Hanging on as small practices slowly die

 

I’ve had to skip several paychecks this year to keep my practice afloat. That makes it hard to pay for my routine personal expenses, like a mortgage, so I have to take the money out of my family’s “rainy day” savings.

This gets old after a few years of the same cycle. I’m pretty sick of it.

Granted, I chose this path. Solo practice suits me. I’ve been in a large group, and it took me roughly 2 years to realize it was a poor fit for me. I’ve been on my own since 2000 and been pretty happy here.

I’ve come to accept that taking a vacation means a temporary drop in salary down the road. My family is important to me, and I don’t want them to remember me as the never-home father immortalized by Harry Chapin’s “Cat’s in the Cradle.”

Trouble is this: What if you still work hard, and find your income falling? I see patients from 8 to 4 most days, with a full schedule, but reimbursements keep dropping and costs keep climbing. Isn’t the idea that hard work will bring success central to the American Dream? Especially when you toss in 9 years of medical school and residency? Apparently not. The American Dream, whatever it is, is pretty much dead for most small-practice doctors.

These are tough times for solo docs, regardless of field. I’ve seen several posts on sites such as Sermo that show I’m not the only one in this boat, skipping paychecks to keep the door open and lights on. Most small practices are running into the same issue. Some, like me, are slugging it out and hoping things get better. Others are folding up and moving, or joining large groups, or signing up with a hospital system.

I’m not sure those last two are options I want. Most of the docs I know who’ve joined hospital outpatient systems are pretty unhappy with them, too. They talk about computer systems designed for billing rather than patient care; unrealistic amounts of time allotted to each patient by a nonmedical person; and jumping through hoops to get certain tests or treatments done.

I suspect it’s a combination of factors, though others see more sinister forces at work. Some posts I read suggest that it’s part of a government and/or insurance conspiracy to destroy small practices.

Regardless, it seems to be succeeding. Small practices are in crisis. Doctor suicides are up. And solo practice has been found to be a risk factor for suicide. There are days when I can see how that seems like the only way out for those who came here just to care for people, and now find that economic circumstances won’t let them.

I don’t have a castle, or drive a Rolls-Royce, or send my kids to private school. We live fairly modestly, but even then it’s getting hard to keep up with costs.

We’re in an election year, and, as always, medical care is bandied about by both parties as a bargaining chip to get votes. But I haven’t heard either side talk about this, nor do I get the impression that either major candidate really cares. Both of them, and members of Congress, get pretty top-notch care without having to worry about cost. This isn’t reassuring to me and all the other solo docs hanging on by our fingernails and trying to practice ethical, honest medicine.

I’m sure some will say it’s progress, but I think the gradual death of the American small and solo practice is sad. It’s a model that’s been the backbone of Western medicine for a few hundred years now, caring for people in big cities, small towns, and everywhere in between. Portrayed in fiction as Marcus Welby, Michaela Quinn, Joel Fleischman, and (my favorite, from Willa Cather’s “Neighbour Rosicky”) Ed Burleigh. Sometimes brilliant, sometimes quirky, sometimes all-too-human ... but still doctors, caring for their patients and communities.

Like the unnamed protagonist in Dr. Seuss’ “I Had Trouble in getting to Solla Sollew,” I tend to find that no matter where you go there will be troubles, and sometimes you’re best off staying in one place and fighting the ones you know.

And, for now, that’s where I am and hope to stay. But I’m scared.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

I’ve had to skip several paychecks this year to keep my practice afloat. That makes it hard to pay for my routine personal expenses, like a mortgage, so I have to take the money out of my family’s “rainy day” savings.

This gets old after a few years of the same cycle. I’m pretty sick of it.

Granted, I chose this path. Solo practice suits me. I’ve been in a large group, and it took me roughly 2 years to realize it was a poor fit for me. I’ve been on my own since 2000 and been pretty happy here.

I’ve come to accept that taking a vacation means a temporary drop in salary down the road. My family is important to me, and I don’t want them to remember me as the never-home father immortalized by Harry Chapin’s “Cat’s in the Cradle.”

Trouble is this: What if you still work hard, and find your income falling? I see patients from 8 to 4 most days, with a full schedule, but reimbursements keep dropping and costs keep climbing. Isn’t the idea that hard work will bring success central to the American Dream? Especially when you toss in 9 years of medical school and residency? Apparently not. The American Dream, whatever it is, is pretty much dead for most small-practice doctors.

These are tough times for solo docs, regardless of field. I’ve seen several posts on sites such as Sermo that show I’m not the only one in this boat, skipping paychecks to keep the door open and lights on. Most small practices are running into the same issue. Some, like me, are slugging it out and hoping things get better. Others are folding up and moving, or joining large groups, or signing up with a hospital system.

I’m not sure those last two are options I want. Most of the docs I know who’ve joined hospital outpatient systems are pretty unhappy with them, too. They talk about computer systems designed for billing rather than patient care; unrealistic amounts of time allotted to each patient by a nonmedical person; and jumping through hoops to get certain tests or treatments done.

I suspect it’s a combination of factors, though others see more sinister forces at work. Some posts I read suggest that it’s part of a government and/or insurance conspiracy to destroy small practices.

Regardless, it seems to be succeeding. Small practices are in crisis. Doctor suicides are up. And solo practice has been found to be a risk factor for suicide. There are days when I can see how that seems like the only way out for those who came here just to care for people, and now find that economic circumstances won’t let them.

I don’t have a castle, or drive a Rolls-Royce, or send my kids to private school. We live fairly modestly, but even then it’s getting hard to keep up with costs.

We’re in an election year, and, as always, medical care is bandied about by both parties as a bargaining chip to get votes. But I haven’t heard either side talk about this, nor do I get the impression that either major candidate really cares. Both of them, and members of Congress, get pretty top-notch care without having to worry about cost. This isn’t reassuring to me and all the other solo docs hanging on by our fingernails and trying to practice ethical, honest medicine.

I’m sure some will say it’s progress, but I think the gradual death of the American small and solo practice is sad. It’s a model that’s been the backbone of Western medicine for a few hundred years now, caring for people in big cities, small towns, and everywhere in between. Portrayed in fiction as Marcus Welby, Michaela Quinn, Joel Fleischman, and (my favorite, from Willa Cather’s “Neighbour Rosicky”) Ed Burleigh. Sometimes brilliant, sometimes quirky, sometimes all-too-human ... but still doctors, caring for their patients and communities.

Like the unnamed protagonist in Dr. Seuss’ “I Had Trouble in getting to Solla Sollew,” I tend to find that no matter where you go there will be troubles, and sometimes you’re best off staying in one place and fighting the ones you know.

And, for now, that’s where I am and hope to stay. But I’m scared.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

I’ve had to skip several paychecks this year to keep my practice afloat. That makes it hard to pay for my routine personal expenses, like a mortgage, so I have to take the money out of my family’s “rainy day” savings.

This gets old after a few years of the same cycle. I’m pretty sick of it.

Granted, I chose this path. Solo practice suits me. I’ve been in a large group, and it took me roughly 2 years to realize it was a poor fit for me. I’ve been on my own since 2000 and been pretty happy here.

I’ve come to accept that taking a vacation means a temporary drop in salary down the road. My family is important to me, and I don’t want them to remember me as the never-home father immortalized by Harry Chapin’s “Cat’s in the Cradle.”

Trouble is this: What if you still work hard, and find your income falling? I see patients from 8 to 4 most days, with a full schedule, but reimbursements keep dropping and costs keep climbing. Isn’t the idea that hard work will bring success central to the American Dream? Especially when you toss in 9 years of medical school and residency? Apparently not. The American Dream, whatever it is, is pretty much dead for most small-practice doctors.

These are tough times for solo docs, regardless of field. I’ve seen several posts on sites such as Sermo that show I’m not the only one in this boat, skipping paychecks to keep the door open and lights on. Most small practices are running into the same issue. Some, like me, are slugging it out and hoping things get better. Others are folding up and moving, or joining large groups, or signing up with a hospital system.

I’m not sure those last two are options I want. Most of the docs I know who’ve joined hospital outpatient systems are pretty unhappy with them, too. They talk about computer systems designed for billing rather than patient care; unrealistic amounts of time allotted to each patient by a nonmedical person; and jumping through hoops to get certain tests or treatments done.

I suspect it’s a combination of factors, though others see more sinister forces at work. Some posts I read suggest that it’s part of a government and/or insurance conspiracy to destroy small practices.

Regardless, it seems to be succeeding. Small practices are in crisis. Doctor suicides are up. And solo practice has been found to be a risk factor for suicide. There are days when I can see how that seems like the only way out for those who came here just to care for people, and now find that economic circumstances won’t let them.

I don’t have a castle, or drive a Rolls-Royce, or send my kids to private school. We live fairly modestly, but even then it’s getting hard to keep up with costs.

We’re in an election year, and, as always, medical care is bandied about by both parties as a bargaining chip to get votes. But I haven’t heard either side talk about this, nor do I get the impression that either major candidate really cares. Both of them, and members of Congress, get pretty top-notch care without having to worry about cost. This isn’t reassuring to me and all the other solo docs hanging on by our fingernails and trying to practice ethical, honest medicine.

I’m sure some will say it’s progress, but I think the gradual death of the American small and solo practice is sad. It’s a model that’s been the backbone of Western medicine for a few hundred years now, caring for people in big cities, small towns, and everywhere in between. Portrayed in fiction as Marcus Welby, Michaela Quinn, Joel Fleischman, and (my favorite, from Willa Cather’s “Neighbour Rosicky”) Ed Burleigh. Sometimes brilliant, sometimes quirky, sometimes all-too-human ... but still doctors, caring for their patients and communities.

Like the unnamed protagonist in Dr. Seuss’ “I Had Trouble in getting to Solla Sollew,” I tend to find that no matter where you go there will be troubles, and sometimes you’re best off staying in one place and fighting the ones you know.

And, for now, that’s where I am and hope to stay. But I’m scared.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.