Solo practitioners driven by entrepreneurial spirit

As the former football free safety for the University of Florida Gators, Michael D. Gilmore, MD, knows the challenges of going it alone—and thrives on them.

“Being a solo practitioner is much more difficult than trying to cover a receiver one-on-one in front of 100,000 people,” he says. “It’s much more challenging than that.” As a successful solo practitioner in Florida’s panhandle (Marianna), Dr. Gilmore enjoys being his own boss.

It’s a sentiment that other solo practitioners—including Lawrence P. Bruno, MD, of Brunswick, Ohio; Alexander A. Davis, MD, of Modesto, Calif.; and G. Klaud Miller, MD, of Chicago—share.

“I like the autonomy of being a solo practitioner, of having the ability to control my own destiny,” says Dr. Bruno, a general orthopaedist who sees sports medicine patients as well as those with hand and foot problems.

“I have a great sense of freedom,” says Dr. Davis, who left a group practice 8 years ago to go it alone. “I make all the decisions and am free from people telling me how to run my practice. But I’m also responsible for everything that occurs. It’s a double-edged sword.”

The rewards of going it alone
“Everything I’ve wanted as an orthopaedic surgeon I have found as a solo practitioner,” says Dr. Bruno. “I’ve developed long-term relationships with my patients. I saw my patients and their children when they were young, as high school students, and now as young adults.”

Dr. Miller also enjoys seeing members of the same family during the course of his career. “I’ve seen families for 25 years and that is gratifying. I’ve done mom’s total knee and the son’s arthroscopy. Recently, I treated a girl who broke her arm and 3 weeks later, her twin sister broke her elbow. I would not have seen that in a large, multispecialty practice.”

Drs. Gilmore and Davis also see being a solo practitioner as a tremendous learning experience. “Hiring and training staff is the most challenging aspect of my practice,” says Dr. Gilmore. “It’s more challenging than any kind of orthopaedic surgery.”

“If you want to further your own personal development, solo practice is a great way to do it,” agrees Dr. Davis.

The business of orthopaedic surgery
Being a solo practitioner also sharpens business acumen. “The best run practices are probably solo practices because we have to be completely focused on the bottom line,” Dr. Miller says.

“As a solo practitioner, I have to select those services that support my practice and help keep my doors open,” agrees Dr. Gilmore. “I have to keep my overhead down, my profits up, and retain good quality staff.”

“The business skills needed in solo practice are not taught in medical school or residency,” notes Dr. Davis. “I had to learn them at the school of hard knocks.”

Dr. Davis is a strong advocate for electronic medical records. “Charts take up too much space. You’re paying for square footage for a piece of paper to sit in your office.”

He also outsources services such as information technology (IT) and accounting to small vendors. “Small firms seem to work harder, charge less money, and get the job done more quickly than big companies,” he says. But he keeps an eye on his own finances. “I know every check and every credit expense—everything that goes out.”

Dr. Bruno has changed his practice based on business conditions. “I used to do spine surgery and joint replacements. After about 10 years, I stopped doing spine surgery due to increases in malpractice premiums. I wasn’t doing enough procedures to justify the expense,” he explains. “Later, I stopped doing joint replacements. Each time, I had regrets when I had to make a change. But it has worked out for the best.”

When Dr. Bruno opened his practice, Brunswick was a rural area, and he drew patients from a 30- to 40-mile radius. Now Brunswick is a suburb of Cleveland, and satellite offices operated by urban medical centers compete for patients.

“It’s something you have to accept. Patients have access to some specialized services that I don’t provide. At the same time, the competition has increased,” he says.

Recently, Dr. Bruno shifted to an ambulatory practice, which enables him to volunteer with Health Volunteers Overseas (HVO). He now serves as codirector for HVO’s new program in Costa Rica.

Unlike the cost-containment model used by Drs. Davis and Bruno, Dr. Gilmore enhances his practice with ancillary services. “I’m an independent thinker who likes to find ways to generate revenue,” he says.

His two practice facilities, located in Panama City, Fla., and Crestview, Fla., have outpatient surgical suites. To educate patients about their conditions, he uses large screen monitors in each exam room to display digital radiographs.

Dr. Gilmore also has a durable medical equipment bracing program. “This type of program has to be done on a consignment basis, and the inventory has to be very closely monitored,” he says. “The braces have to be placed on the appropriate patients.”

He offers physical therapy services and uses certified athletic trainers. The trainers go to 15 area high schools to do injury checks and assist the therapists.

With an internist and a bariatric surgeon, Dr. Gilmore developed a “physician wellness and weight loss program.” The program is open to the general public; the physicians are careful not to refer or solicit their own patients to it. “We have our own weight management program for patients with joint or back pain,” he says.

In his first 5 years as a solo practitioner, he has built a staff of 12 full- and part-time employees, including a staff person to support his IT infrastructure.

On call all the time
All four agree that the most significant disadvantage of solo practice is always being on call.

“It’s extremely difficult to take time off. I don’t even worry about when I’m on call; I just go when they call me,” says Dr. Miller.

Dr. Bruno takes many fewer emergency department (ED) calls than he used to but he is always on call for his own patients. “Being a solo practitioner makes it difficult to continue doing a lot of inpatient or ED work. It’s one thing to be on-call for your practice, but another thing to be on-call for a community or a region,” he says.

Though he is always available to his patients during the week, Dr. Davis gets only 2 to 3 calls at night per year. He shares weekend ED call with 11 orthopaedic surgeons in Modesto.

When Dr. Gilmore started his practice, he had to take call almost every night. “I had loads of trauma cases and additional elective cases. It was brutal. I got completely burned out,” he recalls.

When he couldn’t get a dedicated trauma operating room or staff and wasn’t being paid, Dr. Gilmore decided to change his practice. He now performs only outpatient surgery and covers his own patients. If he is out of town, he has a physician’s assistant and an orthopaedic surgeon, if needed, to cover his practice.

The isolation of solo practice
These solo practitioners also miss the camaraderie that their colleagues in group practices share. Whether it’s seeking an opinion about a difficult case or discussing a challenging surgical procedure, the solo practitioner has to build his own network of support.

“Collegiality has dissolved over the years. You have to create it for yourself so you don’t become isolated,” says Dr. Bruno.

“When you’re on your own, you don’t have the advantage of walking down the hall and getting that internal second opinion,” agrees Dr. Miller. “If I need to, I can always go to a colleague and get their perspective. Most surgeons are amenable, and other surgeons seek out my opinion, too.”

Dr. Davis uses technology to keep in touch, e-mailing digital radiographs to colleagues for an opinion. He also attends a small spine group that meets regularly.

Meetings—such as the AAOS Annual Meeting, orthopaedic specialty meetings, and state society meetings—are a good way to stay in touch and to stay current with the latest orthopaedic research, procedures, and technology.

Dr. Gilmore also attends several classes. “I want to learn the newest techniques. I work on all areas of the body. I want to make sure that I perform every procedure just as well as the surgeon that specializes in that one area,” he says.

An endangered species?
“It would be extremely difficult to start a solo practice in a large urban area at this point,” according to Dr. Miller. “Who could come up with $100,000 for malpractice premiums—not to mention the staff and all the start-up costs? You’d have to be independently wealthy.”

“In the future, I think more orthopaedic surgeons will work for academic institutions or large group practices,” says Dr. Bruno. “The number of solo practitioners is probably declining. But that doesn’t mean that solo practice isn’t right for certain people or situations.”

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org