Monday, October 10, 2011

Solo practice: a disruptive innovation?

The buzzwords of cutting-edge primary care reform - the medical home, coordination of care, electronic health records - have usually been associated with large integrated health systems such as Intermountain Healthcare, Group Health, and Kaiser Permanente. If you believe the arguments that economies of scale and financial resources give such organizations built-in advantages over the traditional small group practice, you may be inclined to believe that solo practice is going the way of the dodo. Indeed, immediate past AAFP President Roland Goertz, MD, MBA penned an editorial a few months ago, "Helping Small Practices Survive Health System Change," that, while touting some services that the Academy offers family physicians in these practices, betrayed a decidedly pessimistic outlook on their long-term future.

Not everyone agrees, however. In the September issue of the Journal of Family Practice, Jeff Susman, MD cast solo practices as vital engines of primary care innovation:

The extraordinary, albeit sometimes idiosyncratic, approach to medicine practiced by solo FPs today is often overlooked. Nimble (no bureaucracy to consult when changing policies), in touch (no one knows the local population better), and increasingly likely to use EHRs and health information exchanges (like physicians in larger groups), these doctors are paving the way to a brighter future. Whether they’re focusing on lean design, integrating concepts of public health, or creating environments that foster holistic healing, I see a lot of innovation and passion among solo practitioners who aren’t afraid to take risks or fight for their patients. Moreover, practices with only one or two physicians are frequently on the cutting edge of change and leaders in providing quality health care. What’s more American than that?

Like most physicians of my generation, I've never been in solo practice. But I agree with Dr. Susman that practice models that encourage "the rebirth of the solo family doc" may turn out to be just as good for the health of our patients as the gargantuan, still largely unproven structures known as accountable care organizations. As family physician Doug Iliff wrote back in 1998, solo practice, rather than harkening back to a past epitomized by the 1970s drama Marcus Welby, MD, may yet be the way of the future.