letters

Family medicine vs. retail medicine

I am a family physician who was in private practice for 21 years. After a personal life change, I began working in an urgent care center. These centers appear to be a step between private practice and retail health clinics.

I do not see retail health clinics as a threat to private practice but as a source of growth for private practice. The relationship is more symbiotic than antagonistic. Retail health clinics don't have the capability to perform procedures that have high reimbursement rates. They treat patients with minor problems that the average primary care physician is too busy to handle regularly. This can lighten the physician's call load significantly, which heightens quality of life.

In our urgent care center, we have the capability to provide these services when the primary care physician is unable to. Despite what some family physicians fear, I actively resist providing chronic illness care, and I strongly encourage patients with chronic illnesses to find a primary care physician. Our urgent care center could easily fill a family physician's office with insured patients by referral and would be happy to do so.

Louis H. Reiss, MD
Memphis, Tenn.

Retail health clinics are competitors that further erode our ability to make a living as family physicians. No other licensed industry would put up with this type of competition. Yet family physicians, including AAFP president Dr. Larry Fields, say that retail health clinics are "something to use in a pinch or in a hurry or when you're not too sick." Unfortunately, until our profession has more business sense, we all must put up with low reimbursement.

David Zimmerman, MD, FAAFP, MBA
Mission Viejo, Calif.

Reinventing the specialty, continued

In his response to our letter to the editor [June 2006], Dr. Sanford Brown misconstrued and misrepresented some of our comments. First, between our two offices, we offer and administer all of the ancillary services listed in our letter. We never stated that our physicians interpret each ancillary study. In fact, we have the best cardiologist and radiologist in our respective areas interpret the studies. This type of partnership, borne out of mutual respect, is part of what makes our model of practice work so well. Second, if you buy Dr. Brown's rationale for choosing a gastroenterologist for colonoscopy, then maybe family physicians should refer every sinus infection to the local ENT. Sadly, Dr. Brown's assumptions and response reaffirmed our position about his article more than we could have imagined.

Mitchell R. Grunsky, MD, Sumter, S.C.
R. Henry Capps Jr., MD, Cornelius, N.C.

I am shocked and offended by Dr. Sanford Brown's response to the letter from Drs. Grunsky and Capps. Apparently, Dr. Brown has no idea how easy it is to perform a colonoscopy and upper endoscopy in the modern era. Yes, there are still risks, but gastroenterologists think they have an amazing ability that takes months to cultivate when in fact they are merely playing a video game. Twenty years ago, a family physician was qualified to run a flexible sigmoidoscope into the sigmoid colon to the splenic flexure of an unsedated patient. Now that same physician is easily capable of advancing the scope another two feet and making two left turns in a sedated patient. Those of us who played video games as a kid know that it is more difficult to rescue the princess in a game of Donkey Kong than it is to intubate the cecum. And how many gastroenterologists use a screening colonoscopy as a chance to remind the patient to continue exercising or to re-emphasize smoking cessation?

Kirk Nienaber, MD
Paris, Tenn.

The health plan's job

The subtitle of Robert Edsall's editorial "How Do You Cope With Bundled Claims?" [April 2006] read, "Don't cheat yourself. That's the health plan's job." It is neither the health plan's nor the physician's job to cheat anyone. Nor is it anyone's dirty work to abide by contract provisions. The line was a cheap shot.

John W. Richards Jr., MD, MMM, CPE
Martinez, Ga.

The pros and cons of sole proprietorship

As an attorney who specializes in asset protection and estate planning, I am concerned about an article published in your journal on how to structure a medical practice ["Choosing the Right Practice Entity," November/December 2005]. In the article, the author suggests that solo physicians should be sole proprietors. This suggestion sets up physicians and attorneys for tremendous liability. Put simply, if someone slips and falls on the practice's grounds or is sexually harassed by one of the employees, the sole proprietor will be sued personally. If the practice is structured as a professional corporation, S or C corporation, or a limited liability partnership, the assets of the company, rather than the physician's assets, would be at risk in such cases. Additionally, there are several tax advantages to being treated as either an S or C corporation.

Roccy DeFrancesco, JD, CWPP, CAPP
St. Joseph, Mich.

Author's response:

At the end of my article, I stated that although I usually recommend a sole proprietorship for a physician who does not anticipate practicing with another physician, it's always best to take the time to evaluate the pros and cons. A sole proprietorship makes sense for a physician who is concerned about what it will cost to set up and maintain a corporation, prefers a draw instead of a salary, does not anticipate hiring a midlevel provider and will have mostly part-time clerical employees, has plenty of nonprofessional liability insurance including an umbrella policy and has a lease or line of credit that would typically require a personal guarantee even if he or she had incorporated. No attorney who recommends this approach would be subject to liability. Of course I would explain to the client that there is potential personal liability for a slip-and-fall accident on the premises, but I would add that I have been practicing health care law for more than 20 years and have never had a client who was liable for a slip-and-fall accident in excess of insurance. In addition, there are typically few or no tax benefits for incorporating a sole proprietorship unless certain unique circumstances exist.

Jeffrey B. Sansweet, JD
Wayne, Pa.

Dressing the part

I read "Dressed to Ill" [June 2006] with interest. I think physicians should put more effort into their appearance. Wearing a shirt, tie and slacks gives the patient a sense that you care for yourself and that you can care for them. To say that it is OK for physicians to dress down because the patients look like clowns is ludicrous. Part of being a professional means looking the part.

Ajay Sood, MD
Orlando, Fla.