Perspective
A Different Path
By Susan Rutten, M.D.
Disillusioned with corporate medicine, one physician gave it up to start a solo, rural practice.
How happy are you that you chose a career in medicine? Our profession is an honorable one, filled with challenges and opportunities and amazing privileges. But the sacrifices and inconveniences of practicing in a corporate environment often seem to overshadow medicine’s greater mission and purpose. That drove me to choose a different path.
My career started rather uneventfully. I practiced internal medicine and pediatrics at an Allina clinic in the Twin Cities. I saw many wonderful patients as well as an equal number of people who were “doctor shopping” for some perfect individual who would match up with their ideal. Their expectations were impossibly high for any physician, and they required more time than I or anyone else in the practice had to give.
During the two and a half years I spent at that clinic, I watched the paperwork increase, the formulary restrictions grow, the number of administrative employees increase as nursing positions were eliminated, and the perks for physicians such as lunch and CME money diminish. I saw more and more patients who felt they were entitled to relatively unnecessary tests, procedures, and medications. I saw uninsured patients who were expected to pay double or triple what an insurance company would for the same services. I also noticed that my patients seemed to value the advice of their chiropractor or naturopath, whom they paid cash to see, more than they valued my recommendations.
Surely it doesn’t have to be like this, I thought. Fifty years ago, insurance companies didn’t call all the shots, but Americans still had the best health care in the world, and doctors managed to make a living. How did they do it? And could it be done again?
Stopping the Insanity
As I contemplated making a change, I realized there was no point in simply going to work for some other health care organization only to experience the same frustrations and perpetuate the system that created them. When you work for a corporate monster, you feed the monster. I also had a noncompete clause, which prohibited me from practicing within a 15-mile range of the clinic for three years. The answer seemed simple: Start a solo practice someplace where there were a lot of uninsured or poorly insured people; where there weren’t a lot of other physicians with my training, skills, or qualifications; and where the cost of living would be relatively low.
That led me to Osakis, Minnesota, a community of approximately 1,500 people in the central part of the state. Although I grew up and went to medical school in Michigan, I knew the area from my childhood. My father had grown up in Osakis, and I still have relatives nearby. At the time, there was no internist or pediatrician in Todd County, where Osakis is located, or in several of its neighboring counties. And the state estimated in 2000 that Todd County had an uninsurance rate of 11 percent.
I read dozens of articles on the economics of health care, all of which made it clear to me that my idea would work. I made a list of every material item I thought I would need for an office and narrowed the list repeatedly as I discerned wants versus needs. After months of looking, I found an appropriate house to rent that would double as my office. My landlords went out of their way to make my little office more suitable by installing a sink, improving the wiring, and giving the rooms an overall facelift. Ebay proved to be a great place to shop for medical equipment and supplies at prices considerably lower than those in catalogs.
I contacted the State Board of Medical Practice and read regulations to make sure I would be in compliance with state and federal laws. I had to report to the DEA, find malpractice insurance, apply for local hospital privileges, apply for CLIA certification to do very basic laboratory tests, and get a federal employer identification number and a state tax ID number. The community welcomed me with open arms, and three local newspapers put my picture on the front page when I opened for business.
That was four years ago.
Business Lessons
It has taken longer to grow this practice than I thought it would. One reason is that in a rural setting, people are slower to accept someone who is new. I had to be recommended by a friend or relative before many people found the courage to come to my office. The other is that I see many of my patients every two to three years—when they are desperate. My practice was actually profitable in less than a year, despite its relatively slow growth, and I anticipate it reaching maturity at about five years.
I never know exactly who or what I am going to see on any given day because most of my patients are scheduled within 24 hours of their appointment time. This greatly reduces the number of no-shows. I may get a walk-in who has nearly amputated a finger, someone with metal or glass shards in an eye, someone who has discovered his blood sugar was 400 when he used a friend’s meter, or a truck driver needing a physical. In my previous practice, I served a lot more of what I call the “worried well.” Now, most of my patients don’t show up unless they are genuinely sick.
Looking back, it is clear that there are many things I should have done differently. I should have arranged for a toll-free telephone number from the beginning because up here it is long distance to call from one little town to another. My rates were initially too low, starting at $20 for a 20-minute visit; I should have started them at $30 to cover my expenses. I purchased items that I haven’t used, such as paper exam drapes; I now only use twin-sized sheets, which I launder myself. For the first three years, I had a part-time receptionist. But after the first two years, it became clear that I needed someone full time. And I should have opted out of Medicare from day one instead of experiencing three years of the humiliation of being paid $12 for an office visit when my uninsured patients were happy to pay $30.
What have I gained? My patients, most of whom are uninsured or have insurance policies with high deductibles, appreciate me in a way I have never before experienced. They tell me regularly how thankful they are for what I do. Often, they pay me more than my fee. I haven’t planted a garden, but I have fresh vegetables in the summer thanks to their generosity. I usually have at least a dozen eggs in the refrigerator and fish and venison in the freezer, again, compliments of my patients.
I’ve found that my patients are so motivated to stay well that they actually follow my advice. I have lost count of how many of my patients have quit smoking in the last three months. My hypertensive patients bring lists of numbers from blood pressure readings they’ve taken at home or at the local pharmacy. People I encouraged to lose weight two years ago are coming back thinner.
I am also learning that the “standard of care” is not relevant to people who cannot afford it but there is always something I can do to help. My paperwork is minimal. I don’t take call, except at local nursing facilities and at the Todd County Detention Center, where I serve as medical director, and my patients don’t seem to have much difficulty deciding for themselves when they need to go to the emergency room.
I recently participated in a pilot study for the American Board of Internal Medicine. The study, which is now part of the board recertification process, included a patient satisfaction survey. One hundred percent of the surveys I gave out were completed. On top of that, 100 percent of respondents said that they were given as much time as they needed when they saw me. Based on what I have read of other patient surveys published in national medical publications, most patients complain that they don’t have enough time with their doctor. My rating was better because all my office visits are automatically scheduled for 30 minutes, with 45 minutes for a complete physical. Not everyone needs this amount of time, but it allows me to fit in a few walk-ins, clean instruments, review test results, and do other tasks on the side.
More to Life than Money
Some people are greatly motivated by money. The more they make, the more they want, and they never seem to have enough. For me, career satisfaction is more important than vacations in Paris or a Mercedes in the garage. I am a better physician when I am happy in my work.
My biggest expense is a full-time R.N., who shares my appreciation of career satisfaction and is willing to work for me despite the fact that I offer a relatively lower salary and can’t provide benefits.
My other expenses are minimal. My office is in my house. Because I don’t contract with Medicare or other insurers, I don’t waste time billing and coding. My records are in a simple database on my computer, and I enter the information myself. (It isn’t redundant or pointless because it’s for me, not for an insurance company, and there are no RVUs.) The telephones, both cellular and toll-free, cost about $300 a month. My malpractice insurance premium this year is a little over $4,200. Business insurance is just under $500. My rent is $550 a month for both my living quarters and office. Supplies don’t cost nearly as much as one might think; for example, my nurse just picked up a box of 60 albuterol nebules at a local pharmacy for $6. Making house calls does mean having a suitable vehicle, which costs something, but it is also a big tax deduction.
There are many different models for solo practice. I invented my own, but my situation is a little different than most; my patient population lives in one of our state’s most economically disadvantaged areas, and I consider serving them more of a ministry than an economic opportunity. Had I opened a cash practice in a metropolitan area, where there are also a great many working poor, it would have been relatively easy to make a comfortable living. Word of mouth spreads rapidly about this kind of practice. If you’re at all contemplating leaving the corporate world behind, do the math: Try $45 an office visit x 18 visits/day x 5 days/week x 48 weeks/year. See what you think of the numbers. Isn’t the potential satisfaction worth it? MM
Susan Rutten is an internal medicine and pediatrics physician in Osakis, Minnesota.