A Difficult Time
My Journey in Medicine	by Jerry Sobieraj, MD © 2001
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Chapter 5: Hanging out a Shingle

There was such a social component to becoming a physician. As I proceeded through my training, people would ask me when I was going to “hang out my shingle”. They seemed to long for the days when Health care appeared to be simpler. Hanging out one’s shingle was a way of introducing oneself to a community, and thus, becoming a member of it. During my training, most of my fellow residents weren’t sure they were ready to hang out their shingles. Many were looking at fellowships to train as sub-specialists (e.g. cardiologists), while others were looking at General Practice opportunities. Most practice opportunities meant joining a group, and assimilating into the culture of the particular practice.

A practice’s culture could be quite varied. Some groups had an academic focus (rare), while most focused on productivity and efficiency. Productivity looked at how one’s billing practices compared to others’, and efficiency pertained to how low one could keep their overhead. It seemed to me, that as one became acclimated to primary care as part of a group practice, they would assimilate into the business world. It was often stated in med school that one needed a business degree to practice Medicine. While this may have seemed to be the case to our largely business ignorant profession, the business skills actually required to run a practice were few and well defined.

Since I never fit the mold of such a group practice, in 1990, I set out to build a private, solo practice. This of course was not a common mode for starting a practice at the time. Most physicians at the hospitals to which I admitted patients were members of a group. However, there were a few of us who practiced solo. After discussing the nuances of this process with my solo colleagues, I believed I could gradually grow such a practice.

I was fortunate at the time, to have been involved with a weight loss program at the hospital where I served as Chief Medical Resident. My predecessor as Medical Director of the program had ambitions of striking it big in corporate medicine, and had hoped to move on. Since he and I were of similar academic ilk, I was his logical successor when he finally did move on to Sandoz Nutrition’s corporate offices in Minneapolis in 1990.

I became director of the largest OptiFast® Program in New England. This might have been quite a statement in the late 1980s. But as Oprah regained her weight, the OptiFast® veneer began to lose its luster. I remained fully committed to the idea that people could ultimately improve their nutrition, and thus, their quality of life. Yet, OptiFast® gave the impression of a fad diet (as explicitly stated by my wife one day, much to my annoyance).

In April of 1990, I founded “Preventive and Nutritional Medicine”. I had gained some marketing experience via the OptiFast® Program, and felt I wanted my corporate name to reflect my belief system. I believed in the premise, if you build it, they will come. However, I soon learned that no matter how good I was as a physician, and no matter how good my ideas may have been, it wasn’t easy to get people to change their patterns of behavior. In addition, efforts to function as a nutrition specialist were not supported by referrals from colleagues. Their concerns ranged from fears of losing patients to me, to frank ignorance of what was appropriate nutrition for patients with particular medical issues.

I had always been amazed that even the most academic of physicians derived most of their knowledge about nutrition from sources like Jane Brody at the New York Times. In the days of evidence based medicine, when we were supposed to use only practices that were supported by randomized, controlled clinical trials, our views about nutrition had been formed earlier in our lives. Many of the foolish things we learned in grade school would be profoundly reiterated to our patients as fact. Somehow silly ideas, when spoken authoritatively by someone wearing a white coat, became more valid. A common fallacy was the primacy of breakfast as the most important meal of the day. My attempts to find data to support this statement over the years were fruitless. I came to the conclusion that this concept was likely a marketing strategy created by the cereal industry (Dr. Kellogg in the early part of the twentieth century spent much time trying to make breakfast a nutritious fare, something health food stores would be proud of today, but quite unlike what his name brand cereal company sells as “nutritious” in the year 2000).

Using sound nutritional advice, along with other lifestyle changes, and prudent internal medicine, I hoped to provide outstanding primary care. I also had the good fortune of being able to connect with people. Whether they were indigent, blue collar, or business class, I could speak to them in their language. I always tried to stress a lifestyle change before trying medication, especially when there was no short term danger associated with a patient’s condition.

Since a growing practice has holes in the schedule, it was easy to spend sufficient time with my patients initially. However, as I got busy, it became more difficult. Yet, being my own boss enabled me to ensure that my schedule wasn’t overly crowded. This permitted me to be both on time, and also to have adequate time to address the issues people brought to their visits with me. In private, solo practice, I was able to practice a simple business dictum. Profitability could be driven by a high throughput with little efficiency, or by having a lower throughput, but with improved efficiency. Both could maintain a positive bottom line, and I chose the latter business model.

Most practitioners I encountered had high throughputs with little efficiency (similar to my current practice at an academic medical center). Patients were squeezed in at any possible moment, with little concern as to what they were coming in for, what their needs might be, and whether their needs would be adequately met in the time allotted. Due to the overwhelming demands of third party billing rules and requirements, most practices had plentiful office staff. There were people to check in patients, others to assist the physician in getting people ready, or to perform tests, if needed. Finally others would manage referrals, and other paperwork related to billing, etc. Most practices would estimate that their overhead ran at 40-50%.

Such a low efficiency was particularly unappealing to me, as I saw it as a requirement to see many more patients per hour than I desired. I had a goal of 20% overhead. Most of the 20% would be my secretary and rent for my office space. However, this meant that many clinical responsibilities fell on my shoulders. My secretary was experienced working in medical offices, and could adequately triage calls (i.e. decide who needed to be called back first). Yet, I did all weights, blood pressures, vaccinations, ECGs (electrocardiograms), blood draws, etc., things that non-MD staff do in traditional practices. Much of this was not inappropriate as the rationale for not having physicians do it in busy practices has to do with productivity (i.e. physicians having as many visits that pay as much as possible in the time they are there). Anything that distracted from that, whether helpful to the patient or not, was shunned in most practices.

I was able to meet my overhead goal, and thus, support my salary needs before I left private practice (modest salary needs, indeed, by current standards in primary care). I had even interviewed a woman who I thought would have been a good partner in growing the practice further before I left. Well, if things were so good, why did I leave the confines and control of a private solo practice for a chaotic, group practice in the city?

There were several factors. Some of them related to petty politics while others had to do with the amount of time I had to spend billing insurance companies and processing referrals to other providers in order to keep my overhead down. I had excellent practice software for managing these issues, but despite this, it was still quite onerous. This was in part due to the many billing and referral rules each insurer had, and also by the continual need to update my practice software to accommodate all billing changes issued by insurers. However, for me the straw that broke the camel’s back was capitation.

Capitation was derived from the term per capita (literally Latin for per body). I had refused to become a provider for the insurance company US Health care because they had a capitated program. They would have paid me $100 a year to take care of a healthy young woman. Unfortunately, that would only cover her annual physical and PAP smear. If she had any lifestyle issues which needed modification or any other medical needs, it would be at my expense. This type of capitated system was viewed as acceptable by colleagues of mine who practiced conventional internal medicine. That was, out of sight, out of mind. If the patient didn’t complain about something, they assumed it wasn't broken. Colleagues of mine told me how great it was that a significant subset of their patients wouldn’t even come in for visits. Thus, for those patients, they were paid the capitation fee for having these patients list them as their primary care provider without having to provide them any service at all.

With the type of Medicine I was practicing, this couldn’t work. I would feel it was incumbent on me to make sure they had annual exams. If they were overweight, had a tendency toward diabetes, smoked, or were physically inactive, I would be compelled to see them a few times a year, if not more often, to try and improve their habits. Thus, I couldn’t accept a system such as US Healthcare’s. The problem was, that in the mid-1990s, there was talk of many other insurers moving to a capitated system of payment. Thus, I feared I wouldn’t be able to avoid the capitation juggernaut.

I felt compelled to look for a group to join, so I could share the risk of sick patients who might drain my budget. I also felt that moving to a supportive, like minded group would allow me to continue to practice with a nutritional and preventive focus. My return to the institution where I did my residency seemed to fit the bill, though I ultimately came to learn, I couldn’t have been more wrong.

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