Is Small Better? Physicians Discuss the Ups and Downs of Solo Practice

Lisa Egbert, MD, can't think of a reason why she'd ever leave her solo practice.

It's an ironic twist, given that when she first started, it was the last thing she wanted. She had 6-month-old twins and was just out of a tough residency. But when a solo doctor in her area retired with little notice, she suddenly found herself leaping into the position. It ended up being perfect, she said.

"I was looking to work a more normal schedule and a more controlled schedule," said the Dayton, Ohio-based ob/gyn. With the solo practice, she could do that, and spend as much time as she wanted with her patients. It came at the expense of income, but "what I make is what I make, and it's my choice," Egbert said.

As an example, Egbert notes that being solo has allowed her to limit the number of pregnant women in her practice who are due in any given month; she generally keeps it at 10 or 12. And that gives her the ability "to know each and every one of my patients," she said. When a patient in labor calls, "I know what her problems are, and I know what to watch for," she said. That helps contribute to a better quality of care, said Egbert.

Recently, a woman came in for an annual exam accompanied by her 8- and 11-year-old daughters, both of whom Egbert delivered. The older girl was wearing a baby bib emblazoned with her birth date and "Special Delivery by Dr Egbert."

Egbert gives out the bibs with every delivery. And here was this girl, 11 years later, wearing the bib. "That is so cool," Egbert said.

Like Egbert, David Frankel, MD, a Brooklyn, New York dermatologist, said the ability to "be my own boss," which included setting his own hours, practice standards, and rules, was a potent attraction of solo practice. "I thought there was an opportunity to practice in a manner I wanted to," said Frankel, who retired in October after 20 years of solo practice.

When he finally signed the lease for his solo practice space, it was great timing, as his twin son and daughter had just been born. "Having my own practice allowed me to figure out how I could practice and could also help take care of the kids. I think that if you have those kinds of desires and goals, solo practice, in many ways, is the way to go," said Frankel.

He and Egbert both acknowledge their ongoing struggles with the pressures of running a business. Frankel says that he "was always tempted by the idea of starting my own practice, but I was nervous about running a practice, hiring staff, and all the other chores you need to take care of to run things smoothly."  And the daunting task of being the sole person "dealing with referrals and all the other crazy impediments to care." If a patient has a complaint about a referral not going through, for instance, the solo clinician "is right there, you're not 100 yards away in the back offices where clinical work is done, you're right in front of it," he said.

Who Are the Solo Practitioners?

So who chooses solo practice? Is it someone more likely to enjoy a close relationship with patients? Are they iconoclasts — rebels who don't like authority and rules? Are they more comfortable with risk? Or is it all about being your own boss?

Ask any number of solo practice doctors why they choose to go it alone, and the answers are consistent: freedom, flexibility, autonomy, and the ability to connect with patients on a level that might not be possible in a larger practice or in an employment model.

"My interest is solely aligned with that of the patient," said Erica Swegler, MD, a solo family physician in Austin, Texas who is also on the board of directors of the American Academy of Family Physicians (AAFP). She noted that she's not pressured to refer only within a particular system or to refer to care that might be lower value. And she can perform services to the top of her license — such as skin procedures and endometrial biopsies.

Swegler has her own vision and mission statements, which hang on the walls in her practice. She sums it up as "health plus caring." The mission: to provide all and only the right care at the right time, dictated by the needs and interests of the individual patient, and done consistently for every patient every time.

"I feel that solo practice gives me the best chance to achieve that," she said. 

Said Egbert: "We are in solo practice because we like the autonomy to be able to practice medicine on our terms."

For her, that includes not rushing patients out of her office. "Sometimes I have to sit and talk to patients for awhile," she said, noting that other problems may come up during the course of an annual exam. Instead of telling a patient to come back, she likes to address it immediately.

These solo clinicians also said they like the ability to hire and fire their own staff, and structure their lives in a way that works for them.

Swegler, for instance, said she's been able to spend a lot of time being involved in AAFP activities, which was more difficult when she was employed.

Wayne Lipton, managing partner of Concierge Choice Physicians, who has worked with many solo and independent doctors who were attempting to find a way to stay in practice, said he's found that solo practitioners are individuals "who believe — with good reason — that they can help people and would like to have that opportunity to do so, but don't like to be controlled themselves."

Mary Pat Whaley, a practice management consultant in Seattle, Washington, said in her experience women leaving a hospital practice are most commonly looking to go solo. But she says her clientele might skew toward women because they might be seeking another woman as a consultant. Most clinicians she's advised on going solo want to practice medicine their way, and branch out into things a hospital or larger practice might not be ready to do, such as home visits, telemedicine, or concierge medicine, said Whaley.

A snapshot of the family medicine solo practitioner found, in contrast to Whaley's experience, that such a clinician was more likely to be male, African American, Asian, or Hispanic and to have been in practice for more than 30 years. The diversity may be due to the fact that often, minority physicians tend to go back to service their own communities, said lead author Winston Liaw, MD, MPH, chair of the department of health systems and population health sciences at the University of Houston in Texas.

This study also found that solo practices were most likely to be located in counties that had the highest percentage of the population living below the federal poverty level.

Liaw said that at the time that of his study, which used data from a 2013 survey completed by 10,000 physicians seeking certification from the American Board of Family Physicians, it was surprising to find that half of respondents worked in solo or small practices. He hopes to conduct a follow-up survey to determine how many of these small and solo practices have been forced to consolidate because of market forces. 

"We're requiring practices to do more with less," such as reporting quality measures and installing electronic health records systems, he said. "All of those things are very expensive and they require capital, they require investments, and these are resources that these practices tend not to have," said Liaw.

Better Quality Care?

Despite those limitations, some data suggests that smaller and solo practices deliver higher quality care. And solo independent clinicians believe that they offer better continuity and more attentive care.

A study examining Medicare claims found that practices with one to two physicians had admission rates, under some conditions, that were one third lower than practices with more than 10 physicians. "These findings were unexpected, since small practices presumably have fewer resources to hire staff to help them implement systematic processes to improve the care they provide," write the authors.

They speculated that results were better for small and solo practices because patients may more easily get appointments and talk to the doctor when needed. "It is also possible that physicians, patients, and staff know each other better in small practices, and that these closer connections result in fewer avoidable admissions," they write.

Swegler, for her part, said she believes "that solo practice, or being in a small independent practice, provides the best patient care."  

When she entered practice in 1986, being solo "was much more the norm." After almost 8 years, Swegler moved to a small group, where she stayed for 16 years. But when she concluded that the group was not moving in the direction she wanted to go, she moved back to solo practice, where she has been for the last three-and-a-half years.

"Where we've kind of blown it as a country…is that we came to think of healthcare as discreet biomedical interventions and interactions where both the patients and the physicians can be interchangeable, and that's just bull," said Richard Roberts, MD, JD, a professor emeritus of family medicine at the University of Wisconsin School of Medicine in Madison, and former president of the American Association of Family Physicians (AAFP). "Healthcare is about people."

"If you have a physician you know and trust, you're going to stick with that person," said Roberts. The same is true for physicians — when they know their patients well, "it makes everything easier," he said.

"It makes the risk for error less. And when errors do come up, you tend to pick them up sooner, because there's just this connectedness that you don't find in large groups," he said, adding that he believes communication errors also occur more frequently in larger groups.

Does Small Mean Less Burnout?

Several recent studies have suggested that autonomy makes physicians less prone to burnout. The Medscape National Physician Burnout, Depression & Suicide Report 2019 found that physicians in office-based solo practice were the least likely to report burnout — a result that may be because of more autonomy in those settings.

In July 2018, researchers reported that physicians practicing in groups of 5 or fewer in New York City had a "remarkably low burnout rate" (13.5%). Almost 70% of the clinicians in this low burnout group were in solo practices. These authors, too, attributed this result to more autonomy. "One explanation for this finding could be the autonomy (ie, control of work environment) associated with owning one's own practice," said the authors.  

Frankel said it's not necessarily a given that solo practice in and of itself could lead to less burnout. "I think it depends upon your personality," he said. "I like to get involved and see the outcome of what I do. That's the satisfaction of it." Although being in a larger organization meant having to deal with less of the business side of medicine, that wasn't as satisfying, he said.

"When I see so many colleagues working for large organizations that they don't particularly care for or they don't feel any affiliation with, other than it is their job location, I feel pretty lucky," said Frankel. "There is so much alienation, I find, among my colleagues who work in bigger organizations."

Lipton, however, is skeptical, and suggests that in his experience, solo practice doctors are not necessarily happier or less burned out. "If the solo practice model led to greater personal satisfaction, then you'd have a lot more independents than you do now," he said.

The Unique Risks of Solo Practice

But lack of satisfaction might not be the reason why there are fewer solo clinicians. The hurdles to becoming a solo practitioner are higher than ever, especially for those who come out of training with a large amount of medical debt. And they face challenges that big groups or employed physicians might not ever see.

"They have the problem of being chief cook and bottle washer," said Lipton.

Egbert noted that "in general, running a small business is hard, and physicians are not trained to run a small business." A practice has to deal with an electronic medical record, electronic billing, keeping up with quality measures, and prior authorizations and pre-certifications for surgery. Swegler notes that she also had to be much more attuned to the cost of care. When she was employed, she said, she didn't "really know the cost of providing services," and didn't "appreciate as much what it costs to have, for example, that immunization on hand."

Finding colleagues to cover the practice for vacation or other absences can be a problem too. Egbert said she and a six-clinician group share coverage. Frankel had colleagues who agreed to be available for patients in his absence, but even when on vacation, he would call into the office once a day, and he was always available for staff calls.

Malpractice premiums and risk mitigation can be overwhelming to solo doctors. Frankel conducted all of his own follow-up for skin cancer — letters and calls — which, while time-consuming, was something he wanted to do. "I'd much rather call the patient and talk to them myself because that way I can make sure the message I want to give to the patient is the message they get," he said.

Egbert has continued to practice obstetrics despite the high cost of malpractice insurance and the risk of litigation. But she has back-up in the form of her husband's income; he's an anesthesiologist. He is "supporting my habit of practicing obstetrics," said Egbert. As a solo doctor, she believes she practices more carefully and skillfully, which perhaps mitigates litigation risk. "I've never had a suit against me, knock on wood," she said.

Luck may not stay on her side. In a 2019 Medscape report, 83% of ob/gyns said that they had been named in a lawsuit.

Hollister cites overhead — and specifically rent — as another risk. He just assumed a 10-year lease at his new location, for instance. "I have to plan on meeting that," he said.

Swegler has been forced to move from her current central Austin location because of increasing rent, she said.

Whaley said an increasingly big hurdle for solo practices is credentialing. Most payers take 90 days or more to accept a clinician in-network and begin paying claims. But to start the process, the physician has to have a location, and malpractice insurance. "You're ready to open your doors, you've spent all this money to get started, but you can't get into a network," said Whaley.  Medicare allows clinicians to start seeing patients 30 days after the application and will retroactively pay, but clinicians are spending money in the meantime on seeing those patients, she said.

And 90 days in many cases has now morphed into 90 business days, which means an additional month of waiting to get paid, said Whaley.

Lipton said he's seen smaller independent practices "get hammered" on payment rates from third-party payers and insurers because they don't have the leverage of a larger practice. Egbert agreed. "Basically, you have to take what they'll give you, because they don't care — they can always go down the road to the next big group," she said.

To hedge against low reimbursement, Swegler limits the number of patients she takes from certain insurers, including Medicare. Physicians in smaller practices may also miss out on new payment models developed as part of the Affordable Care Act, as those payments are dependent on patient-centered medical home certification — a process that is difficult to do without a larger staff that includes, for example, a care coordinator.

Meanwhile, the solo practitioner also has to bear the entire cost of running the practice, said Lipton. Among those costs: providing health benefits to employees. Egbert said she "can't afford to provide health insurance," and instead gives a discount to her six employees. For now, she as well as all of her staff are on a spouse's insurance.

Benefits are an issue for Swegler too. "I have absolutely horrendous health insurance right now, but I have the best insurance I can afford," said Swegler, adding, "and that's a sad comment on sort of where we are with that in general."

In part because of the uncertainty of her revenue stream over the last 2 years, Swegler has worked locum tenens in urgent care outside of Texas, where the pay is slightly higher.

"I can get paid better doing urgent care work than in almost any clinic environment doing work in family medicine," she said.

She uses the income to support her solo practice.

Will Solo Practice Disappear?

Despite the growth in the admittedly small number of physicians practicing in concierge or direct primary care models, the solo practice doctor seems to be increasingly rare and on the decline.

In its most recent biennial survey, conducted in 2018, The Physicians Foundation, a nonprofit that helps support physicians in part through grants, reported that 31% of doctors identify as independent practice owners or partners, down from 49% in 2012. Some 18% said they were in solo practice, consistent with the numbers in 2016, but down from 25% in 2012.

The American Medical Association (AMA) reported similar numbers in its 2018 Benchmark Survey, also conducted every two years.

For the first time in the history of the AMA's survey, fewer physicians owned practices (45.9%) than were employed (47.4%). Many doctors, however, are employed by physician-owned practices, whereas others work as employees for hospitals or health systems. Slightly more than half (54%) of doctors worked in physician-owned practices, either as owners, employees, or contractors, down from 60% in 2012.

Younger physicians and women physicians are less likely to be owners than older male colleagues, the AMA found. About a quarter of physicians younger than 40 owned a practice, compared with 54% of doctors aged 55 or older. Only 34% of women own their practices, compared with 52% of men.

The report noted that solo practice has undergone the most change over the last 5 to 10 years. In 2012, 18% of doctors were in solo practice; that decreased to just under 15% in 2018.

In May, Merritt Hawkins surveyed physicians in their final year of residency about job solicitations, career choices, and expectations and found that most were looking for employment, not an independent practice setting. Just under half (43%) said they'd prefer employment with a hospital, while only 2% would prefer solo practice.

Roberts, who also helps young physicians through contract negotiations, said that debt and the complexity of the healthcare system, especially financing and reimbursement, "scare away young doctors from being independent."

The 2018 Future of Healthcare Survey conducted by The Doctors Company, the nation's largest physician-owned malpractice insurer, found that only one fifth of solo practitioners were under age 40, whereas almost half were over age 70. This could also indicate a shrinking pool of future solo doctors, dampening the hopes of current solo practitioners like Swegler, who hopes to someday pass her practice to a younger colleague.

She volunteers with the Texas Family Medicine Preceptorship Program, which matches medical students with a family physician to help them gain real-life experience in a community setting. "I'm hoping that I'm going to find somebody that might then be interested in the type of model and then come back in 6 years to join me," she said.

The Doctors Company also found in its survey that 75% of solo physicians said they planned on staying independent. That does not mean, however, that these physicians were sanguine about the future of this model. The survey quoted one physician who predicted that there will be no solo practitioners in 5 years. Others described solo practitioners as being squeezed out by larger market forces.

Liaw, who thinks it's important to support solo practitioners, laments that "every market force is telling these practices to merge." 

Though larger practices offer gains through information sharing and efficiencies, "there's a lot that we lose by having bigger practices and more integrated practices," he said. 

"There's something very unique about having a small practice where the front desk, the nurse, the physician, the nurse practitioner — they all know the entire patient panel because they're there all the time," he said, adding that they also "have very high continuity."

Egbert believes small and solo practices will always play a big role in small towns, especially as it's more difficult to put together a group in many rural areas. Going solo is "not an impossible thing, but it's hard", she said. At 52, she's not contemplating retiring any time soon. When the time comes, she hopes to find someone coming out of residency or leaving a small group to take over her practice. However, she's not overly optimistic — and with good reason.

Whaley, for instance, said that in the past dozen years as a consultant, only one or two newly-minted physicians were seeking to set up a solo practice.

Indeed, Lipton said he rarely runs across anyone seeking advice on how to start a solo practice. And it's not surprising. "Starting from scratch and putting up a shingle is almost impossible to do," he said. And that's a shame, he said. In his opinion, the decision-making in smaller independent practices is "much more pure." Added Lipton, "It's less about the money and it's more about the medicine."

Hollister agreed, and said he believed that the clinicians who stayed in solo practice had a deeply ingrained belief in the Hippocratic Oath. The more doctors become employees, "the further the risk is they drift away from true compassion and true collaboration within the doctor–patient relationship," he said.

Alicia Ault is a freelance journalist based in the Baltimore area who writes on a range of topics, including art, culture, science, medicine, health policy, politics, and the law. Follow her on Twitter.  

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Cite this: Is Small Better? Physicians Discuss the Ups and Downs of Solo Practice - Medscape - Dec 11, 2019.