Imagine turning off your pager forever. If you are a solo-practitioner on call 24 hours a day, I suspect this thought has crossed your mind. Coordinating time off for vacation, being constantly interrupted at your children’s recital or athletic event, and even making it home to prepare dinner represent common challenges in this setting. A particular obstacle as a solo-practitioner involves the difficulty of running a small business – a topic ignored during medical training. During my 17-year tenure as a hand surgeon, I rented a small office and had only two employees. Because of the low budget business plan, I acted as the office manager. Therefore, I ordered the supplies, paid the bills and payroll taxes, posted my OR cases, did the pre-operative paperwork, coded the visits and procedures, acted as the Health Insurance Portability and Accountability Act officer, did the paperwork and submissions for the Merit-based Incentive Payment System, submitted the pension plan contributions, was the IT manager, and more. The work involved with these non-patient care activities increased exponentially during my time practicing medicine secondary to escalating onerous federal rules and regulations.
As time spent managing the business increased, my reimbursements plummeted. I doubt that many people would start a business with the understanding that their income over the next 15 years would drop significantly. This is exactly what happened to private practice hand surgeons. From 2002-2018, after correcting for inflation, Medicare reimbursements fell by greater than 20 percent for the 20 most common hand procedures. Moreover, the largest private insurer in my region tied its reimbursements directly to Medicare. Medicare and Anthem insured at least 70 percent of my patients. Unlike a hospital or academic center, a solo-practitioner has no lobbying power over large insurance companies. While my income eroded, business expenses increased, and I saw a seemingly larger percentage of underinsured elective patients and uninsured trauma patients. Also, complicating this model, my malpractice insurance was extremely high, despite never being involved in a lawsuit.
There were positive aspects of private practice. After completing my hand surgery fellowship in 2003, I made a reasonable income, albeit less than most of my peers in larger groups, academic settings, and hospital-based practices. Completely free of the restrictions inherent to these frameworks, it was enjoyable to be my own boss. I did not need to meet relative value units or see a quota number of patients per day (unacceptable measures in my opinion). Because of this freedom, I was able to get to know every patient, rarely stressed that I needed to cut a visit short. My office closure was by no means secondary to a lack of patients. Before this decision, the average waiting time to see a new patient was 2-3 months. I treated over 10,000 unique hand patients since the practice opened. I miss both educating and learning from my patients.
The onset of the coronavirus pandemic clinched my decision to leave medicine on July 31, 2020. Despite the forthcoming vaccine, this virus has forever changed how individuals will socialize and practice medicine. A recent article in the New York Times well illustrates the stress that this pandemic has caused physicians. As a former solo-practitioner, I can empathize with the vignettes described. The article also references a study which estimates that 16,000 practices in the United States will permanently close secondary to the coronavirus. For my practice, in particular, the open-ended restrictions on performing elective cases became unsustainable. Already having difficulty paying myself, this quickly became impossible. With the recent resurgence of the virus, hospitals throughout the United States are again eliminating elective surgical procedures. The job security associated with private practice waned significantly with the onset of the pandemic.
I have closed my practice, but I have no plans to retire at the age of 52. I have started the journey to become a high school science teacher. There are frequent internet postings and blogs by physicians with strategies to retire young. I suspect that many of us, not near traditional retirement age, still desire to work. At this point, I do not yet have a passion for traveling the world or for driving around the country in an RV like many former physicians. Furthermore, I still have two children who are not yet college age. I enjoy working, and I fear mental stagnation were I to retire at this point. Currently, I am pursuing a Master of Arts in Teaching degree. From pre-school through hand fellowship, I have had 28 years of formal education. It is time for me to reciprocate and to honor the extraordinary minds of my teachers and mentors. I am excited to become a high school teacher. I was a chemistry major in college, and it will be a smooth transition to teach high school science. I judge success not by financial wealth, but by contributing to the community and finding happiness in life. I don’t miss my pager.
Timothy Bill is a plastic surgeon.
Image credit: Shutterstock.com
