advice?

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About the Author

Doug Iliff, MD, is a family physician in solo practice in Topeka, Kan., and a former member of the FPM Board of Editors.

Note: This blog is no longer updated; this is archived content.

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Making It is a Family Practice Management (FPM) blog. However, the views expressed here are those of the individual authors. They do not necessarily reflect the opinion of FPM or the AAFP. The FPM blogs are not intended to provide medical, financial or legal advice. For more information see Terms of Use.