Mark has asked me to give you the low down on private practice.  I am A GENERAL INTERNIST in private practice for 22 years.  Mark and I shared a clinic in the Bronx in the late 70's.  We've been friends ever since.  He asked me to give you a day in the life of---, but first, how I got here.

I went into private practice naively.  I took over an existing, practice from a retiring physician, his office, his equipment and his nurse, who single-handedly was nurse, secretary, and bookkeeper.  She made coffee in the morning and brought me lunch.  Insurance was easy.  The patients paid cash.  We would submit their insurance.  No CPT Codes, no ICDM Codes, no E/M bullets, no RBRVS.  You charged what you wanted.  You did the office labs you felt comfortable doing --- no CLIA.  When I wrote a prescription the patient went to the pharmacy and filled it.  No formularies, no appeals, no three tiered
system.

My overhead was about 1/3 if my gross.  I didn't need an accountant, an attorney or a billing service.  Medical malpractice insurance was about $1,000 per year.  I didn't need a computer.

Over the years I grew my practice to four.  One physician left in September 2001 to do a fellowship in GI, so now we are three.

Today was April 14th --- HIPAA Day #1
From 6 to 7 I do homework--labs, mail, look through an issue of Journal Watch.  At 8 1 head off to the nursing home.  I admit 3 new patients and round on another 15.  Then I go to the office.  I own the office with my partner-that is I'm paying off the loans.  This is no lie: The furnace is down, the new computers we installed last week have crashed, our new shredders are jammed, and the fax machine is sending black stripes.  My desk looks like the Himalayas with charts piled high.  There are the requests for motorized wheelchairs, competency forms for probate court, lawyers requests for updated reports on accident victims, appeals for non-formulary drugs, messages from patients, abnormal labs to review.  Fortunately the afternoon moves smoothly and I finish up the customary hour behind, but thankfully with no admissions to the hospital.  I return several phone calls and go home - not on call.  If on call I return to the hospital, covering for eight other internists, and usually get one or two admissions, make second rounds on unit patients, and go home around 9 PM.  We have a house physician who covers admissions from 9:30 PM to 5 AM.  On average I have 4-5 on-call days per month including one weekend.  I average 60 hours per week including on-call time.  I estimate I have 2000 active patients in my practice.

Obviously there are problems in the practice of Internal Medicine, or we wouldn't be here.  My colleague and friend [EM] and I view things from the perspective of small city internists in small group or solo private practice.  I list the main problems:

Uncompensated time: phone calls, phone prescription requests, insurance forms, disability paperwork, pharmacy appeals, length of stay appeals, travel cancellation requests, ...

Underpayment of E/M services: general internists have traditionally taken care of the most complex patients.  With [an] aging population and an ever expanding body of information for which we are responsible, it is difficult to cover the essentials in the time allotted.

Failure of RBRVS to honestly account for increases in practice expenses: malpractice has risen 200% in the last two years and other office expenses continue to rise; we got a 1.6% increase from Medicare for 2003, and we anticipate cuts in reimbursement for 2004.

Regulatory Nightmares (FIPAA, OSHA, CLIA): these regulations, though well intended, are daunting to small private practices that have no administrative superstructure.  Their implementation is costly; the cost of the fines is astounding.  HIPAA violations can bring fines of $250,000.

Fraud and Abuse (guilty until proven innocent): give backs are not uncommon.  Example: A review of 20 charts reveals a 10% incidence of improper coding.  You saw 10,000 patients over the past three years and overbilled by $30 per patient.  At $30 apiece, you owe us $30,000.  There is always the threat of criminal prosecution hanging above your head.

The malpractice atmosphere and the stratospheric rise in rates (1K to 23K in 22 years for general internists in New London County); interestingly other specialties are not seeing the rate of increase seen in general internal medicine.  We are being held accountable for failure to diagnose.  The inherent uncertainty of being on the front line in primary care is becoming a liability.  Our malpractice rates are identical to invasive cardiology and gastroenterology, yet these subspecialties generate incomes 5x that of general internal medicine.

Rising expectations of patients and their families (from service on demand to demanding the latest technology) coupled with the waning of the Dr./patient relationship (a quote from my associate, "you little shit--you killed my (90 year old) mother"

Time pressures: as the population ages the complexity of the IM patients increases.  The same issues confront the private practitioner as the clinician in academia.  We are craftsmen and are paid by the piece.  Unfortunately very complex pieces rarely bring in any more than simple ones.

Lack of adequate leisure time including time to read.

Office management increasingly complex.  The complexity of billing requires a computer system that could run the Pentagon, and the patience of Job.  In addition pre authorization of just about everything requires office personnel and lots of phone lines.  For a three physician practice I have eight lines plus a dedicated fax and a dedicated modem.

Public misunderstanding of what we do ("But all you did was talk to me.")  The general internist is the guardian of the vault.  We are trained to order tests leanly and appropriately and to rely heavily on our clinical expertise.  We deal with a procedure oriented population that believes that more is better.  (They also believe that we are paid by the good fairy.)

Conclusions

The cost of being a general internist is high, and the return is low.  Private practice may be out of reach for a freshly trained internist to start.  Existing practices may be unable to afford to hire new internists.  The daunting problems of practice may inhibit our colleagues in training, from choosing this specialty.