Solo and small medical practices are becoming fewer as economic pressure builds for care providers to join larger firms or clinics. But what is lost? wonders family physician Henry Hochberg.
SOMETHING didn’t look right with Ms. “Smith.” My patient for 25 years, widowed for the last 10, she had been meticulously coifed, groomed, dressed in her Sunday best — and with an unmistakable twinkle in her eye. But on this day that perennial twinkle was nowhere to be found.
I have seen this loss of twinkle many times in more than 26 years as a solo family physician. Sometimes it is a signpost in a patient’s fight against a critical disease. Once, for example, it was the very first clinical indicator of a difficult battle with progressive Alzheimer’s. Mostly though, I have seen it as a subtle indication of unrecognized or denied depression.
After giving Ms. Smith the time and space to unburden, it became apparent that her loss of twinkle betrayed a deep-seated depression finally coming to the surface after her beloved yellow Labrador had died. With that recognition, Ms. Smith is now doing well on appropriate treatment.
Ms. Smith’s experience represents a classic but common example of a benefit of small or solo family practices, in which we physicians are able to sustain long-term relationships with our patients — and actually know them as people.
I have been hearing about the demise of such solo and small independent family medicine practices for 30 years. Little did I realize that it is already here.
This is not to suggest a conspiracy to rid America of small practices. It is simply, as far as I can tell, that no one is coming to take our places. The current economic, bureaucratic and health-care climate has made practices like this challenging at best — and unsustainable at worst.
When we solo practitioners or members of small independent groups retire or surrender to the economic pressure to join large practices or clinics, this former mainstay of American medicine will quietly evaporate like the morning fog before a rising sun — just like the twinkle in the eye of a secretly depressed patient.
The reality is that medicine has become largely corporate and depersonalized. The office visit must be recorded electronically, often right in front of the patient. Metrics rule the day. Physicians now get paid and evaluated by codes. There are diagnosis codes, procedure codes and, to a certain extent, “time spent” codes. We can be as precise as coding for a patient who was “sucked into a jet engine” (V97.33X) or suffered from “water skis on fire” (V91.07XA)!
But there is no diagnosis code for “loss of eye twinkle.” And no time code for “needing to be heard.”
Although there are now patients — and even physicians — who have never experienced this small and intimate therapeutic relationship, there is something precious and powerfully therapeutic about having a deep and caring connection between patients and their health-care providers. It is these deep relationships that will be the major casualty of the disappearance of small practices.
Is the momentum against solo practice already too great to be changed? If these small practices are to continue, then those who pay for, regulate or teach medical care must be shown or reminded of their value. We must not allow them to silently disappear.
But what can you do as an individual? Start the conversation. Tell someone. Put it out on social media. Tell your neighbor, your local or national representatives, your governor or the insurance commissioner, even your president. They need to know it is important to you and in many ways for all of us.
So, will you miss us when we’re gone? There may come a time in the future when you wave a Bluetooth device over your body, get a diagnosis on your computer and a drone drops a fix at your door. But who will listen to Ms. Smith?