Letters

We were gratified by the response to our 100th issue (October 2003), in which we published articles from the FPM archives that were particularly well received when they were originally published and that remain relevant to the challenges family physicians face today. Your letters affirmed the enduring value of these articles and of FPM itself. The articles "Solo Practice: The Way of the Future" (Douglas Iliff, MD, page 23) and "Rediscovering the Joy of Family Practice" (C. Carolyn Thiedke, MD, page 57) generated the most numerous and most passionate responses. Here's a small sample of the comments we received. - Editors

Stepping up to the challenge

To the Editor:

We need more articles like "Solo Practice: The Way of the Future." I am planning to start a solo practice in Texas after I complete my residency this year. I have received very little encouragement from the faculty to do this and have heard many comments like, "That is very brave these days." I had to go outside the program for advice on ways to start a solo practice. I now have help and am very excited about starting my practice. It is encouraging to hear family doctors in solo practice say how much they love it and that they would not change it. I hope many residents read this article and realize there is an alternative to joining a large group. You don't have to be a fool to try solo practice.

Debra Krieg, MD
San Antonio

Recapturing job satisfaction

To the Editor:

Thanks for the great article on solo practice. Everything Dr. Iliff says is true. I am a 34-year-old family physician (five years out of residency) who recently opened a solo practice in Camden, N.J., the second poorest city in the country. I provide full-spectrum care, including obstetrics, in a population where about half of the patients speak Spanish. I have never been happier, and my patients have never been happier. We have acquired 1,400 patients in nine months, and they are still coming; I'll need to close the practice to new patients eventually. Revenue is great, even in such a poor community, because the office attracts a healthy balance of privately insured patients, and we're extremely efficient. If you want to work in a poor, urban community, then say no to community health centers and open a solo, private practice. It's time to recapture what we lost when family physicians gave up on solo practice: better care and greater job satisfaction.

Jeff Brenner, MD
Camden, N.J.

Solo is best

To the Editor:

Finally! What a great article by Dr. Douglas Iliff, a physician who understands how it's supposed to work. Solo practice has always made the most sense. Providing personal, one-on-one service in the exam room is just that - personal. Large corporate practices cannot and do not deliver personal service, and they never will. I agree that our residents don't get the education they need to go into solo practice. I hope that will change because "there's no place like (the) home (office)."

Robert W. Shreck, MD
Las Vegas

Reinventing solo practice

To the Editor:

I read with interest "Solo Practice: The Way of the Future," as I am going out of business in my solo rural practice. I will be personally bankrupt as well. I have not had an income for two years, and I can't keep it up anymore. Basically, I can't see patients fast enough and still do a decent job if I only spend a few minutes with each. The PPO discounts are so low that I can't keep the overhead paid. It's more complex than that, but I have been in my current location a year, built a wonderful practice that I love and have a good reputation. I am going to try to reinvent myself as a mobile practice with little to no overhead. I will try to emulate the phoenix from the ashes and see if I can continue to take care of the people who are my friends and neighbors and who don't have a lot of options in a rural area.

Marsha McKay, DO
MiWuk Village, Calif.

Keeping medicine meaningful

To the Editor:

I want to share the positive impact "Rediscovering the Joy of Family Practice" had on me. Since the article was first published in FPM seven years ago, I have been using many of the practices Dr. Thiedke recommended in my personal and professional lives. I believe that I am a better doctor today because of it. These principles need to be taught in medical schools and residency programs.

Elizama Montalvo, MD
Bronx, N.Y.

Focusing on the positive

To the Editor:

I was most impressed by "Rediscovering the Joy of Family Practice." I agree 100 percent that it is very important to know yourself, accept yourself and focus on the positive to lead a fulfilled life and be of more help to your patients. In the rush of today's world, we tend to forget these basic truths.

David Uirab, MD
Namibia

Words of encouragement

To the Editor:

Many thanks for the wonderful article "Rediscovering the Joy of Family Practice." Although I am a gynecologist rather than a family physician, I could identify with every aspect of the issues discussed. There have been times when I have felt like giving it all up, but articles like these are a source of tremendous help, a great tonic.

Paul Mensah, MD
Dumfries, Scotland

"Overcoding" the statistics

To the Editor:

As Mark Twain said, "There are lies, damned lies and statistics." I think "How to Get All the 99214s You Deserve" [October 2003, page 31] "overcoded" the statistics a little when it referenced a 33-percent undercoding rate.1 In the study by King et al, expert coders reviewed family physicians' choices of codes for hypothetical established patients.

Compared with the expert coders, physicians did undercode 33 percent of the time for established patients, but they undercoded only 1 percent of the time for new patients. If averaged over a representative patient population, that would yield less than a 33-percent rate.

The King study also references three other studies that weren't mentioned by the author. In the first, trained nurses observing actual patient visits noted that physicians assigned incorrect codes 55 percent of the time, split equally between undercoding and overcoding.2 Two retrospective chart reviews found similar results.3,4 These studies suggest that undercoding is not as common as in the hypothetical situation the author referenced and that physicians undercode and overcode equally.

Gil Solomon, MD
West Hills, Calif.

Documenting history

To the Editor:

In "Two Tried-and-True Tools for E/M Documentation" [October 2003, page 51], the progress note uses a check box to indicate no change in the past, family and social history (PFSH). While this is perfectly appropriate, the Documentation Guidelines for Evaluation & Management Services indicate that the date of the last review of the PFSH must be indicated as well. It states, "A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. ... The review and update may be documented by describing any new ROS and/or PFSH information or noting there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH."

Susan Welsh, CPC
Brentwood, Tenn.

Editor's note: We've made the change you suggested in the online version of our form at http://www.aafp.org/x20091.xml. Thank you for helping us to improve it.

"Doing it all" with open access

To the Editor:

I have enjoyed Dr. Gordon Moore's series of articles on his model of practice ["Creating a Vital, Burnout-Proof Practice," September 2003, page 51; "Going Solo: Making the Leap," February 2002, page 29; "Going Solo: One Doc, One Room, One Year Later," March 2002, page 25; and "Answers to Your Questions on Solo, Idealized Practice," May 2002, page 39]. However, some of his ideas seem contradictory. For example, to grow your practice, he recommends promising patients, "I will see you on time" and, "We will have all the time you and I need. No rushing."

I can see my patients on time, but that necessitates limiting each patient to the time allotted. I can take all the time we need, but then I cannot predict how long it will take, and subsequent patients cannot be given an accurate appointment time. How does he propose to achieve both of these goals?

Denise Taylor, MD
Cedar Park, Texas

Author's response:

WE WANT TO HEAR FROM YOU

Send your comments to fpmedit@aafp.org. Submission of a letter will be construed as granting AAFP permission to publish the letter in any of its publications in any form. We cannot respond to all letters we receive. Those chosen for publication will be edited for length and style.

In a typical office practice, doing all of these things together is impossible. On the other hand, it is possible to grow your new patient volume with open access. When I was working with a hospital system, its two pilot sites (internal medicine in the community and residency practice in ophthalmology) had prodigious growth based on the "see you today" principle alone. This experience is shared by countless other practices offering true open access.

If you'd like to do it all (i.e., "I'll see you today," "I'll see you on time" and "We'll have all the time you want and need"), you must entirely transform your office practice. Some cutting edge folks are doing this now: Dr. Linda Lee in Rochester, N.Y., Dr. Michelle Eads in Divide, Colo., and Dr. James Sturgis in Prairie Village, Kan., to name just a few. They have chosen to eliminate the bulk of their expenses in their renewed practices. By reducing their costs dramatically, they escaped the productivity death spiral, allowing them to craft the practices of their dreams.

1. King MS, Sharp L, Lipsky M. Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract. 2001;14(3):184-192.

2. Chao J, Gillanders WG, Flocke SA, Goodwin MA, Kikano GE, Stange KC. Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract. 1998;47:28-32.

3. Kikano GE, Goodwin MA, Stange KC. Evaluation and management services: a comparison of medical record documentation with actual billing in community family practice. Arch Fam Med. 2000;9:68-71.

4. Zuber TJ, Rhody CE, Muday TA, et al. Variability in code selection using the 1995 and 1998 HCFA documentation guidelines for office services. J Fam Pract. 2000;49:642-645.

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