The Price of Private Practice

I started medical school in 1990 with a clear dedication to the practice of women’s healthcare in the inner city. I completed my MD at the University of Pennsylvania, went on to do my residency in OB/GYN in New York City, and subsequently worked as a staff physician at Bronx Lebanon Hospital, serving some of the poorest women in the nation. After eight years, I left to do what I never thought I would do…open a private practice.

While at Bronx Lebanon, I was happy with the service part of my job, but I didn’t like working for a large institution. I chafed at the lack of flexibility and lack of encouragement for innovation. I was always stressed about whether or not I would be able to be off for my kids’ birthdays or for school plays. And the commute was very, very long.

By 2005, when I left the Bronx, I had had a child, gotten divorced, gotten remarried, and gotten pregnant with my second child. With that second pregnancy, the rigidity and stressors of hospital practice became overwhelming. After a year of soul searching, I took the plunge and “hung out my shingle.”

I started out in a subleased office that I shared with a dermatologist. I was determined to practice medicine in a way that was not possible in the inner city clinic, where patients with complex medical and social needs were booked every 15 minutes with little access to consistent follow-up. I have chosen to participate in most insurance plans. I book patients for 30 minutes at a time, and I return calls and emails within 24 hours. For the most part, my patients are aged 20 to 50 years with some pediatric referrals, a fair number of adolescents, and a sprinkling of women older than 50. I now have my own office in Manhattan, with 2 nurse practitioners, an RN, a medical assistant, and an administrative staff.

Nine years later, as I approach my 50^th birthday, I have begun to re-evaluate my career-again. While by all counts my move to private practice has been a success, it did not happen without a cost. I have my independence and the flexibility that I wanted as the mother to my two boys. I earn about what I would earn as a hospital employee. I still work about 60 to 70 hours a week, but it's on my own terms. However, I no longer practice to the full extent of my training.

In New York City, annual malpractice insurance for a full-spectrum OB/GYN practice is $200,000+ (completely unaffordable). I knew that going in and accepted from the outset that I would have to give up my obstetric practice. As the first two years in private practice unfolded, however, it became clear that it was financially impossible to continue to do GYN surgery in light of the enormous costs of the malpractice insurance coupled with the poor reimbursement for surgical procedures. I could either give up private practice and go back to being a hospital employee or give up doing much of what I was trained in and maintain my independence. I chose the latter.

I practice medicine the way I think it should be practiced, taking time with each patient and addressing both their medical and social needs whenever I can. I am proud of the practice I have built, but the practice of medicine in America is changing fast. It is not clear that a private practice model is viable in the long term. Will I need to live under the umbrella of a hospital or large multispecialty group? Will I need to open a second location? How will we maintain our patient base if pap smears are no longer a yearly ritual? What other office-based services can we offer that are appropriate or reasonable? (I flatly refuse to enter the world of cosmetic procedures.) Will we become a “concierge” practice? How can I maintain my moral integrity and commitment to my patients and still make a living that will allow me to offer my children the life they are entitled to? How can I incorporate teaching and public health into my career again?

As I struggle with these questions, I realize that all of my friends are thinking similarly. I hope that in the coming years we will find our way to a practice of medicine that is both professionally and personally rewarding while staying true to our principles. Only time will tell.