Do you whistle while you work? You should.

When I was a kid, I remember having a small amount of dread whenever my mother took me to see my pediatrician Dr. Storts, a solo practitioner, for some routine vaccination, a lingering sore throat or cough, or a small cut or abrasion.  It wasn’t that I didn’t like Dr. Storts; in fact, I think I actually almost enjoyed those visits.  Although, it seemed that most of these visits ended with me getting a shot of some sort, he would talk to me - even though I was just a kid.    

Another thing I remember vividly about those visits was the way I could tell he was progressing down the hall: working his way from one room onto the next until he reached my room for the eventual encounter with “the needle.” He whistled! He actually whistled a lot! I really don’t know if this was a sign that he either really enjoyed his work or that he was really looking forward to the shot that he would likely give me (kidding). 

Looking back, it's interesting to note what it was like to practice pediatrics 50-60 years ago in the solo practitioner’s office: except for the nurse taking the patient’s vital signs, the doctor did almost everything. He wrote a brief one or two line note in the patient’s chart (certainly not up to the standards of today’s electronic medical record), discussed the diagnosis and treatment, filled out the necessary requisition for lab tests, drew up the medication into a syringe, and administered the “dreaded shot.”

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My reason for bringing this up is related to the details of a recent AAD dermatology practice survey that have just been released. This survey shows a continued decline over the past nearly ten years in the percentage of solo dermatologists practicing in the United States.

Since 2007, the number of dermatologists in solo practice has dropped from 44% to 35% in 2014. This decline is even more striking when one looks at the ages of the dermatologists in solo practice settings. The most recent survey results from 2014 show that only 15% of dermatologists under 40 years of age are in solo practice. As age increases, so does the statistic: 40 to 49 years of age (28%), 50-59 years of age (41%), and over 60 years of age (50%). These results clearly show that fewer younger dermatologists are practicing in solo settings while those older dermatologists over 60 years are continuing that practice.

The AAD survey shows that for all age groups in dermatology, except those over 60 years of age, the combined percentages of dermatologists in dermatology specialty group practices and multispecialty group practices average 50-60%. The real question is why has this dramatic change occurred?

NEXT: A Changing lanscape

A changing landscape

To provide some possible answers as to why this is occurring, I return to my old pediatrician, Dr. Storts.  I believe in Dr. Storts’ world, physicians with primary outpatient type practices (dermatology, pediatrics, family practice, ophthalmology, psychiatry and possibly gynecology and internal medicine) most often were in solo practice. That certainly is no longer the case today. I believe that some of this change is due to the far greater complexity involved in the management of patients with skin diseases today compared even to the relatively recent past. This complexity not only involves new diseases and treatments but also a heavy amount of administrative requirements, which I personally believe reduces the “fun” of practicing dermatology. After all, did anyone really go to medical school to become an accountant or bookkeeper? These changes makes it really difficult for most solo practitioners to be efficient while attempting to do everything tlemselves, like my old pediatrician (although some still try). 

As a result, in today’s world it is often more efficient and cost effective to divide responsibilities among a group of differently trained non-physicians who can deal with the complex government regulations including the Clinical Laboratory Improvement Amendments (CLIA), the Health Insurance Portability and Accountability Act (HIPPA) as well as the use of the electronic medical record (EMR). This division of labor can be most cost-effective when done in a single-specialty practice or a multispecialty group practice where these trained assistants work for a number of physicians who share the expense. Add to that the somewhat daunting requirement to remain current with the seemingly endless changes in billing codes required by a multitude of insurance companies and Medicare, and I believe the “fun” of practicing dermatology can be diminished for the solo practitioner.

With all of these developments, is it any wonder there are fewer solo practitioners in dermatology than even just a few years ago?

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However, through the cost-effective shared use of trained assistants who properly use the EMR, document and properly bill for the professional services provided, schedule patients for different types of office visits, and ensure that the referring physician is kept informed, dermatologists can do what they are trained to do: dermatologic patient care. And maybe the “fun” of practicing returns without negatively impacting the quality of care being provided. 

I believe this is one of the reasons the AAD survey shows growth in both single and multiple specialty practices. These practice settings can provide a means of collectively working together as a unit to make things easier and, hopefully, like my whistling pediatrician of years past, more fun. 

I’m not saying that the solo practitioner can’t do all these things by himself, but in doing so his efficiency is greatly reduced.

NEXT: Physician availability

When one looks at the need for physician availability in order to maintain the most ideal patient care, it simply would be exhausting for any physician to attempt that alone. Call schedules, vacations, attendance at educational meetings and simple family events become major detractors in the lives of many solo practitioners and, thus, in$my opinion, another presumed reason for their reduction in numbers.

I’ve come to the realization that the balance between life and lifestyle is the 500 lb. gorilla in the corner. If someone wants a certain type of lifestyle, he must do what’s necessary to attain that goal. If that requires associating with a group of other physicians to share the patient care and administrative responsibilities so that he can have more time to enjoy other things in life, then he should do that. If, on the other hand, the physician likes the independence of practicing on his own and doesn’t mind the added amount of responsibility and effort required to “do his own thing,” then he should do that. 

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For that reason, I don’t believe that the diminishing number of solo practice dermatologists means that they are “on their last legs.” I don’t think it matters if dermatologists practice as soloists or group members so long as the whistling doesn’t stop! Maybe it’s time for a change if you’re not one of the whistlers.

Ronald G. Wheeland, M.D.