I am a little fish in a big sea. And so are most of us. Or used to be. For better and for worse, the era of private-practice, outpatient medicine as we know it is coming to an end.

And faster than we thought. The choice now: down size or super size. No longer can a doctor operate a private practice as a solo practitioner or in a small group practice. We are getting swallowed up very quickly now by the bigger fish in the sea.

I tried this route after my residency, and so did you, probably. But the declining insurance reimbursements coupled with the increased administrative load has made the business of medicine into something I can no longer engage in. I, like you, try and try to make it work with faster software and electronic billing and automatic this and automatic that.

But at the end of the day, running the practice took over the energy of the clinical practice. Instead of being able to spend time with my patients, I found I had to spend time with my patient’s insurance company.

“Hey Doc, I have one more question,” my patient tells me.

Not one more question, I think, I still have 36 people I have to see and now I am running behind.

In order to keep up we have to give up or give in. Not everything, of course, but the stuff that matters.

So the choice becomes this: will you down size and choose to limit how many patients you can take care of, reducing your staff and all of the administrative burden. Maybe even choosing to not file insurance any more?

Or will you super size and join a big group or corporation or hospital practice where there are lots and lots of staff and lots and lots of doctors to treat lots and lots of patients?

You really can’t choose both and it is becoming clear that you have to make a decision.

Really small or super big. There is no right answer, of course, the only bad decision will likely be not deciding.

I chose to down size and drop insurance and drop my staff and drop my office. Now I see patients in the back of a converted ambulance (my new mobile office) at home or work or even a Dunkin Donuts parking lot. It was most important to me to be able to get to know my patients and spend time with them and convenience them.

But plenty of you, in fact, most of you, will choose to super size and join the bigger and bigger groups.

Either way, please choose. Our patients require lots more attention now than ever before. And the worst thing we can do is to pretend that we can keep up this private practice gig, like we have been for the past 50 years.

We all have different ideas about how best to take care of our patients, but we do need to agree that now we must choose: down size or super size. The regular size is no longer working.

Craig Koniver, author of Connected: The New Rules of Medicine, consults with physicians around the country at The New Rules of Medicine.

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