Doctors are a pretty conservative bunch. We get to where we are by saying no to many things that are a lot more immediately enjoyable than studying biochemistry. It can and has been said that doctors are a risk-averse group. Why then would any physician in their right mind say “yes” to private practice when there are no financial guarantees, no colleagues, maybe even no employees, no 401(k), no one paying your malpractice insurance, maybe you have some patients, but maybe you don’t even have that!

Why on earth would you say yes to private practice?
Well, for me, it felt like a necessity, and I suppose many adventures start out that way. I have run a private psychiatric practice for the past 5 years. I call this a “holistic” practice because I want to work with the whole person, not just in a reductionistic, psychopharmacology model and also not in a 10-15 minute medication check, high “productivity” practice. I started a private practice because I felt it was the next step in my ongoing medical education.

After I had been running my practice for awhile, I came across the term, “micropractice,” and I realized that is what I was doing. Low overhead, no employees, 30-90 minute appointments (longer sometimes for initial evals), I came to call what I do quality care as opposed to the quantity care that I had experienced in other practice settings. So, I found out that I wasn’t the only doctor striking off into this hazy territory of private practice who was compelled to practice medicine according to my own rules rather than the rules of health care delivery systems. It reminded me of the old punk rock DIY (Do It Yourself) attitude!

For the first year or so of private practice, I found I had to say no to a lot of other things in my life in order to really stay on top of the responsibilities I had taken on. Learning how to do billing, tracking down denied claims, figuring out the multiple reimbursement systems (Public Aid, Medicare, and the myriad of private insurance companies), returning phone calls, scheduling and rescheduling patients, phoning in prescriptions, all of these things took exponentially more time than I had thought they would. If you have “support staff” where you work, I can tell you that you are probably not fully appreciating all that they do for you!

After about two years, I felt like I was able to take a deep breath. I started having more of a social life again. I started to get back into things that supported me, exercise, painting, music, watching movies, and seeing friends. I found that it was really important for me to start saying yes again to social life, and let me tell you, with a private practice, it can be a constant struggle to keep the practice from eclipsing the rest of your life.

Eventually, I realized that with the full-time clinical work, coupled with the late nights and weekends of doing administrative work, I was not feeling like a whole person anymore and as I am fond of saying to anyone who will listen (unfortunately, I myself am not always that listener) you have to be a whole person to treat a whole person. I then started saying yes to anything that would get me out of the office and put me in touch with other people, teaching at the community college, getting an appointment at the local medical school, running workshops, sharing both sane and crazy ideas with colleagues, intentionally networking with other people, not always sure where that might lead – curating an art show in my office space, ok, why not!

In the movie, Yes Man, Jim Carey’s character is putting all of his energy into avoiding anything life has to offer. He joins a cult-like self-help group and takes the challenge to say yes to anything someone asks him, any opportunity that comes up, no matter how crazy. Things go exceedingly well for him – up to a certain point, and then they don’t go so well. He learns that you cannot literally say yes to everything. Certain “yeses” exclude other possibilities. There is only so much of oneself to go around. It could be said that what he learns is to not say no out of fear, out of arguing for one’s limitations, out of a fixed risk-averse attitude. What he learns is that what is important is saying yes to the right things, saying yes to the things that your heart is really in. That leads to the question, how do you know what is really in your heart. Maybe you are lucky and you already know, otherwise you just have to try something different and see if you like it.

Here I am, encouraging you to say yes to private practice. What am I doing? I am closing my private practice! Why on earth am I doing this after putting so much work into creating this darn thing that was supposed to free me from the restrictions of other health care delivery systems? Well, it may seem hypocritical writing about starting a practice at the same time I am closing mine. What I am realizing, though, as I go through this process is that I am seeing a lot of things more clearly in my practice now that I am starting to get some distance from it. Sometimes you don’t know what you are learning when you are in the thick of things. I’ll invoke H.D. Thoreau, here, “I left the woods for as good a reason as I went there. Perhaps it seemed to me that I had several more lives to live, and could not spare anymore time for that one,” (The Portable Thoreau, Walden, p. 562).

The truth is, I felt like my practice was getting imbalanced. I looked at several ways to re-balance it, I spent more time teaching and networking (and my income went down proportionally), I then tried to see as many patients while still squeezing in the things that I loved and needed to do (the outcome is probably obvious: a frazzled, stressed, and sleep-deprived “holistic” doctor), I hired a part-time office assistant, I looked into finding a business partner, I looked into the possibility of starting a non-profit holistic health center, but none of these seemed to get things back in balance. I felt like I had committed myself to saying yes to things that my heart was no longer in. I don’t know if I would say that I burned out so much as that my heart had moved on before the rest of me followed. It was kind of like realizing that I had learned all that I needed to learn in the practice.

So, what am I doing instead of the practice? Well, my wife and I are moving to New Zealand! I haven’t been this excited about something since starting medical school. The idea of moving someplace new and experiencing different cultures and working in a new health care delivery system (a national health service) sends a thrill of excitement through my core. Saying yes to this new reality means saying no to private practice, at least for now.

However, I really do feel like I have such a clear perspective on my practice as I am ending it. I hope to share more of my experiences and what I have learned, here at PrivatePractice.MD, about starting and running a holistic psychiatry micropractice.

Today one of my patients kindly gave me a basket of tomatoes and other vegetables harvested from her garden just this morning. I was touched by her friendly gesture, and surprised because I practice in that urban mecca called Hartford, CT. I’m not sure how many productive gardens there are near me (not to mention that few tomatoes have survived the blight wiping out the tomato harvest in Connecticut this summer).

Reflecting on my day during my drive home, I recalled a wonderful and eye-opening family practice rotation during my fourth year in medical school (1987) to fulfill the AHEC requirement. I lived with a family practice physician’s family in a small central Ohio farming community for one month. Everywhere she went, I went. I scrubbed in and watched her deliver babies. I observed her examining endless patients in her office until early evening many days, helping or assisting when I could, and then went to her home for dinner before crashing into the spare bed in her guest room each night to sleep. Her family welcomed me, as did her many patients.

Maybe Doctors Feel Like Celebrities in Rural Communities (but are too humble to admit it.)

By the end of the month I was recognized and greeted as “doc” by people I passed on the street as I walked to the post office or corner store (pretty cool experience for a new doctor), and I couldn’t help but smile and feel lucky to be there. These patients often brought my hard-working preceptor vegetables from their garden, or a freshly baked pie, or a scarf knitted just for her. Clearly they welcome their doctors into their lives as another family member.

The family practice rotation accomplished its goal of exposing a city boy to rural primary care medicine. I didn’t even think about the logistics and practice management aspects of my preceptor’s practice, so different from others I had seen up to then, or talk to her about her salary. She mentioned she loved the “life of a country doctor” and “don’t consider it if you want to make a lot of money”. Practicing medicine for the sake of practicing medicine, and being such an important part of these patients’ lives and families, was definitely appealing to me.

What Do You Mean You “Want To Be A Country Doctor”?

When that rotation ended, and I returned home to my reality, I was convinced I would follow in that inspiring family physician’s footsteps and hang up my shingle in a small rural town someday. Alas, it was not to be. For reasons you can guess, trite reasons to some degree I’ll admit in retrospect, I was tempted by the fruit of other specialties and ended up denying my dream of a rural primary care practice. It was the right decision for me then, and I enjoy my medical practice now, but I still remember that very special experience in small town America and sometimes even let myself wonder how my life may have been different had I chosen that career path.

A basket of garden vegetables brought it all back for me today.

Recently I discovered the blog Ideal Medical Practices which is a group or collaborative blog (like I’m working to build here at PrivatePractice.MD). In their own words, the authors state their blog’s purpose is “to pursue, support, evaluate, and educate others with regard to delivering superb health care in a vital and sustainable environment. ” I share that goal!

Currently they are sponsoring a blogging contest for participants at their IMP Camp in Seattle, WA August 14-15, 2009. Participants will blog at the camp about their concept of an ideal medical practice.

Go check it out. I think you’ll find it as useful and interesting as I have!

Social networking websites for doctors and other healthcare providers are proliferating on the internet. I belong to a few of them myself and find them very valuable. PrivatePractice.MD’s focus will be a little different from those sites because this community of doctors will welcome the advice and guidance these experts can offer. There will be an exclusive “Doctors Only” area on PrivatePractice.MD where doctors can chat and exchange ideas privately, but much of the site will encourage the conversation between doctors and all the other important people who make a practice successful. PrivatePractice.MD is about the business, the logistics, and the mechanics of the heart and soul of a healthcare practice. The other sites help doctors discuss clinical issues, this site helps them learn and share best practice management practices. The end result is that everyone is happier and healthier, including your patients, your staff and you.

So please join in the conversation. Tell your colleagues about PrivatePractice. MD. Tell your lawyer, your accountant, your office manager, your medical billing staff, your life insurance agent, your financial advisor. Tell anyone and everyone who helps make your practice the success it is.

To be clear, it can be very frustrating to deal with the bureaucracy of Medicare, (translates as the government) but from a billing standpoint, this is not the case in my experience.

I find customer service very knowledgeable, the remits are easy to read with even denial codes explaining what is wrong with a claim. The phone numbers to contact either a person or an automatic information system are very clear. The website is cumbersome, but someone will walk you through it while they remain on the line with you. There are forms for everything if you cannot accomplish something by phone and while it is true the every “I” has to be dotted and “T” has to be crossed, the work I put in yields results. I cannot always say that about the other plans. Sometimes I wonder where the other plan’s rules come from – like a 90 day timely filing limit with NO room for appeal, explanation, or human error. Medicare’s timely filing deadline is one full year! And even after the year, there is another level of payment available with only 10% taken off the top; that seems fair to me in assigning mutual responsibility instead of simply throwing out the claim and forcing me to write an appeal usually in vain.

I know that a major argument against Medicare is the fee schedule, but if you examine your others plans closely, you will find there are non-Medicaid plans that pay the same or LESS than Medicare. And some of those plans make you jump through hoops to get certain procedures authorized, most of which do not require authorizations by Medicare. And there are also many codes that are bundled with non-Medicare plans but the proper use of modifiers can get you paid for each code with Medicare. Even when Medicare sends you a request for information, they have a standard system in place to process your response.

Finally, Medicare replacement plans have become popular of late mostly because it eliminates people from having to carry a secondary insurance. I am very opposed to them not only for the reasons that I like Medicare, but because these plans have wreaked havoc with beneficiaries. The replacement plans are not properly explained to retirees. So not only are doctors having more plans for which they have to obtain authorizations, I have been the bearer of bad news to patients when I have had to tell them that they must have signed some paper that transferred their health insurance to a replacement plan when that was not their intention.

The bottom line is that if you work within the process of Medicare you can spend more time caring for your patients and less time arguing with their insurance.

Fran Glucroft
Medical Office Manager
Fairfield, CT

In the description directly from the X Prize website it states “This first-of-its kind competition will focus on reinventing the health care system in a bold, measurable and scientific fashion to catalyze dramatic improvements in health and health care value in the United States. The Grand Challenge for the Healthcare X PRIZE is to create an optimal health paradigm that empowers and engages individuals and communities in a way that dramatically improves health value. The proposed prize is designed to improve health value by more than 50 percent in a 10,000 person community during a three year trial.”

The rest of the details can be found on the X Prize website if you want to start imagining how your ideal system would function.

Several private medical practices located relatively close in one region could easily create and treat a community of at least 10,000 patients. These practices could pool resources and create a microcosm, a medical utopia of sorts, along a new paradigm to show that patients received comprehensive care (including preventive care and education), while the small business community of private medical practices also thrived. We have to think big ideas in this uncertain time, and come out stronger and better. The X Prize might provide the impetus for positive change. What do you think? Can we private practice docs pull this one off?