Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Going To Work

One of the strongest statements yet made in support of the private practice of medicine was made this morning at 8:00 AM, EST. I went to work.

What’s the big deal? Of course you went to work. You’ve got a job and today is a work day. Ah, Grasshopper, there’s the rub. I am a doctor in private practice. I don’t have a job, I own a job. I don’t report to any centralized HR department; there’s no single supervisor looking over my shoulder. Nope, I’m a practicing physician in a private practice specializing in eye care, and this morning there are some 60 patients who’ve scheduled appointments and a staff of 14 on their way in to the office, all of whom are depending on me going in. So even though I feel like a damp campfire long past its useful life, I came to work.

If all I had was a job I’d a stayed in bed.

The dirty little secret of private practice medicine is that market-based economics works on a micro basis. There’s payroll to meet and rent to pay. The mere perception that your patients will leave your practice if you don’t go to work drives the private practitioner to work even when she feels lousy. Even more than that, the absence of a corporate barrier between doctor and patient makes the private practice doc think twice before he takes that sick day, because each one of those patients belongs to him, and vice versa. The unfiltered connection is so personal that the private practice doc thinks about what Mrs. Pistolaclionne (bonus points if you name the movie) will say if he calls off sick.

The dirty little secret in large, corporate medical practices is that market-based economics work there, too. All that talk about how your “World Class Clinic” doctor isn’t paid by how much work he does? Nonsense. In fact, the amount of money generated by any individual doctor is even MORE closely monitored and includes stuff like how many tests and procedures get done on her patients even if she isn’t doing the work herself. That doc’s compensation is absolutely driven by how much revenue she is responsible for bringing into the institution.

It’s just that the corporate Doc doesn’t own a job, he simply has a job. He has no direct responsibility for the staff surrounding him or the bricks and mortar over his head. His compensation is driven by his corporate performance, and that compensation includes time off for vacation and for sickness. Leaving time on the table is the same as leaving money there. There’s no bonus for loyalty to the institution. Points aren’t accrued for attendance. Frankly there are no real points to be won for extraordinary customer satisfaction, only demerits for egregious behavior. Unused time off, like extending your hours or taking patient calls when it’s not your turn, is simply donating your services and talents to your primary constituent, your boss the institution.

We should all be very cautious about the trend toward fewer private practice doctors and more docs employed by ever-larger institutions. Continuity of care is more than simply an always available electronic chart, it’s also a relationship forged over time between two real, live people with skin in the game. The next time you see your private practice doc and she’s a little sniffly and hoarse, remember to give her a little pat on the back and a ‘thank you’. After all, she owns this job and could have stayed home today, but she knew you had an appointment.

She knows who she works for!

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6 Responses to “Going To Work”

  1. February 18th, 2012 at 4:07 pm

    Bailey says:


    Thanks for the insight into the private end of health care. Our school’s doctor recently morphed his practice into the Borg that is the local regional health care network run by the large regional hospital. I know that it made sense for him from a business perspective. However, when I speak with the athletic trainers and other support staff that treat our kids I get the feeling that he is afraid he sold a piece of his soul for the business gains. I am sorry to hear that this is where the personal relationships of medicine are heading.

    I am VERY afraid that education is heading down the same road. But, that is another conversation to be had at a later date.

  2. February 18th, 2012 at 4:19 pm

    darrellwhite says:

    Not every employed doc gives up the private practice ethic, but those who hold on to the manner in which they practiced when they were “chief and bottle washer” actually INCREASE whatever level of frustration they might have as they push against the machine inside as well as out. Your guy might be one of them. He likely did NOT make any gains, simply hoped to hold the line. Failing that, perhaps he traded off income for reduced hours and admin work. A shame.

    For however long my guys and I can do so we will hold out. Kinda like Ionescu’s “Rhiniceros”…


  3. February 18th, 2012 at 4:41 pm

    Bailey says:

    Gotta admit. I tried to cheat and google Mrs. Pistolaclionne AND movies. I had no luck. Bonus points carry over to the next class.

  4. February 19th, 2012 at 8:22 pm

    Carol says:

    Very well stated. Those of us in private practice know who we work for, and why we work for them. The relationship with our patients is priceless.

  5. February 24th, 2012 at 12:21 am

    Marge says:

    If you add a “like” I would put this over Facebook.

  6. February 24th, 2012 at 8:56 am

    darrellwhite says:

    Working on it!

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