Lost in Transition

“I really admire you for embracing change at this point in your career,”  a colleague tells me.

Translation:  “You are crazy.  Better you than me.”

After almost 15 years of private practice, being my own boss and calling the shots about how the business was run, I have accepted a faculty position and become an employee of a university health system.   It’s something I swore I would never do again after the last stint at a different health system.

But experience has a way of changing one’s convictions.  I am a primary care general internist.  My private practice started when I became disillusioned with the way the health system ran our practice in the late 1990’s.  That was the time when the big hospitals were buying up every practice they could get their hands on- and then running them into the ground.  I fried out after a few years of being triple-booked, running through days without time to go to the bathroom or eat, and dealing with disgruntled patients who could not reach me on the phone and had to wait for hours to be seen.

My private practice was a reaction to that.  I was ‘boutique-ish’ before boutique practices were in fashion.  Patients paid fee-for-service to get extra time and TLC and I figured I could keep it small and controlled.  I kept taking Medicare.  (Sadly, here in Pennsylvania, it pays better and is easier to work with than many of the commercial insurances.)  I was raising children and trying to balance a life.  And for a while, it worked pretty well.  One of my partners from the university practice joined me.  We were practicing medicine the way we thought it should be practiced.

I don’t quite know how the whole thing turned on me, or whether it was partly that I changed over the years.  Somehow, the practice got big.  And it wasn’t controlled.  It was a business, and we were not business people.  We tussled with medical assistants who didn’t show up for work, accountants whose bookkeeping didn’t make sense, billers who couldn’t keep up with the billing, Medicare rule changes, and the 2008 economic crisis that left some of our patients unable to pay for services.  Still, somehow we stayed afloat.  We just didn’t make much money.

The electronic medical record was the last straw.  Not the way it was for some doctors, who couldn’t learn the system or just hated the move away from paper charts.  For me, it was the extra burden of the need for information technology support, the prospect of attesting to meaningful use on our own, and the fact that our medical assistant of seven years quit right in the middle of EMR training, leaving us to find and train a new MA at a critical crossroads.  I was fried again, and this time it was worse.  I went home in tears many days.  I could have won the ‘crispy critter’ award.

I threw up my hands.  I was a terrible businessperson.  I couldn’t handle all the patient demand and also run a business that was becoming increasingly complicated and burdensome, unless I hired more people to help run it.  I was already bringing home absurdly little money for the time I put in, and if I hired managers, it would be even less.  And when I picked up my head and looked around, I didn’t see many private practice primary care docs anymore.  If they didn’t work for a health system, they were going ‘concierge’- taking hefty fees up front from their patients to give the extra time and TLC that the patients wanted, and a few could afford.  This was no accident.  The medical environment is hostile to primary care, despite the fact that a primary care doctor is something that everyone needs.  Without a larger system behind us, primary care is a hard row to hoe.

I entertained the thought of going concierge- for about a minute.  That’s where the change in me really became apparent.  When I watched patients who had happily written checks to cover visits with me at one time struggle to make payments, or worked with Medicare patients who couldn’t afford their medications, I felt increasingly uncomfortable.  I truly believe that good healthcare is a right, not a privilege for the well-heeled only.  I wanted to be part of the solution, not part of the problem, for our fractured healthcare system.  I started to circulate my CV.

When an opportunity arose to become faculty and head up a women’s comprehensive health initiative, I jumped.   Maybe from the frying pan into the fire.  I may have been burnt out, but I’d made an excellent reputation for myself as a primary care doctor and I had many wonderful patient relationships.  This career move kept me in the Philadelphia area, but a different part of the geography, one that many of my patients found to be too far to travel for care. I would have to build a patient base again. I was taking on a complicated project, as well.  Despite that, I was sure that the time had come to close up shop in the private practice and try something new.

Perhaps I am truly a cliché, the middle-aged woman, emptying her nest and then ‘embracing change.’  Perhaps I am, as I suspect my colleague was insinuating, crazy to make a leap of faith this far into a career.   She may have known something I didn’t:  that dismantling a practice was a huge undertaking, one that I really wasn’t quite prepared for, and that took more energy than I really had.

Nevertheless, I am on the other side of it now.  While my new position presents many challenges, I am enjoying going to work again for the first time in a long time.  I have some variety in my days- patient care, of course, but also program development, student and resident teaching, and, best of all, collaboration with other providers.  I don’t have to run the office- the medical assistant magically appears and does her work well, the information technology support staff is available 24/7, and I don’t count the money or make the bank deposits at the end of the day.  My patients use their insurance, not their checkbooks. I have a little more clout than I had as a young doctor just working in a university-owned office.  I admit it’s been an adjustment to have to answer to other people-in fact, a lot of other people- but I guess I’m old enough to know that in some way, we always do.

Yes, I have embraced change.  The way I see it, change is going to happen whether I like it or not.  It’s part of aging, and I want to age gracefully, not go down kicking and screaming.

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Rosalind Kaplan, M.D. is a general internist specializing in women’s health issues and medical management of eating disorders. She graduated from the University of Pennsylvania School of Medicine and did her residency at Temple University Hospital in Philadelphia. She is currently an Associate Professor of Clinical Medicine at Temple University School of Medicine and the Director of Temple Health Women’s Care, a multidisciplinary practice for women.