A cramped, solo slice of heaven

This tiny, bare bones ‘micropractice’ is FP Gordon Moore’s idea of paradise. No secretary, no nurse — and no hassles

By Peter Woodford
http://www.nationalreviewofmedicine.com

“In many ways this is a Norman Rockwell practice with a 21st century technological backbone,” muses solo FP Dr Gordon Moore of his Ideal Micropractice vision, speaking to NRM from his tiny Rochester, NY, office. “I’ve had some docs who’ve been practising for 35 years who’ve said ‘you haven’t invented anything here’ and they’re right — I’m just using technology to make it possible today.”

Exactly what Dr Moore, who’s also a researcher at the Institute for Healthcare Improvement (IHI), is doing will strike many doctors — particularly Canadian MDs — as completely nuts.

Imagine answering your own office phone and giving out your email address and cell number to patients. Throw in some same-day booking and 30 minute patient visits and you start to get an idea of how things work in Dr Moore’s office. But there’s a method to the madness — in fact it was his IHI research that led him to hang out his micropractice shingle. Well, that, and the pressure to see more than 30 patients a day at his former group practice in a big HMO.

It’s been six years since he said goodbye to group practice, and he admits there are some adjustments to make. A doctor who opts to follow the micropractice model — no secretary, no support staff, just the doctor and his computer — can expect to make less money than by joining a traditional practice. The dollar difference largely depends on how good one is at keeping down costs but as a ballpark estimate, expect to earn 30% less than you would in a group.

So why would anyone want to take a pay cut? For pretty good reason, says Dr Moore: micropractice docs get to spend more time with patients, be their own boss, and generally be under less stress. “The joy-of-work quotient for us in our practices is huge,” beams Dr Moore.

THE FOUR PILLARS
For Dr Moore, if a micropractice is to work it requires four things: great access, enhanced patient interaction, reliable clinical care and practice vitality in the form of low overhead. He’s a big proponent of open-access scheduling — also called same-day booking — as a solution for access problems. “We think open access is a delight for patients and less work burden for a practice because we don’t have to negotiate a delay — you’ll be telling them “Sure, come on in today,” he says.

But giving patients his cell phone number and email — meaning he’s essentially always on call — is a recipe for disaster, right? “No, the inappropriate call is a very, very rare event. People are very respectful. It’s been a delight compared to working in a call group, which I found overwhelming,” he says.

TECHNICALLY SPEAKING
Without a good EHR, Dr Moore wouldn’t have been able to run his practice essentially on his own (he rented a room in a specialists’ office and the main receptionist lets him know via intercom when his patient walks in, but he does everything else himself). He feels many EHRs lack the flexibility to work for micropractice but some very inexpensive ones like Amazing Charts (about $1,000US) do the job with aplomb. Even cheaper, in March Google announced it will soon release a free web-based EHR software, paid for by advertising. Dr Moore’s EHR advice is “try before you buy.”

Yet in keeping with Dr Moore’s low-overhead mantra, he doesn’t think you need to spend a lot for that EHR. For him, free advertiser-supported technology like Yahoo mailing lists are a boon for doctors wishing to go solo. He says that the micropractice mailing list that he started contains a wealth of searchable information for anyone thinking about getting their feet wet. Plus, you can submit questions and expect helpful responses and support from more experienced solo docs who subscribe to the list.

He estimates that his overhead costs eat up about 35% of his revenue — that figure is usually about 60% in a typical group practice. This cost cutting allows him to see fewer patients for longer without going broke. “The only reason we succeed with micropractice is with very low staffing ratios and high information technology support,” he says. “The payment model is a driver for the status quo and we really need to explore different payment models in the US as well as Canada — it’s dysfunctional and gets in the way of really good care.”

So far, he hasn’t seen a Canadian FP take the micropractice plunge but he’s spoken to several who are considering it. Resisting the pull toward group practices and capitation that’s happening in most provinces won’t be easy for most MDs.

THE CRITICS
There are other reasons Canadian docs might not get on board.

The reaction to micropractice by non-solo MDs isn’t always positive. “I’ve seen some incredibly irrationally angry responses,” admits Dr Moore. “I suspect that some are just expressing their pain.”

But there are some valid concerns being raised as well. Dr Sydney Smith (a pseudonym), a veteran FP who writes the blog MedPundit, thinks micropractice, where doctors tend to have smaller rosters, is bad news for broader public health (her blog states she uses a nom de plume “to avoid offending the sensibilities of any of her patients who may accidentally find the website”). “There would be a lot of patients going without routine healthcare and more visits to emergency rooms,” she says in a phone interview from her office, “both for acute problems that would normally be handled in a physician’s office and for complications of untreated chronic disease.”

This could have pretty big implications for Canada, with its massive physician shortages. “If a physician lives in an area that has a ratio of 3,000 patients per doctor but all the doctors only accept 500 patients then that leaves 2,500 people per doctor without a physician,” notes Dr Smith. “Overall, it’s a losing situation for public health.”

Dr Moore takes a different view of micropractice’s effect on public health. “We have people who are using this practice model and running 1,300-1,500 patients — a pretty respectable patient load,” he says. “And also we’ve found this model to be very attractive to med students — they’re banging on the gates asking how to get involved. They’re thinking “Wow, for the first time I’m seeing an effective primary care model where a clinician is actually happy!””

Dr Moore invites interested Canadian physicians to take part in a free IdealMicroPractice (IMP) Project cohort. For more info visit www.idealmicropractice.org
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