Over the past two decades, the health care industry has transitioned away from private practices toward larger medical groups. Though initially welcomed, the shift has caused a number of clinicians to feel mistreated, burnt out, and nostalgic for a more autonomous way of business. Post-COVID, the desire to strike out on one’s own — be it via locum assignments, career change, or independent practice — has blossomed. Doximity spoke to several clinicians at the vanguard of this wave: NPs who, over the past few years, have created their own clinics in search of the autonomy and patient relationships lacking in mainstream health care.
From Medicine to Business and Business to Medicine
Graig Straus, DNP, founder of Rockland Urgent Care Family Health in West Haverstraw, New York, explained the impetus for creating his own clinic justly: “I went through the whole nine yards [of working at a hospital] and I saw that there's a lot of bureaucracy and a lot of red tape. … And I was sick of that and I said to myself, let me just open my own office and do my own thing. And this way I can take care of people how I want … and it's wonderful. It's complete autonomy.”
Bradley Bigford, NP, founder of Table Rock Mobile Medicine in Boise, Idaho, concurred: “When you're working for large organizations, it's committee after committee to make a small change — whereas with me and my business now, if I want to make a change, I just ask my employees if they like it and if they have any suggestions, and then we change it. I like the fast-paced improvements.”
Unlike NPs Bigford and Straus, the recently retired Matt Freitas, NP, owner of Aspen Family Medical Group in Modesto, California, began his career in business first. It was his success in that domain that enabled NP Freitas to return to school to pursue his passion for medicine; on becoming an NP business owner, he said, “It wasn’t planned, it was chance and an understanding of where my strengths were. I brought those [business] strengths into my medical practice, which were the strengths that most primary care physicians didn’t have.”
NP Freitas’s gambit succeeded: After merging his two worlds, he built a lucrative practice while working primarily with patients without insurance or insured with Medicaid/Medicare. “I set up a program where if you had no insurance, you were seen for free and your medications were free,” he said. “It was a mix of common business practices and marketing and happiness coming from helping people. And that’s what medicine is about.”
That “happiness in helping” is another driving factor for creating one’s own clinic. Beyond benefiting personally from a more autonomous arrangement, several NPs acknowledged that such a humanistic approach is helpful for patients. Kevin Smith, DNP, one of the founders of The Good Clinic, an entirely NP-staffed primary care practice in Minneapolis, Minnesota, shared that he came to his current role after reflecting on the problems in primary care — namely, a high degree of burnout and turnover due to a lack of face-to-face time with patients. To remedy these issues, NP Smith and his colleagues sought to build a clinic with a more patient-centered perspective. “In health care, we’ve done a lousy job with … customer service, feeling like you're being taken care of,” NP Smith said. “So [my partners and I] wanted to really shake up primary care and make it into a different experience. … We have 30-minute appointments, and every new patient has a 60-minute appointment. … [We wanted] to create that environment where individuals have the space to talk about those things that are maybe very personal, maybe they haven't had that trusting feeling with a provider before.”
NP Bigford employs a similar method in his mobile clinic: “We average about one person per hour per provider … which is also a selling point for [clinicians] that are looking to join us because you're not physically running between rooms and seeing 35 to 50 people a day, which is what you would see in a regular clinic or an ER. And so I think that's a huge benefit for both the employees’ mental health and well-being, as well as [for] the patients.”
That opportunity to create the kind of clinic one wants to see pays off: “Our patient satisfaction scores are through the roof,” NP Bigford said. “I don’t think it's because we do anything different clinically; we still treat evidence based and treat standard issues. But I think it's because [patients] get to spend so much time with us and their anxiety is lower.”
NP Smith agreed: “The quality of the visit and the relationship is going to create more loyalty.”
In addition, running one’s own clinic as an NP can be an exercise in self-advocacy, especially in states that don’t require a supervising physician. NP Straus shared: “There have been a number of things that I’ve changed just because of my practice. … I've been like, ‘That’s not a law, that's just a regulation and it's hampering me, so can we just change this?’ And [the regulators I spoke to] were like, ‘Yeah, OK.’ … It's pretty wild. You talk to these advocacy groups and they're fighting for your rights as a nurse practitioner to practice to the full scope of your ability, but unless you're a business owner, you don't know what your full scope is.”
The opportunities for growth available to business owners are more substantial than those available to NPs working in hospital networks or physician-run practices. In the latter environments, NP Straus explained, “You sign off all the paperwork, you leave it on the pile, and then the physician just walks by and co-signs it; you don't even think about it. But then when it's just you in your office and there is no physician, how do you go about that? The buck stops with me; the buck doesn't stop with anybody else. So I need to make sure that I have these policies and procedures in place to be able to help all my patients.”
NP Smith affirmed the notion of recognizing and encouraging NP capability. When asked why his clinic is entirely NP-run, he said, “When we looked at those gaps in primary care, [this] came out of an ER doctor's mouth before mine: ‘If we're gonna do primary care, it should just be NPs.’ And I said, ‘Yep, I was going to say that.’ … NPs are really good at primary care.”
Although NP enthusiasm for joining NP-run clinics is high, with NP Smith even stating that he “can’t keep up with the interest on the NP side,” the clinics themselves are not immune to the problems facing the larger health care system. COVID-19 and the Great Resignation have hit these practices hard; NP Bigford shared that the NPs on staff during the height of the Delta wave “have all left.”
In addition, today’s job seekers are not as committed. “People don't necessarily want to work,” NP Straus said. “It's very difficult to find people that are very dedicated. Nobody is going to have the same work ethic as an owner.”
NP business owners also struggle with the obliteration of work-life balance. “The first five years, I was on ramen noodles, to be totally blunt,” NP Straus said. “There was no balance. It was: establish the practice, make sure that it's gonna be self-sufficient, make sure that it's gonna run, make the sacrifice because it'll be rewarded in the future.”
NP Bigford agreed: “When I first started out, my work-life balance was pretty horrible. … I would say if someone’s thinking about starting a business, if they love the 9-5 40-hour work week, probably [doing this] is not for them.”
Finally, the business side of being an NP business owner comes with its own pain points. As NP Freitas explained, “One of the areas of medicine that’s always been in deficit is management of a business” — meaning that such knowledge must be gained through a combination of time-consuming study and trial and error.
For NP Bigford, “Maintaining the business [itself] can be challenging. ... It's establishing relationships with other clinics, [because] we get a lot of referrals. … It's a lot of managing staff. … And then the other challenge is the bookkeeping side. In nursing school, they don't teach you how to balance a budget and manage inventory. That's been another learning curve for us.”
Nevertheless, curiosity about running one’s own clinic is only increasing, especially as authorization and scope of practice for NPs expand. “It happens once a week now where [NPs] call me [with questions],” NP Bigford said. “There is a huge need for ideas on how to start your own business and how to keep it going. … There's a lot of people out there that wanna do this, that don't necessarily know how.”
To “keep the business going,” the NPs all agreed, dedication to one’s overarching values is a must. “You have to have a drive,” NP Straus explained. “If you didn't have a drive, this would never have [happened]. I knew that I wanted to be my own boss. I knew that I wanted to be able to take care of patients my way and ensure that they get the appropriate care. And I just grinded it out and it was great. It was the best thing I've ever done.”
Have you ever opened, or been tempted to open, your own clinic as an NP? Share your experiences in the comments below!
Illustration by April Brust