The number of doctors practicing alone may be declining, but some still manage to succeed.
The number of doctors practicing alone may be declining, but some still manage to succeed.
These are not the best of times to be a solo practitioner.
Over the past decade, the percentage of soloists among physicians responding to the Medical Economics Continuing Survey has dropped from 49 to 35 percent. Even those who still practice alone occasionally wonder about the wisdom of their choice. When we asked doctors in another survey to list the biggest mistakes they'd made in their careers, quite a few cited their decision to go solo. "Would I do it again?" asks Jeffrey Schulman, an ob/gyn in McLean, VA. "Heck no!"
Nevertheless, many soloists manage to survive, and even thrive. And every year doctors still decide to open shop on their own. They leave groups, quit employed positions, even start out fresh from residency. How do they manage to succeed when so many seem to be giving up or dropping out?
We asked current and former soloists to identify the factors that led them to set out on their own, helped them succeed, or caused them to give up. In other words, we looked for "the right stuff" required to make it in solo practice. GP Andrew Wells, who's been practicing alone for nearly 25 years in the little town of Bethlehem, CT, offers the following criteria:
"You have to be independent-minded, because you're completely on your own.
"You have to be self-confident, and willing to take risks. Most doctors aren't willing to risk relying on themselves. They need the safety net of a group.
"You need some sense for business and management. In a group, administrators do most of that for youbut they often screw it up.
"You can't expect to take much time off, even if you're sick. If you don't show up, you don't make a penny.
"You have to really like people, and enjoy spending time with them. If you don't, you won't attract patients or keep them."
A desire for independence. This is the motive cited most often by soloists. Because he's his own boss, Wells can run his practice the way he wants. For him, that means spending plenty of time with each patient, despite pressure from managed care plans. As he explains, "That's the only way to find out what's really wrong with someone."
FP Eli Sorkow, who's been practicing on his own for 14 years in Lake Charles, LA, left a group there because he wanted "to shape a practice my way. And I'd do it again in the same circumstances."
Sudhakar Rao, a solo pediatrician in Warren, OH, left a group 16 years ago because he'd grown "tired of working for someone else, without proper rewards and recognition." He also disagreed with the group's management, which he felt interfered with his "dedication to patient care."
A surgeon in Ohio spent nearly 20 years with a big group before going solo a few years back. Would he do it again? "Definitely," he replies. "In fact, I wish I'd done it sooner. I think I'm providing better care now, and I love being in control of my own practice. I don't have to clear things with partners, or go through channels when I want to do something. And I don't have to go to all those meetings or serve on committees."
Market research. Practice management consultants advise would-be soloists to choose a town with few other nearby doctors, or a location where they won't be in direct competition with several established groups. If you can't find such an ideal location, they suggest you try attracting new patients by offering evening or weekend office hours, or creating a practice that fits a niche.
Family practitioner Abi Rayner, for example, spent 16 years at a multispecialty clinic in Madisonville, KY, before she opened a solo geriatric practice in 1997. From the start, she was able to rely on her many nursing home patients, a big advantage. Donna Alderman, an FP in Glendale, CA, has built a prosperous solo practice based largely on her subspecialty in prolotherapy, a nonsurgical treatment for chronic pain.
Careful financial planning. It's essential for soloists to limit start-up expenses, consultants say, and to have a financial cushion big enough to carry them until the practice is well established. FP Rayner, for example, had saved $80,000 during her years as a clinic employee, which helped her get through her first solo year. She also kept her start-up expenses down by buying used office equipment and bargain shopping for supplies.
FP Steven Gordon of Fulton, NY, learned the importance of financial planning the hard way. His start-up solo practice failed because his income didn't cover expenses and he didn't have enough cushion. Now part of a group, he still thinks about trying solo practice again some day. Next time, however, he hopes to be better prepared financially. "Ideally," he says, "I'd have no debt, and enough savings to live on for a year, so that I won't have to draw a salary during the start-up phase."
Versatility.For many primary care soloists, versatility is a key to success. Since they don't have the luxury of the staff of a typical group, they have to be willing to take on more routine office chores themselves. GP Andrew Wells, for instance, has no nurse to assist him, so he does his own ECGs, minor lab tests, blood pressures, injections, and preliminary workups. By necessity as well as by choice, he's become a jack-of-all-trades: minor surgery, orthopedics, dermatology, pediatrics, and gynecology, along with a dose of psychiatry.
To keep his overhead down at first, FP Steven Gordon did much of his office work himself: "I answered the phones, vacuumed the carpets, and cleaned the exam rooms and toilet," he recalls. Eventually he hired a part-time receptionist and a cleaning service.
No safety net. For many doctors, leaving the comfort of a group to set out alone is like leaving the womb. "I was scared to death when I started out," admits one orthopedist. "It's extremely difficult to go solo after years in a big group where all the little details of running a practice are taken care of by others. Now I have to handle those details myself."
Internist Beverly Dolberg opened her solo practice in Media, PA, two years ago, after three years with a large hospital-owned group. She, too, faced considerable anxiety. "The financial and emotional stress of setting up solo is enormous," she warns, "and probably not for everyone. But it's more than compensated by the freedom of being able to identify and solve a problemor adjust to itwithout any bureaucratic oversight."
Coverage problems. Even soloists who succeed financially are often under constant pressure because they can't find physicians to share coverage. It took Andrew Wells several years before he managed to persuade three local doctors to share call with him. That arrangement now enables him to take plenty of weekends off, plus generous vacations.
Brian Clarke, an Indianapolis gastroenterologist, left a group to go solo in 1994 and found himself working harder than he wanted because he was on call every weekend. After enduring that burden for several years, he persuaded two other solo gastroenterologists to share call with him. Since then, he's been able to spend more time at home with his family and can get away more often for long vacations.
Biting off more than you can chew. Steven Gordon felt pretty cocky when he quit his job three years ago at an urgent care center in upstate New York and opened a solo practice across town. He rented a large suite with four exam rooms and plenty of space to expandmuch more than he needed, as it turned out.
After six months, Gordon's practice income was barely covering his overhead, which left nothing for his salary. After eight months, he had run through his savings, fallen behind on his rent, and missed student loan payments. When another group offered him a full-time position with a good salary, he couldn't refuse; he shut down his practice "with a mixture of regret and relief."
Struggling with managed care. The problem seems to be particularly tough for many soloists. Take FP Kathleen Maley, who set up shop in Espanola, NM, in 1987. After 12 years, she gave up and joined a local rural health clinic. What went wrong?
"I did okay at first," says Maley. "But when managed care took over in our area, my income began to fall. Then there was all the extra time and paperwork involved in processing claims and getting approvals from the HMOsmore than I'd ever imagined."
The extra work forced Maley to hire more staff, which increased her overhead and reduced her own income. "When I didn't bring any money home for almost a year," says Maley, "my husband started asking if my practice had become a hobby. I realized then it was time to quit."
Solo practice is personally rewarding, says pediatrician Sudhakar Rao, "but we're a dying breed because of the HMOs." He blames them for an "enormous increase in paperwork, repeated interference in patient care decisions, and steadily declining reimbursements"all of which are particularly burdensome for solo practitioners.
Even those who've achieved some measure of success at it wonder about the future of solo practice. One problem is finding a doctor willing to take over when they're ready to retire. Andrew Wells gets help from a steady stream of primary care residents from nearby hospitals, who join him for several months each year. Few have shown any interest in going solo themselves, however. Most join large groups. "They all want the protection of an established practice," Wells explains glumly, "with someone else running the business."
"I'm not sure what the future of solo practice will be," says internist Beverly Dolberg. "Perhaps it will become more prevalent as young physicians become disenchanted with the constraints of large-group or corporate-owned practices. In time we'll know if I'm the beginning of a trend or a relic from medicine's bygone age."
Maintaining an independent practice is important to me. I own two medical offices in a beach resort community where the population swells from about 20,000 in winter to more than 300,000 in the summer. Every other physician group in Ocean City is employed by one of the two hospitals that dominate the area. Our innovative program allows us to compete successfully with them.
We make most of our income in four short months, but we don't loaf through the winter. It takes six months to get ready for the summer. We use niche marketing, offering comprehensive programs in weight management, nutritional medicine, vitamin counseling, cellulite reduction, and smoking cessation. We're about to embark on a plan for "drive through" flu shots where patients can receive injections without leaving their cars.
We do plenty of traditional family medicine, toocovering everything from pediatrics to geriatrics, preventive medicine through urgent care. Our clinics are equipped with their own labs, a pharmacy, and X-ray, ECG, and other monitoring equipment. During the summer, the clinics are open 20 hours a day, seven days a week.
We've been very successful at attracting patients. Our two medical offices log 20,000 patient visits a year, which is more than the emergency room at one of the local hospitals. I credit our marketing effort, which includes ads in the Yellow Pages and newspaper, and on TV and radio. We distribute 20,000 magnets a year with our clinic logo and phone number. We send out newsletters, birthday, and Christmas cards. We make follow-up calls to most of our patients, even tourists who live out of state, to see how they are doing. During the off-season, we do free community-service programs in our clinics.
Technology helps us stay organized and efficient. In fact, all of our managers have computers at home that tie into the office. We implemented an e-mail system long before the Internet became so popular. Patients can schedule appointments through our two Web sites (www.75thstmedical.com), as well as get useful medical information.
We're currently working on voice recognition and imaging systems for even better medical records management. Because the records are computerized, our Baltimore accounting firm is able to tie into the system, via modem, and manage our accounts.
During the summer, our payroll swells from 10 to 40, which includes five physicians, two full-time PAs, and 10 other PAs who rotate throughout the season in exchange for a free vacation. We have four full-time radiology technicians, plus other clinical and office staff. It's easy to recruit physicians with a benefits package that gives them free use of ocean
front condos. The chance to work at a beach resort is a big attraction.
To maintain quality, we run orientation and customer service training programs. We've also used practice guidelines for years.
Who says the small practice is a dinosaur? We've proved that David can compete with Goliathif the owners of the small practice are willing to take some chances, invest wisely, and search for innovative ways to prosper.
Berkeley Rice. Do you have the right stuff to go solo?. Medical Economics 2001;1:121.