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Wednesday, August 4, 2010

Getting Back to Medicine

Two weeks ago I opened a new medical practice. It's been a long haul. One year ago, after 12 years in practice as an academic general internist, I decided to make a change. After sifting through a wide range of opportunities within the Atlanta metropolitan area I made the decision to open a solo general internal medicine practice. Some might consider it crazy, in an era when physicians are increasingly leaving private practice in favor of large employed groups. Employed groups do offer certain advantages for physicians, including being able to negotiate better contractual rates from insurers, cost-sharing with respect to benefits and pricey equipment, including electronic health records, and more opportunity for shared night call and weekend coverage. 

However, I had just left a large employed group and was witness to the kinds of problems with patient care, access, and continuity that can occur in this type of practice setting. Cost reducing practices, implemented under the guise of efficiency, such as off-site call triage centers, tend to reduce doctor-patient communication, in favor of "teamwork" so that doctors can be left to their revenue generating activity of frenetically seeing 20 to 25 patients daily. 

What I was after was a smaller, more personal practice, where I wouldn't have to spend the first five minutes of my fifteen minute doctor-patient encounter apologizing to my patients for systemic problems that affected the care that they were receiving.

In opening my practice there were several keys decisions to make: first, my practice location. I left my old practice with a two year non-compete covenant restricting me from the practice of general internal medicine in the area where I had built my life and home for twelve years. Would I be forced to move? Or, would I add on an extra hour of driving, and practice outside of my non-competition perimeter? I grappled with this decision for six months. It's funny how many of my friends questioned the legality of this type of contract within the state of Georgia. However, the three lawyers that I spoke with felt it was too risky to violate it. Fortunately this issue is now resolved, and I have established my practice close to home and plan to have a good working relationship with the institution that I left.

Another major decision was whether or not to purchase an electronic health record. The final "meaningful use" criteria tying Medicare and Medicaid reimbursement and incentives to the adoption of electronic health records by eligible medical professionals and hospitals were released two weeks ago. Being somewhat of a techno-geek and a relative "early-adopter," I opted to shell out the cash and buy an electronic medical record (EMR), with hopes that a promised link to my main referral center would become functional in the near future. We'll see how this pans out. I am already concerned that the commercial lab that I have contracted with is hesitating on what I thought was an agreement to upload my lab data directly into my EMR.  Apparently EMR providers charge extra to "turn on" this interface.  If the lab refuses I will be left to cover that cost as well. Those of you in the process of purchasing electronic records should be sure to verify in writing all of the links and interfaces that you want to function, and who will cover the costs associated with turning them on.  Meaningful use requires that lab data is entered into one's EMR as structured data, as opposed to scanned in, which makes the data usable when looking for trends and for generating quality reports and automated reminders.   Don't get me wrong, I am still happy with my expensive new "toy," though it's taking me twenty minutes, instead of two, to type in my office note, as opposed to dictating. Hopefully that will get faster. My implementation support has been wonderful, which I am grateful about.

Finally, I had to decide on staffing. I had originally planned to hire an office manager, but with the purchase of my EMR I decided to outsource my billing to the same company, which meant that I had more flexibility. An opportunity became available for me to hire a wonderful LPN with whom I had worked for many years. I feel so fortunate to work with a capable and loyal employee, who "knows my ways," and with whom I have shared common processes and protocols in the past and who is partnering with me in this endeavor. This is the decision that I am most confident about.

As I began to see patients again two weeks ago, I was surer than ever about my career choice to become a general internist. I can only hope that in the near future my practice will become something more than an expensive hobby.  In the meantime I will continue to work on the side at Georgia Tech in student health to make ends meet.


  1. Thanks for the post. As a young FM doc just out of residency, and someone who wishes to do private practice in the future, it's reassuring to see that people are still taking the plunge.

    Are you doing a traditional insurance-based practice, or starting with a retainer type set-up. Or a hybrid of both until you have enough retainer patients?

  2. Thanks for reading. My practice is a retainer type practice, although I plan to operate in the usual manner (through insurance) for about 10% of my patients eventually. These are patients who I know can really not afford my fee, including some medically complex Medicaid and Medicare patients. My annual fee covers the personalized service that my practice includes. I contract with many health insurance plans for the medical services that insurance covers. Were I to open a traditional practice I would be careful to limit the number of employees that I opened with until the practice grows. In my practice it was important to be electronically linked with my main referral center, which guided my choice of EMR. However, it a different scenario I might be more inclined to considering a less costly EMR.