How I changed my private practice glass from half empty to half full

How I changed my private practice glass from half empty to half fullA guest column by the American College of Physicians, exclusive to

A few months ago, I attended a social event and ran into a few colleagues whom I had not seen in a long time. In the interest of privacy, I won’t reveal their specialties but I will note that I was the only primary care specialist in the group. As usually happens when physicians gather at non-medical functions, we talked shop. Most of the conversation was about what the other physicians didn’t like about their jobs: electronic health records, low reimbursements, insurance companies, hassles, hospital administration, and trouble recruiting colleagues. I walked away from the conversation wondering why they were still in practice and feeling guilty that I was not as miserable as they appeared to be.

Unhappy physicians seem to be everywhere, not just at receptions. If you don’t believe me, just read some of the comments on Or the responses to Bob Doherty’s ACP Advocate Blog posts. While I suspect some of the negativity reflects the national malaise, physician discontent existed even when the general public wasn’t angry about everything.

This is an issue that affects more than just physicians. It’s been said many times before in many different ways: nobody wants to see a cranky doctor. Also, a happy doctor probably does a better job taking care of patients than one who is unhappy.

Physician satisfaction is getting more attention these days, as shown by a couple of recent publications. The first is Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy, a RAND report commissioned by the American Medical Association. It looked at the factors that influence physician satisfaction and included recommendations for improving physician satisfaction and, as a result, patient care. The second paper, In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices by Christine A. Sinsky, MD and colleagues, studied 23 highly-functioning practices and identified processes that helped increase satisfaction and decrease burnout, including the use of technology and data as well as team-based care.

Increasing professional satisfaction has been a priority of the American College of Physicians (ACP) for years, both as an explicit goal and through efforts to address the many threats to physician satisfaction, such as inoperable EHRs, excessive administrative burdens, and the dysfunctional payment system. ACP’s advocacy for the patient-centered medical home (PCMH) was driven in part by the belief that practice transformation can increase physician satisfaction. In the position paper that introduced ACP’s vision of the model, the College called for physician satisfaction to be a metric for assessing the effectiveness of the PCMH concept.

After that cocktail party conversation, I thought about why I was not as bitter about my practice as my colleagues seemed to be about theirs. I deal with the same barriers that they mentioned, while earning a fraction of what they earn, yet I was happy with how things are going in the office and optimistic about the future of my practice. And it’s not because I’m out of touch with the realities of practice. As regular readers of this column know, I have been a partner in a private, fee for service group practice for over 20 years. What you might not know is that as recently as a few years ago, there were times that I saw the practice glass as “half empty.” During those difficult times of excessive overhead, skipped paychecks, and extra-long and frustrating days, I counted down the days to retirement and paid more than passing attention to my junk mail from recruiters offering signing bonuses and guaranteed incomes in warm locales.

“Redemption” may be too strong a term for what I experienced a few years ago, but a few events changed my attitude towards my career in private practice. First, I addressed my overhead problems by consolidating my two-physician, one-PA office with a three-physician, one-NP office located just a couple of miles away that was part of my multi-site group practice. Not only did this allow me to move to office space that was more appropriately sized, with more partners with whom to split expenses, but it also created a more interactive and stimulating professional environment. The second major change was full adoption by my group practice of new delivery and payment models, including the PCMH. With the support of the practice leadership and local payers, we are doing many of the things that Sinsky et al described as components of a “joyful” practice.

Not all is perfect, even in my practice world. My group recently surveyed our physicians to measure their happiness with their practices (we did the same with our staff and our patients). The survey revealed that while there is general satisfaction, we have work to do regarding the usability of the EHR and more efficient use of the team to allow physicians to work “at the level of their licenses.”

Like it or not, increasing physician satisfaction in today’s practice environment requires a willingness to change how we do our jobs. Sometimes the change is relatively minor, such as when modifying office workflows, but in other cases, we have to make more substantive modifications, as I learned first-hand. However, the return on investment is significant if it restores our happiness with our careers as physicians and helps us feel like we are doing what we set out to do when we decided to go into medicine.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • Margalit Gur-Arie

    Funny, I started writing a blog post last night, and it begins very much like this one, with the comments on this blog. I am a slower writer, so it will take a few more days, but in the interim, I think there is a bit of a problem with the solutions suggested here. Far be it from me to tell doctors how they should feel, but I am not convinced that this is about “joyful” practice, or the search for something that helps people “feel like” they are doing what they want to do. And I also don’t think it’s about finding a way to practice in bigger groups, which means that solo and small practice is somehow less “joyful” or incompatible with the new normal.
    To me, from the outside, and hopefully the objective outside, it seems that something other than lack of joy is at play here….

  • Bob

    You perhaps didn’t realize it but you were the only one at the party who worked for yourself and your patients and not a “system”.
    But you are still reliant on the others to “fix” the patients you cannot and to integrate your patients EHR’s to the various systems they are “trapped in” and hopefully update your patient records “seamlessly”..
    But since the ACA relies on PCP’s how many more can your practice handle and what does a mandated 15 minute max “eye to eye” simultaneously with “patients and laptop” for low reimbursement do to your practice today or over time?
    You are lucky for you don’t have to change.

  • John Booke

    EHR seems important so please don’t give up on it. Also the practice portals are very important. Not sure if the portal and EHR are connected. I have found it very convenient to use one of my doctors’ practice portal. When I have a question he usually answers me the same day. I don’t use it much – about once a month. Another doctor, my primary care doctor, point blank refuses to communicate through his group’s practice portal. He says he likes to talk to his patients face-to-face when they have questions. His portal contains the results of my blood test which is really nice. The only thing is he will not post the abnormal results even though the practice protocol says the abnormal results should be posted within 48 hours after notifying the patient.

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