A little over a year ago, I found myself burning out and realized that my worklife was unsustainable.

I’d been working at an FQHC clinic, and had become the site’s medical director a few months before. I was practicing as a primary care doc, trying to improve our clinical workflows, problem-solving around the new e-prescribing system, helping plan the agency’s transition from paper charts to electronic charts, and working on our housecalls and geriatrics programs.

All of this was supposed to be a 50% position — plus 5% paid time for follow-up — because I had two young children that I wanted to have some time for, and was also working one day/week for a caregiving website (Caring.com).

Needless to say, this job was taking far more than 55% of my time, and seemed to be consuming 110% of my psyche. I very much liked my boss and colleagues, was learning a lot, and felt I was improving care for older adults.

But I was also irritable, stressed out, and had developed chronic insomnia. And clinic sessions were leaving me drained and feeling miserable: try as I might, I couldn’t find a way to provide care to my (and my patients’) satisfaction with the time and resources I had available.

One evening my 3 year old daughter looked at me and asked “Why are you always getting mad and saying no?”

Good question, kiddo.

A few weeks later, I told my boss that I’d be resigning my position in 5 months. And I started trying to reimagine how I might practice geriatrics.

My current clinical practice, which I launched last October, is the result of that reimagining.

My goals for a new geriatric practice

Here were the goals:

  • To keep practicing the part of my work that I loved the most. For me, this means person-centered outpatient care with a focus on geriatric syndromes and on helping people navigate the medical challenges of late life.
  • To be able to promptly meet the needs of patients and families. It often took me days to get back to people in my conventional job, or it could take weeks before a clinic appointment was available. I wanted to try a more “open-access” approach.
  • To try to offer the most help per unit of my time. Since there is a national shortage of geriatricians (currently 4 per 10,000 Americans aged 75+), I think it’s important to consider how to best deploy us for society’s benefit.
  • To leverage technology to better meet patients’ needs, and improve efficiency. Technology allows us to do some things faster and better. I wanted to see how that could be used in helping older patients with their geriatric needs.
  • To have some flexibility in my day and my week. Flexibility is very very helpful to the working parent, especially when children are very young as mine are.

How my geriatric practice works

To do all this, I’ve relaunched myself as a direct-pay solo micropractice offering housecalls and geriatric consultative care. Here’s how it works:

  • I offer geriatric specialty care that is meant to complement existing primary care, so for the first time ever, I’m not a primary care doctor, I’m a specialist. This feels a little weird (it’s a change in my professional identity) but I’m getting used to it. Also kind of quirky: I’m a specialist who is mainly recruited by families directly, rather than via referral from primary care doctors.
  • I charge a flat hourly rate for all time spent providing service, whether it’s in person, by phone, by email/secure messaging, coordinating care with other clinicians, or otherwise assisting a person with his or her healthcare. There is no membership fee or monthly subscription fee. (I was inspired by Doctalker , which is a full-service primary care practice using this billing model.)
  • I return all phone calls within two hours, and all written messages within one business day. Housecalls are available within 1-2 business days.
  • I let patients and families decide how much time they want with me, although I do advise them as to what I think is the minimum needed time for the issues they want me to help them with.
  • I don’t provide care after-hours or on weekends. I do explain to all patients and families that my practice is not meant to provide urgent or emergent care, but instead is meant to provide additional support and service regarding geriatric issues. I also try to help families really understand the medical issues, so that they are better equipped should they need to urgently engage other clinicians.

How the new practice is working out

So far, so good, even though it will take a while for my practice to fill. (My goal is to get to about 20 hours/week; otherwise I’d like to keep writing about geriatrics and technology, and I still collaborate with Caring.com and a few other companies serving the needs of elders.)

The people who contact me are usually concerned adult-children, or sometimes geriatric care managers. They like that I provide a comprehensive overview of the older person’s health, can help them make sense of what the other involved clinicians are doing, have lots of experience managing geriatric syndromes, and am available easily by phone. (The home health nurses like that too!)  They also like that I follow-up promptly by phone on a management plan.

As for me, I like that most of my time goes to meeting the needs of patients and families, rather than dealing with insurance, prior authorizations, or too many other administrative hassles. I also like that I don’t have to manage anyone else, or be managed by anyone else. However, I still feel I’m part of a team since I collaborate with other doctors, assisted living personnel, home health agencies, private caregivers, geriatric care managers, and family caregivers.

As for Medicare and society at large, I’m sure they don’t like that I’ve opted out. I understand, I don’t like it either. Until a few years ago I was a big proponent of Medicare-for-all, so it’s dismaying to find myself having left the fold.

On the other hand, I do think Medicare currently makes is absurdly difficult for geriatricians to focus on just practicing geriatrics, and on creatively rethinking geriatric care. For instance, with Medicare it’s usually hard to be reimbursed for phone time, or for care coordination. Opting out is what allows me to spend as much time as people need when I make a housecall, or when I’m on the phone with families or with other clinicians.

Instead of chasing face-to-face visits, and wrangling with the complexities of billing Medicare, I can often answer my phone when people call me, and I can look for new technologies that might improve geriatric care.

And since I don’t have a packed clinic schedule, it’s easy for me to rearrange things when one of my kids gets sick, or if something else unexpected crops up.

In short, rearranging my practice has been terrific for me, and seems to offer a lot of value to those patients who have sought me out (and, of course, are willing to pay). Over the next year or two, I hope to learn more about how to use technology to better leverage my geriatric expertise.

And who knows, if my personal experiment in geriatrics continues to go well, perhaps more geriatricians will end up being outpatient consultants, rather than primary care doctors as they customarily are in the U.S. And perhaps Medicare and the other insurers will find a way to cover the kind of service I’m now providing.

Summing it up

After burning out in a more conventional primary care setting, I opted out of Medicare and launched a direct-pay solo micropractice providing housecalls and geriatric consultation.

Unlike most geriatricians in outpatient care, I’m not a primary care doctor. Instead, my services are meant to complement existing primary care and specialty care.

Because I charge a flat rate for my time, I’m able to give patients and families as much of my time as they want. (Patient-centered care!) I also try to use technology whenever possible to improve efficiency, since this helps make my services more affordable to patients, and frees me to help more people in the time I have every week for clinical care.

I hope that Medicare will eventually make it easier for geriatricians to focus on practicing geriatrics, and I hope that what I learn in my own practice will eventually benefit other practices serving older adults.

Leslie Kernisan, MD, MPH, has been practicing geriatrics since 2006, and is board-certified in Internal Medicine and in Geriatric Medicine. She blogs at GeriTech.

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7 Responses for “One Woman Brand: How one Doctor Started Over Again With a New Practice, a New Specialty and a Great New Outlook on Life”

  1. John Ballard says:

    Housecalls. Wow. What a concept. You will save clients and providers tons of money (either costs or revenue, depending on which side of the balance sheet they are looking at). I’ve been in the senior care field for ten years now in my post-retirement avocation. I have seen it all up close and personal — from apartments and homes to assisted living facilities to hospitals to long-term care. It is always better to take medical care to the person than to take the person to the care. If someone needs to “get out” or “have a change of environment” trips to a clinic or doctor’s office is the worst of all excuses. Much better to have an afternoon with a friend or family member or go out for lunch and a movie.

    And while you’re there, you can see first-hand scores of ways to resolve or avoid problems before they happen — tripping hazards, lack of grab bars, lack of easily-found equipment, furniture clutter, inappropriate table ware. And you may see first-hand evidence of dietary habits or inventories of over-the-counter meds that make medical problems worse. The list of discoveries is endless.

    Thanks for what you are doing. I hope it works out. And pass the word to your peers.

  2. southern doc says:

    Another great doc who is forced to go outside of the insurer racket to deliver high quality, cost efficient care. The primary care societies are trying to ignore this, but it’s definitely happening more and more.

  3. Whatsen Williams says:

    Oh my! Problems w e-rx devices. They tell me it was so easy. I successfully opted out last year. Not clear if there is any technology that substitutes for good old fashioned medical care. Congrats on your venture and bon chance.

  4. Dr. Mike says:

    We have been working beyond what is possible to do well for many years. There are always those outliers who seem to do it so well and so the rest of us keep trying. There is no easy answer because the third parties simply do not have or are not willing to spend what it takes to make a sane sustainable primary care practice lifestyle possible. Burnout is almost inevitable for most of us. Expect to see a lot more mid-career changes of course. Funny thing is, after you make the change you realize that you don’t actually want more money for what you were doing, instead you are much happier making less money doing what you enjoy doing. That is why everything everyone is trying to do to save primary care is less successful than they think – even without all the strings they attach before they let you pry the cash from their clenched fists the money still isn’t enough to overcome the sheer insanity of modern primary care.

  5. Thanks for these comments and for the encouragement.

    I completely agree with Dr. Mike in that I think most PCPs don’t want more money for what they are doing. They want what they are doing to feel more sustainable, and more like what they went into medicine to do. This is why offering debt-relief to those going into primary care or geriatrics is probably not going to work.

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  7. Texas Bones says:

    Note – she doesn’t take Medicare and practices as a geriatric practice? Shame on you.

    Another doc who is turning her back on the very people who paid for her to become a doctor (Medicare pays for almost all of the residency and internship in the US) and she is somehow supposed to be an example? You took a slot that a doctor who can handle the pressure of a full time practice young lady so please pay back the cost of your education (over 800,000 for your post medical school training)

    Perhaps the take away is yet another A young mom who didn’t realize it would be difficult to be a doc and a mom? Oh please – more evidence on why women aren’t qualified to be primary care docs or one who thinks that we as a country can afford to pay for her lifestyle is the take-away..

    Shame on you for hurting our health care system and putting your own needs first.. Perhaps we should to screen selfish women like you out of medical school in the future?

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