Feature Article

Doing the Right Thing

By Eric Holmberg, MD

In the spring of 2004, I left a salaried position at the Petaluma Health Center and embarked on a solo medical practice. This move seemed to fly in the face of common sense because the number of private-practice physicians in Petaluma has steadily dwindled over the past decade, with the principal efflux going to Kaiser and most of the remainder to practice opportunities outside of Sonoma County.

As recently as when I completed my family-practice residency in 1992, most young physicians I knew would have been happy to open their own offices or join existing practices to replace their happily retiring older colleagues. Today, however, the ravages of managed care, and the advent of a health system controlled by the insurance industry and neglected by government, have left a barren landscape for new physicians.

I helped shepherd the Petaluma Health Center in its early growth from a small two-MD, one-FNP practice with about 6,000 patients to the federally qualified health center it is today, with many physicians and midlevel providers and more than 150 patient visits daily. During our growth, we responded to the needs of an increasingly neglected group of uninsured or underinsured patients. Meanwhile, a large subset of our practice consisted of patients on managed-care plans without access to local doctors, as private practice had begun to shrink and the number of available physicians had declined. Doctors, midlevel providers, and ancillary staff were added progressively to account for the increasing demand; the clinic hours were expanded; the practice burgeoned.

We became, however, victims of our own success in attracting patients. After 10 years, the patient load, combined with the overload of information that we generated, reached the point that the quality of care I was able to provide had declined markedly. We began to outstrip our capacity to file information in a timely manner, to return patient phone calls, or even to locate a chart at the time of a patient visit. Our antiquated phone system could not begin to keep up with the volume of calls coming in, and patients began coming to the office in lieu of calling because they were frustrated with the extended times on hold. Many patient visits began with my apologizing for the amount of time they had spent waiting to see me. The burden of on-call work and the inpatient load had also grown, to the point that weekends were mostly spent in the hospital. Previously, weekends had usually allowed me a fair amount of freedom.

I had for some time thought about returning to a smaller model of care, and the shift finally seemed right last year. I didn’t intend to practice completely alone; but when partners did not readily materialize, I realized that solo practice was quite doable and perhaps in some ways for the best, given where I was coming from. I’ve been on my own for almost a year and have been enjoying my work once again. I’ve also been able to fix nearly everything I was unhappy about previously.

The model I follow is really not much different from that used by the older established physicians in the office complex I’m in now. They were independent from the start and have stayed that way. I work with just one office assistant, who serves as manager, receptionist, referral coordinator, biller, and sometimes medical assistant. She and I are the only people our patients have to know.

Our goals are to keep our overhead low; to maximize the time spent with patients; to see patients on time; to minimize the layers between patient and doctor; to deal with patient problems as they arise and not put them off for the next day or the next week; to provide current, high-quality care; and to thrive economically. The ultimate plan is to see about 70 patients over four days, with another half-day for management tasks.

Patients are delighted to have a person—rather than a voice mail system—answer the telephone. About half our schedule is prebooked, with the other half left open for same-day care. I use a low-end but decent electronic medical record system (eClinicalWorks) to handle the practice management and charting.

With the exception of a few out-of-town trips, I have taken all my own call during this time. Call is much less burdensome than I thought it would be, other than the need to be always available. Patients have both my home and cell phone, and they don’t abuse them. I know the patients who are calling, and I can access their charts and our appointment schedule over the Internet. I never have to quibble with the on-call doctor’s decisions. My patients seem quite happy, and the practice continues to grow steadily without the need for advertising.

To date, the few drawbacks to solo practice are mostly those of availability and fatigue. It is also difficult to care for patients when you are ill. I recently had the hilarious experience of fielding phone calls from patients when I found myself one morning in the ER with biliary colic. Another drawback is that electronic charting is hard to do well, and creating an electronic patient note is less efficient for me than handwriting. Without a larger support system in place for information sharing, many of the potential gains of electronic charting are not realized.

Although it happens seldom, the potential of being called on at any time alters the social dynamics with my family and friends, and I haven’t as yet found it easy to get time away out of town. There are many areas of rural Sonoma County where cell phones don’t work, so even taking a weekend hike may require finding backup. The illusion of freedom faces the reality of needing to run an office: the necessities of understanding bookkeeping and deciphering PPO contracts are not much fun to learn after office practice is finished for the day. I’m also dismayed that even though I continue to see many patients with Medi-Cal or HMO insurance plans, I can no longer afford to take care of others because of lack of insurance.

The practice is almost thriving, even though we are only at 80% of the planned patient flow. I have far more space than needed in my 1,000 square-foot office, and I could easily house another physician interested in similar low-volume, high-quality work. As patient fatigue with the HMO model progresses, I hope more and more physicians will return to private practice. It provides satisfaction and enjoyment to both our patients and ourselves. My work has grown easier, even as it has occupied more of my time, and I provide much higher quality patient care than before.

To be of real value to patients, the private-practice community needs to offer something unique. We need to differentiate ourselves from the HMO model by being more accessible, flexible, and caring, and by knowing our patients as well as we possibly can. We have lost the early battles for information retrieval, system organization, and pharmacy management; but as we strive to improve these aspects of our practices, we should also offer the one alternative that patients are most enamored of: the chance to know and be known by your doctor.

Dr. Holmberg is a Petaluma family physician in solo practice.

Sonoma Medicine, Volume 56, Number 2 (Spring 2005).