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How the Small Independent Provider’s Role Has Come Full Circle

by Stephen Bien, MD

When I came to the rural Maine town of Farmington 30 years ago, the independent private practice was the norm, and I fell right in. After all, our mentors back then — certainly mine — were all independents. They all had a hospital practice where they went through the requisite rhythms of in-patient care before retreating to the office they could almost call home.

Hospital practice was more an extension of office life than a discipline of its own, but it was a public space, unlike the office, and there was a light touch of regulation from the functions of committees and peer influence. The physicians’ offices by comparison were utterly empires unto themselves where physicians were free (almost expected) to practice as they saw fit according to their training, experience, and whims. Patients were more often than not subject to their physicians’ judgments and inclinations without much question or recourse as relatively few, in my experience, comparison shopped or moved around.

Lest I be considered a romantic, retrograde fool, let me make clear that there is much from those old days that is better left behind. Physicians were almost exclusively men, a patriarchy whose authoritarian nature did not leave much room for patient involvement. Physicians could be arbitrary and foolishly idiosyncratic. For instance, I had an OB attending who did not allow any infant suctioning in the delivery room. Another chose to deliver babies as breeches. Needless to say, there is plenty that I am happy to see in the rear–view mirror.

The emergence of ‘family practice’ as a field was meant to be antidotal to the lack of science and organization in primary care. The doctor–patient relationship was recalibrated to become the partnership it needed to be, body and psyche were woven together in new behavioral health models, and an emerging primary-care science was developed to help inform what we did. This was the banner our generation of family doctors marched under in the 1980s, and we flew that flag over our small, private offices. So, when I started practice here in 1982, as one of ten family physicians and a half-dozen internists, we were all in this type of private practice. Jump ahead ten years and everyone seemed to be running for the exit doors. Fast forward another decade or so, and I was one of only two primary-care docs left. What happened?

In my view, a great souring occurred as the fundamental paradigms of medicine shifted under the influence, which still operate powerfully today, of consumerism and cost containment. The profession’s noblesse oblige and, its flip side, arrogance, had to give way to external oversight and patient demands. These were and are entirely appropriate influences but many physicians ended up wanting cover from the demands of the consumer movement and the increasing power of insurance companies to call the shots and constrain practice. Cost containment paradigms, complicated insurance arrangements (and their administrative burdens), our collective financial insecurity, and the desire for a comfier career — financial and otherwise — all worked to lure many providers away from private practice. Hey, why not trade long hours and shrinking reimbursement for regular hours under a roof where one was taken care of?

Well, you don’t know what you’ve got until it’s gone, and working for a hospital or care network was not all wine and roses. Some doctors worked longer hours and the doctor–patient relationship — the heart of medicine’s satisfaction — was at best weakened and, at worst, seriously eroded by the dynamics of the physician employment model. But there was another result: People like me seemed to be getting a second wind and thriving. Smiling even.

I stayed the independent, small-practice course, more from being stubborn than possessing any business savvy, but I did see changes and opportunity coming. I saw that my weaknesses — small size, isolation, independence — could be played as assets. Patients, some of whom left to try out the hospital network, came back because they liked the personal, small approach of a private office. Suddenly I had a new niche. And soon discovered, quite by accident, that innovation was pretty easy, fun, interesting, and good for business.

Five years ago, because our practice is small and self-directed, we were asked to participate in the first e–prescribing pilot in our community. That was our entry into computers and a new way of thinking about tasks and the management of information. We then took another leap and were among the first participants in our state’s medical home pilot. This allowed us to re-tool and re-invigorate our primary–care vision while enriching the care of our patients. Association with other practices in the pilot gave us access to outside resources and expertise. Now, we had the best of both worlds: independent, but no longer isolated.

We then implemented athenahealth’s cloud-based EMR because it seemed a natural fit for our medical home model and ongoing independence. Before long, we were the first primary–care practice in Maine — yes, the very first — to receive a Meaningful Use incentive check.

At one time, using the physics of their day, entomologists concluded that bumblebees could not fly. This was not quite the evidence of their senses, but of their study. In like manner, my office, with its weighty overhead and apparently flimsy finances shouldn't fly either. But new practice models and technologies that value both time and care, have made the old mode sustainable again. This is my hope and my bet.

To learn more about athenaClinicals, athenahealth's cloud-based EMR, and how it guarantees Meaningful Use payments, visit here.

Dr. Bien is an independent physician at Wilson Stream Family Practice in Farmington, Maine and an athenahealth client.

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