The transition to direct care: Considering the consequences

“This could be big,” he said after I told him about the company who wants me to cover their 100+ employees.  I pay him to give me the stark reality of things, but his optimism made me uncomfortable.  ”You’ve got to go for this.  I know you don’t feel ready for it yet, but this could really be huge for your business, and I don’t think you should pass this up.”

I sighed.  Yes, this is a victory of sorts (still only theory, not reality), but what if I can’t deliver?  What if I fail?

“You know,” a colleague told me during another phone conversation, “you are the buzz of the medical community right now.  We talked about you for half an hour at lunch today … and it was all good!”  He went on to use phrases like “our only hope,” and “the way out,” to describe the potential for my practice model.

“No,” I thought, “I am not Obi-Wan.  I’m not your only hope.”  I sighed.  I don’t want that kind of pressure on me before I even see my first patient.  What if I fail?

Even worse: what if I succeed?

One of the main things that separates good clinicians from the rest is the ability to think through contingencies.  When I order a test or prescribe a treatment I have to consider the possible outcomes: if the test shows X, then we do Y; if it shows not-X, then we do Z.  Or, here’s the plan if you get better on the medication, and here’s the plan if you don’t.  The more contingencies I can anticipate and plan for, the more direct the path to the ultimate destination: resolution (or management) of the problem.  I find that my experience in thinking through contingencies serves me well in my current job of building a new and innovative practice.

Obviously, if I fail to get enough patients to support the business, things could get really tough.  I have bills to pay and the evil overlords of college tuition to placate.  The fear of this failure has driven me to spend a large part of most days over the past two months working.  I don’t want to fail and I will bust my butt to prevent that outcome.  The question is not simply, “can I succeed?”  I must also consider the possible consequences of success, and plan how to deal with them.  When I consider those consequences It quickly becomes clear how scary they could be.

Consequence 1: Getting overwhelmed

This is the easiest danger caused by success to anticipate.  When I open the practice, I may be met with an overwhelming number of people wanting to sign up.  If I open the doors too wide and too many patients become my patients at once, I could have trouble keeping up with demands.  It’s like a restaurant that opens up to a flood of patrons before it is ready to handle the volume.  The result is poorer quality food and longer waits, which could doom the ultimate success of the business.  This is one of the reasons I was nervous when I was contacted by the business about becoming their “company doctor.”  I don’t want to put out a poor quality product.

The solution for this is to open the practice slowly, or have a “soft opening.”  As much as my former patients are banging on my doors to open up, I may be tempted to let people in before I am able to give care that is worthy of their trust.

Consequence 2: Getting distracted

I had the husband of a patient pay me an off-handed compliment after hearing my presentation about my new practice: “So when you become real successful in this, how long will it be until you don’t have time to see patients any more?”  I appreciated use of the word “when” rather than “if” in his question.  He not only saw the merit in the idea of what I was doing, he saw the potential for building a big business on this idea.

My answer was simple (and perhaps  somewhat over-confident): “Never,” I said.  ”I am leaving my old job so I can do what I love: see patients.  I am not going to allow this business to take me away from the very reason I started it.”

Others have suggested starting a franchise, writing books, or making money as a consultant for practices who want to follow my path.  I hate this, not only because I haven’t seen a single patient or gotten a single check (and thus have the practice equivalent of vapor-ware), but because I see this as a real possibility.  The solution to this will largely depend on the people who I end up working with.  If I hire well (which is not an easy thing by any stretch), then I can delegate to people worthy of those tasks.  But I am not a micro-manager (unlike most docs), so my temptation will be to get lazy and put too much in the hands of people who haven’t shown they deserve that trust.

Consequence 3: Kicking the hornets’ nest

Let’s say I dodge consequences 1 and 2, have a thriving practice and a bunch of money coming from consulting and from my show on Oprah’s TV network (giving Dr. Oz the heave-ho in the process).  It’s a roaring success, the money is coming in, and doctors are leaving traditional practices in droves to emulate my incredible business model.  I’ve been able to dump the administrative tasks to others, leaving me to see patients and scoff at the pittance demanded by the tuition gods.  That would be a dream come true, wouldn’t it?

Not necessarily.  One of the most common criticisms I hear for what I am doing (and one I often bring up to myself) is that it is not generalizable to the whole of health care.  I am cutting back my patient load from approximately four thousand patients (the number I carried in my old practices) to one thousand.  That is one of the keys to this type of practice: keep patient volume down so patients get more time.  So what happens if this business model takes off and a significant percentage of primary care doctors “abandon” 75% of their patients?  It turns a shortage of PCP’s into a crisis.  It turns direct care practices into a real threat to the viability of the entire system.

It would create a huge backlash.  Direct care would have enemies, and those enemies could do things like requiring doctors to accept Medicare and/or Medicaid to have a license to practice.  I’ve heard it suggested already, and it terrifies me.

This is one of the main reasons I’ve become increasingly focused on a new goal: to grow my practice back to the same size it was in the old system.  I would have to do so using my “organic medical home,” hiring dietitians, home visiting nurses, social workers, counselors, and other professionals to manage aspects of my patients’ care, allowing me to increase my overall panel size (and perhaps even lowering my monthly fees).  If primary care physicians can have a profitable business without selling their souls, if patients can be given more access to care, better care, and save money, and if all of this can be done without threatening to destroy the system itself, perhaps some specialists will become envious and come back to “real medicine.”

Wouldn’t that be cool?

Yes, this could be big. Now I have to decide if that’s a good thing.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

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  • margo

    You know what I learned the hard way after graduating was that if depends on the area you are practicing in. Socioeconomic factors play a large role. If you are in a fairly affluent area you will probably do well. Good luck!!

  • Stephen

    Just what if… you succeed with 1000 patients and Dr’s who are leaving (because of patient overload) and med-students who hear horror stories of being over-loaded and under-paid see your success and that you 1) have a life and 2) enjoy praticiing medicine and decided to be a general practitioner instead of a specialist. wouldn’t that be great too!

    • http://doctor-rob.org/ Dr. Rob

      Or if a specialist saw primary care and decided to go into it for the lifestyle and to make a bigger difference!

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