My first word of advice is this, say yes. In fact, say yes as often as you can. Saying yes brings new things. Saying yes is how things grow. Saying yes leads to new experiences, and new experiences will lead to knowledge and wisdom. Yes is for young people, and an attitude of yes is how you will be able to go forward in these uncertain times,” (President of the University of Connecticut, Michael Hogan’s 2009 commencement address, quoted in “How a New Jobless Era will Transform America, by Don Peck, The Atlantic Monthly, March 2010, p. 48).
Doctors are a pretty conservative bunch. We get to where we are by saying no to many things that are a lot more immediately enjoyable than studying biochemistry. It can and has been said that doctors are a risk-averse group. Why then would any physician in their right mind say “yes” to private practice when there are no financial guarantees, no colleagues, maybe even no employees, no 401(k), no one paying your malpractice insurance, maybe you have some patients, but maybe you don’t even have that! Why on earth would you say yes to private practice?
Well, for me, it felt like a necessity, and I suppose many adventures start out that way. I have run a private psychiatric practice for the past 5 years. I call this a “holistic” practice because I want to work with the whole person, not just in a reductionistic, psychopharmacology model and also not in a 10-15 minute medication check, high “productivity” practice. I started a private practice because I felt it was the next step in my ongoing medical education.
After I had been running my practice for awhile, I came across the term, “micropractice,” and I realized that is what I was doing. Low overhead, no employees, 30-90 minute appointments (longer sometimes for initial evals), I came to call what I do quality care as opposed to the quantity care that I had experienced in other practice settings. So, I found out that I wasn’t the only doctor striking off into this hazy territory of private practice who was compelled to practice medicine according to my own rules rather than the rules of health care delivery systems. It reminded me of the old punk rock DIY (Do It Yourself) attitude!
For the first year or so of private practice, I found I had to say no to a lot of other things in my life in order to really stay on top of the responsibilities I had taken on. Learning how to do billing, tracking down denied claims, figuring out the multiple reimbursement systems (Public Aid, Medicare, and the myriad of private insurance companies), returning phone calls, scheduling and rescheduling patients, phoning in prescriptions, all of these things took exponentially more time than I had thought they would. If you have “support staff” where you work, I can tell you that you are probably not fully appreciating all that they do for you!
After about two years, I felt like I was able to take a deep breath. I started having more of a social life again. I started to get back into things that supported me, exercise, painting, music, watching movies, and seeing friends. I found that it was really important for me to start saying yes again to social life, and let me tell you, with a private practice, it can be a constant struggle to keep the practice from eclipsing the rest of your life.
Eventually, I realized that with the full-time clinical work, coupled with the late nights and weekends of doing administrative work, I was not feeling like a whole person anymore and as I am fond of saying to anyone who will listen (unfortunately, I myself am not always that listener) you have to be a whole person to treat a whole person. I then started saying yes to anything that would get me out of the office and put me in touch with other people, teaching at the community college, getting an appointment at the local medical school, running workshops, sharing both sane and crazy ideas with colleagues, intentionally networking with other people, not always sure where that might lead – curating an art show in my office space, ok, why not!
In the movie, Yes Man, Jim Carey’s character is putting all of his energy into avoiding anything life has to offer. He joins a cult-like self-help group and takes the challenge to say yes to anything someone asks him, any opportunity that comes up, no matter how crazy. Things go exceedingly well for him – up to a certain point, and then they don’t go so well. He learns that you cannot literally say yes to everything. Certain “yeses” exclude other possibilities. There is only so much of oneself to go around. It could be said that what he learns is to not say no out of fear, out of arguing for one’s limitations, out of a fixed risk-averse attitude. What he learns is that what is important is saying yes to the right things, saying yes to the things that your heart is really in. That leads to the question, how do you know what is really in your heart. Maybe you are lucky and you already know, otherwise you just have to try something different and see if you like it.
Here I am, encouraging you to say yes to private practice. What am I doing? I am closing my private practice! Why on earth am I doing this after putting so much work into creating this darn thing that was supposed to free me from the restrictions of other health care delivery systems? Well, it may seem hypocritical writing about starting a practice at the same time I am closing mine. What I am realizing, though, as I go through this process is that I am seeing a lot of things more clearly in my practice now that I am starting to get some distance from it. Sometimes you don’t know what you are learning when you are in the thick of things. I’ll invoke H.D. Thoreau, here, “I left the woods for as good a reason as I went there. Perhaps it seemed to me that I had several more lives to live, and could not spare anymore time for that one,” (The Portable Thoreau, Walden, p. 562).
The truth is, I felt like my practice was getting imbalanced. I looked at several ways to re-balance it, I spent more time teaching and networking (and my income went down proportionally), I then tried to see as many patients while still squeezing in the things that I loved and needed to do (the outcome is probably obvious: a frazzled, stressed, and sleep-deprived “holistic” doctor), I hired a part-time office assistant, I looked into finding a business partner, I looked into the possibility of starting a non-profit holistic health center, but none of these seemed to get things back in balance. I felt like I had committed myself to saying yes to things that my heart was no longer in. I don’t know if I would say that I burned out so much as that my heart had moved on before the rest of me followed. It was kind of like realizing that I had learned all that I needed to learn in the practice.
So, what am I doing instead of the practice? Well, my wife and I are moving to New Zealand! I haven’t been this excited about something since starting medical school. The idea of moving someplace new and experiencing different cultures and working in a new health care delivery system (a national health service) sends a thrill of excitement through my core. Saying yes to this new reality means saying no to private practice, at least for now.
However, I really do feel like I have such a clear perspective on my practice as I am ending it. I hope to share more of my experiences and what I have learned, here at PrivatePractice.MD, about starting and running a holistic psychiatry micropractice.