"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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