Many doctors are frustrated by pressures to practice a faster and more impersonal brand of medicine, but some are actually doing something about it. I recently spoke with one such doctor, Tom O’Connor, MD, who practices general internal medicine in central Connecticut. He and his partner, Paul Guardino, MD, believe they were the first US physicians to begin building a fully concierge medical practice the day they completed training. In the concierge model, their practice collects an annual fee of several thousand dollars from each patient, enabling better access, more personalized care, and even house calls.
But the real story about physicians such as O’Connor is not that they are opting for a different model of financing their practices. Instead it is the unmistakable sense of excitement with which they talk about the way they care for patients – an attitude that has become noticeably rarer in recent years. Says O’Connor, “I have been practicing medicine for nearly ten years this way, and I am happier than ever.” His enthusiasm stems largely from the fact that, unlike most physicians, he is not employed by a hospital or a large practice group. Instead, he works for himself. He is his own boss.
Of course, the idea of doctors running their own practice is not a new one. For much of the 20th century, most physicians were self-employed, and many operated in solo practice. Today’s trend away from physician self-employment is driven by a number of factors, including increasingly complex and costly regulation of medical practice by government and insurance companies, the failure of medical schools and residencies to prepare physicians to manage their practices, and big financial incentives for hospitals and health systems to buy medical practices in order to capture patient referrals.
Enter a new breed of physician that includes O’Connor. He did not want someone else telling him who he could care for, what tests and medications he could order, or how long he could spend with each patient. In his practice, he and his partner – the doctors who actually see the patients every day – make such decisions themselves. He sees all his own patients, whether in the office, the nursing home, the hospital, or at home – wherever care needs to be provided. They do not go to walk-in clinics and they are not cared for by teams of hospitalists. O’Connor is their doctor in every context.
Most primary care physicians have several thousand patients in their practice, and they see dozens in the office every day. This means that they cannot devote very much time to any individual patient, forcing them to rely on others – nurses, minute clinics, emergency rooms, and hospitalists – to provide much of their patients’ care. By contrast, O’Connor and his partner each serve hundreds of patients. A typical day at the office consists 6 to 10 patient visits. As a result, they can do it all, and they can take their time.
“Seeing such a relatively small number of patients each day enables me to take the time necessary to research their medical issues and discuss their cases with other physicians,” he says. “I spend two hours a day reading journals.” He tells story after story of patients whose diagnoses were missed, not because their doctors weren’t highly knowledgeable, but because they did not have the time to dig deeply. As he puts it, “Good medicine is incompatible with fast medicine. And every time a patient is handed off from one health professional to another, knowledge is lost.”
O’Connor feels privileged to know his patients so well. Except when they go to the emergency room or require referral to a specialist physician – both of which are less likely to happen to one of O’Connor’s patients, compared to those of his peers – he is the one taking care of them. When they need care, he is the one they see, and every time he interacts with them, he gets to know them even better, building still stronger relationships. As he puts it, “I am able to provide true continuity of care, and this is probably the single most important contribution I make to my patients’ quality of life.”
O’Connor is not making more money than his peers. He sees patients in a wider variety of contexts, which makes his practice more complex. And he must be available a greater number of hours than most other primary care doctors. But to O’Connor, it is all worth it, because it enables him to come as close as possible to realizing his full potential as a physician. He can provide the kind of care that he would want for himself or a close friend or relative. In fact, he can provide the kind of care he wishes were available to every patient.
Not coincidentally, a relatively high percentage of O’Connor’s patients are medical specialists and their families. Another prominent patient group in his practice is hospital administrators. Why are doctors and the people who run hospitals so over-represented in his practice? Presumably because they see the value in having a doctor who can devote the time and attention necessary to practice the best medicine – and also, it must be said, because they can afford it and are willing to pay for it. They are voting with their feet and their dollars.
But not all O’Connor’s patients can afford his services. He was caring for a well-to-do family, and in particular their elderly mother, who had a live-in attendant. One day the family asked what else they could do for their mother. O’Connor pointed to the attendant, a woman from the Caribbean who suffered from diabetes and hypertension. If they wanted the best care for their mother, he said, they should ensure that their mother’s attendant, on whom she depended so heavily, remained as healthy and fit as possible. So the family enrolled her in O’Connor’s practice.
After some years elapsed, the elderly mother died. The family ceased employing her attendant and making payments for medical care on her behalf. Did O’Connor strike her from the rolls of his patients? No he did not, and he still cares for her today. In part, he does it out of a sense of loyalty to his patient. But he also does it as a celebration of his professional autonomy. When he weighs such a decision, he relishes the fact that he doesn’t need to seek his employer’s permission. He can do it, because he is his own boss.
To repeat, O’Connor’s style of practice is not cutting edge. In fact, it is rather old school, in the sense that most primary care physicians were once self-employed. The underlying motivation is one of the oldest and soundest imaginable – physicians designing their practices around optimal patient care. As O’Connor puts it, “Just imagine what kind of doctor you could be – and how rewarding it would be to practice medicine – if you could be your patient’s doctor all the time, in every context, and you knew that no one else was preventing you from doing your very best for them.”