Medical practice from both sides now

September 1, 2006

My professional life has changed radically over the past several months. I have left academic medicine and have started a private practice. Living in the professional cocoon of the university, I had absolutely no idea of the complexities, pressures, anxieties and great joy associated with this enterprise. I never dreamed that I would be paying a practice management consultant, a phone installation consultant, an employee health insurance agent, a computer consultant, an office security consultant, a janitorial consultant and the credit card processing company sales associate to provide advice.

I have been assured that I will soon be very busy and will not have to be concerned about my finances. At this stage, most of what I have experienced is writing checks to others. In spite of what all of the consultants say, I am still very nervous about making a living. I actually stopped buying useless toys-for-boys on eBay and have temporarily discontinued the pursuit of the perfect computer or home theater system.

To achieve fiscal solvency, I have been doing some things that, in my previous professional life, would have been considered an out-of-body experience. For example, I have been reviewing old "Ms. Codit" articles from this magazine. I have joined the local medical society. I have sent out promotional mailers to prospective patients and referral physicians with my picture prominently displayed and have negotiated contracts with insurance carriers, haggling over whether they will pay 105 percent or 110 percent of Medicare rates.

The single most difficult aspect of entering private practice for me has been the time-consuming and frustrating experience of "getting on the plans."

The vast majority of people in our community are insured through PPO policies which dictate where they can receive their care. As my practice management consultant reminds me continuously, some of these plans are impossible to deal with because they handle claims in an erratic way, they make it a chore to get the appropriate authorization, or they have fiscally understandable but medically irresponsible rules that make it very difficult to practice quality medicine.

Thus, I am already refusing to see patients that I have cared for over many years because they or their employers have chosen one of the "bad" insurance carriers.

Of all of these adjustments, the most heartening has been the way that I have changed in my approach to patients. In an academic setting, patients with complicated medical problems are often viewed as "interesting cases." In private practice, one gets the opportunity to interact with the individuals on a more personal level. One learns a lot about their lives and how the skin problems impact on them as people. It is not difficult to become friends and even confidants of these people. This is extremely satisfying for me as the physician, and, I suspect, for the patient as well.

Some have warned me that it will get lonely and perhaps intellectually sterile in the office without trainees present at all times. Although this is possible, I am hopeful that our active local dermatologic society will provide the intellectual stimulation through regular Grand Rounds presentations and journal clubs. In addition, enforcing a discipline of monitoring the recent medical literature as it pertains to the individual problems of my patients should keep me interested and up-to-date.

I suspect that it will be very difficult to keep abreast of the newest developments in basic science research without the gentle push of the dermatology residents. I would hope that through reading and attendance at educational conferences, I will be able to remain relatively current in subjects of particular interest to me.

Potential for conflict

The single most difficult issue that I have faced as a newly minted private practitioner is the potential financial conflict of interest in each patient encounter.

When I was a salaried employee of a big organization, it mattered little to me how much the patient was charged. As I am now the proprietor of the business, it matters to me quite a lot. I have talked with many friends in private practice who indicate they do not think about charges for various therapies, and only try to do what is in the best interest of the patient.