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Best of Both Worlds: The Case for Private Practice in Rural America

Within three minutes of the car engine rumbling to a roar in the morning air, cruise control is set, freshly ground coffee in hand and NPR playing on WOSU 90.5. I settle in for the morning news on my 45-minute commute to the hospital. Sure, I could have found a hospital closer to shorten my commute, especially since I live in the 14th largest metropolitan city in the country. If I had wanted, I could be knocking out carotid endarterectomies at a level one trauma center, three blocks away from my front door. But no, that is not what does it for me. What does? It is having the opportunity to be my own boss and care for salt-of-the-earth folks in rural America. You see, five years ago when I finished my vascular surgery fellowship at Good Samaritan Hospital in Cincinnati, I opened my own, solo private practice in a rural community: population 30,000. Yep that’s right, you heard it, I hung a shingle and went old school. And now as I reflect over the lessons learned during the first half-decade of my practice at Ohio Vein & Vascular, Inc., I can tell you it has been a hell of a ride, and boy, have we learned a lot. The better half of the ‘we’ is my wife, Crystal, who doubles as my practice administrator, with her own solid foundation coming from her Doctorate in Physical Therapy. We have successfully built a small company with four full-time employees, one contract RVT, and two therapy dogs who serve over 3,500 patients to date.

From the first day I opened my doors to this small-town, rural community, I realized that it is not what you know, but rather who you know. Well frankly, I didn't know a soul! Fortunately, my front office manager was born, raised, still lives in Wilmington, and knows everyone’s mother, brother, sister, niece, and grandchild in what felt like a 60-mile radius. She gave this young, slick city kid from Columbus instant street cred despite all the fancy credentials behind my name. I ditched the tie and fancy shoes and embraced my new ‘work’ home with open arms. In a community such as Wilmington, Ohio it’s the little things that count. I wear my own scrubs on days when I operate. Not only do they have my practice logo embroidered on the chest pocket, but they are also adorned with the brown leather symbol for Carhart, a clothing brand. In rural America, Carhart denim clothing – overall bibs, jackets, gloves, etc. are considered king. When my patients see that symbol, there is an instant point of mutual appreciation and almost always results in some good laughs – who knew Carhart made scrubs. As a result, I’ve been offered opportunities to ride combines, go drag racing, and hunting for the infamous morel mushrooms. Just to be clear, I haven’t found a morel yet, so I guess I will stick to my day job as a surgeon. Having a good laugh and connecting with my patients was something I was not accustomed to in my training. I was there to operate, and rarely participated in office days. At times, this routine left me feeling unappreciated by my patients and their family. I was just a surgeon delivering bad news. I now find myself fortunate to have the opportunity to get to know my patients and participate in their health care, and I know they appreciate me for it.

A Medscape Malpractice survey cited a finding that the more a patient ‘likes’ their physician, the less likely they are to file a malpractice lawsuit against them (1). Other reports have suggested that the relationship a physician has with a patient is a critical factor, more so than any single medical mistake, in determining whether or not a lawsuit is filed (2,3). While I feel appreciated and ‘liked’ by my patients, I’ve learned that I am not necessarily their favorite employee in the office. This honor is most often bestowed upon Claire and Whitney aka “The Girls” – our two, miniature labradoodles who serve in the capacity of therapy dogs and have perfected the ability to nap in nearly any situation. Try as I may to convince patients that what am saying is important, they never lose focus on The Girls. They are the first thing patients ask about, I swear they receive more gifts than I do, and always are on the receiving end of some good ‘pets’ as my patients leave the office. Despite any bad news they may have been told, very rarely does a patient leave my office without a smile on their face. It keeps me humble, as I think most of my patients aren’t really here to see me, after all I am just a fancy plumber. 

Speaking of plumbing, I could’ve sworn that the ginormous two-volume Rutherford edition always gave me the impression that vascular disease is comprised of 75 percent venous disease and 25 percent arterial disease. However, our fellowship training in the US makes Rutherford seem like he had his numbers flipped - 99.8% was arterial with a splash of venous as an afterthought. Truth be told though, I see roughly 55 percent venous, 25 percent dialysis, and 20 percent arterial – I guess that wasn’t made up after all. If my practice name, Ohio Vein & Vascular, didn’t give it away, I admit that I focus marketing efforts towards venous pathology. This has significantly improved my work-life balance. Let’s face it, not everything we do as a surgeon is fun and can certainly carry a large amount of stress. I devote an honest amount of time to developing what ‘type’ of practice I desire. I communicate regularly with my referring doctors about the types of disease I focus on, write press releases to the local paper, and always have my elevator speech handy when speaking with fellow physicians and potential patients about what I do as a surgical subspecialist. In such a small community, the more my vascular surgery practice grows, the more likely the podiatrist and his wife (also a podiatrist) across the hall will grow their practice. Same holds true of the cardiologist upstairs and the nephrologist down the hall. It’s not rocket science that the more I help their businesses thrive, the more likely they are to do the same for mine. We are all one large family working together with the common goal to stay independent, a rarity these days amongst the conglomerate of hospitals taking over.

Wait, did I mention that I have never run a business before? Well, let me share the most important lesson I have learned…some days it is really hard. I remember having to let go the first medical assistant we hired after her 90-day review. All of my medical training never prepared me for how hard that conversation was going to be, and she wasn’t even losing her leg. My wife, a trained physical therapist, jumped right in until we eventually got the gusto to hire another MA. Fortunately, we found a remarkable individual who is worth her weight in gold. The same holds true for our other employees and we aren’t about to let them leave so we pay them well, fund 80% of their health insurance premiums, established a 401K with matching funds, and we profit share with each employee. We foster an environment that makes our employees want to work hard, although like my patients, sometimes I think they come to work just to see The Girls. All in all, we treat our staff with respect and provide a significant monetary carrot to each of them at the holidays; this is unmatched in our area. Just like the saying a “happy wife makes a happy life,” happy employees are instrumental to my work life and have a direct impact on the success of my practice. All boats rise with the rising tide, and we are sailing smoothly. 

Despite all the challenges and hard work, nothing is better than being your own boss. Nothing. I don’t know a single physician whose desire was to trek through grueling medical school, years of residency and fellowship to ultimately become an employee of a post-graduate degree holder in health care administration. I cannot recall having had a single conversation with any surgeon or physician who is 100 percent happy with their working situation who isn’t self-employed. Sure, do I work now more than I ever thought I would, absolutely. But the work I am doing isn’t simply waking up at all hours to operate or trudge through countless hours in a lab or clinic. No, the work I do is running a successful small business – and even better yet, it is great! Life is short and I’m trying to enjoy every minute that I have on this planet by spending my time working in a manner which I find enjoyable. Being the fancy plumber in rural America provides me that opportunity. I hope others realize that it is still possible to navigate health care’s oftentimes unknown waters as a solo private practitioner and be successful. That they too could be taking the bull by the horns and changing up their work-life balance for the betterment of themselves, the care they provide to patients, and their families.

And in the meantime, I’ll jump back in my car and head due north for a 45-minute decompressive drive, chat with family and friends, dictate the last case of the day and continue to enjoy the best of both worlds living in the big city and working with the most genuine folks in rural America. You should try it.

References

1.     Medscape Malpractice Report 2015. https://www.medscape.com/features/slideshow/public/malpractice-report-2015#page=30 Accessed June 9, 2018.

2.     Crozer-Keystone Health System. http://www.crozerkeystone.org/healthcare-professionals/medical-staff/physician-info/cme/articles/decrease-your-risk-sue/ Accessed June 9, 2018.

3.     New York Times. https://www.nytimes.com/2015/06/02/upshot/to-be-sued-less-doctors-should-talk-to-patients-more.html Accessed June 9, 2018.

Previously published in MD Edge.

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