Out With the Old, In With the New

FP Achieves Wellness by Bucking Traditional Practice

July 05, 2017 10:15 am Jill Sederstrom

Professional burnout is an all-too-common problem that plagues many family physicians. As part of the AAFP's strategic focus on overcoming professional burnout and cultivating physician well-being, AAFP News spoke with California native Chris Flores, M.D.(www.familydocs.org), a family physician who left traditional practice to open his own low-volume, low-overhead solo practice. And he's never looked back.

[Chris Flores, M.D., with his wife, Maricela Fernandez]

For Chris Flores, M.D., shown here with his wife of 23 years and office manager, Maricela Fernandez, taking time to relax and rejuvenate is key to maintaining a healthy work-life balance. He urges his family physician colleagues to take a close look at what they value in life and what they want to accomplish -- and then figure out how to make that happen.

Q: Can you start by talking about the circumstances you were in when you started thinking you might be suffering from burnout?

A: It was about 15 years ago. I was probably six or seven years into my postgraduate career, and I had already been in three different positions.

The first job I had after residency was a multi-specialty group, a private, for-profit, group practice in Albuquerque, N.M. I thought that was going to be a good fit for me because it had a strong primary care base, but it was also very closely integrated with all of the specialists. Pretty quickly, we started having to look at productivity and RVUs (relative value units) and they started sending all of us to these classes -- not for medical education but for learning how to code the visits and how to maximize the billing potential for a visit.

I started to look at that and say, "That's kind of strange; it seems like we're just focusing on the dollar and not on the quality." I was at that position for about three-and-a-half years, and I realized it wasn't for me.

My wife and I moved back to California. I had done my residency with Kaiser Permanente, and so I joined Kaiser in Northern California because I felt, "Oh, this is familiar, and this is a closed system, and they have all these wonderful reviews; they are always excellent on quality and it's a tightly integrated medical system." But that was the same type of high-patient-volume experience.

So, then I went into teaching. I was looking for "the perfect fit" -- the balance between quality medicine and things I enjoy doing, like teaching and spending time with patients. But, it was the same thing. I always felt like there were insurance issues and government-payer issues in the room with me -- even though physically it was just me and the patient -- and those issues were driving my decision-making about patient management, whether to get an imaging exam or not or whether to pick a branded expensive medication versus an inferior treatment.

I hit a dead end. I guess that's what you would call burnout. I just felt demoralized and like I was at the end of a road. I felt like I was not in control of patient management decisions, yet I was responsible and liable for them; that is not what I signed up for.

I was feeling really disillusioned about not only about my career choice -- even though I knew in my heart that this is my passion and I loved medicine and I loved clinical encounters -- but I was beginning to wonder if my vision of patient-centered care was possible in this health care system that we have.

In 2005, my wife and I moved to Southern California and we opened a low-overhead, low-volume type of practice that is cash only. I have no contracts with any insurance companies; I actually opted out of Medicare back in 2005.

So, now 12 years later, I'm in this same practice. Just my wife and I, and we also have an information technology specialist who is under our employment.

Q: When did you know it was time to make the leap and go out on your own, and what steps did you take to achieve that?

A: I'd say it was 2003 or so. My wife and I were planning to move to Southern California, and that was about the same time that (fellow AAFP member) Gordon Moore, was championing this low-overhead, low-volume idea(idealmedicalpractice.com). He was actually doing it solo. He had no staff, and he had no employees; it was just a cubicle and a tiny office where he could see patients.

(My wife and I) went to lectures about it, and we learned all we could. There was a really good email listserve through Yahoo! that was working at that time that helped us immensely to plan for the practice. It was probably a two-year process. Before we even opened the office, we spent a lot of time with the small business development center.

It wasn't a rash decision. It was a very methodical, deliberate decision. We visited probably 20 different practices -- focusing on solo physician and small practices -- to meet with them.

Q: Can you describe your practice now and how it's different from your previous work experiences?

A: I think it's the pace of the patient flow. For the most part, we schedule one patient every hour. I may only spend 20 to 35 minutes with that patient depending on what's going on, but within that hour I am also getting messages, talking to people on the phone, doing the paperwork, doing the med refills, reviewing the labs -- all the other million things we have to do that in a regular practice there's never any time allotted for. I do house calls and see patients in the hospital, and I also do a lot of virtual visits -- nonface-to-face encounters via phone or secure portal.

It's a small practice; I only have maybe 700 patients -- 750 perhaps -- and so I know them pretty well.

When people come into our office, there's usually no one waiting, or maybe there's one person. But in general, from the patient perspective, they are the only one.

Most physicians' offices are somewhat hectic, chaotic places. You walk in and there's a number of people in the waiting rooms, and the medical assistant seems to be running around here or there, the phones are ringing. Our place is more like a sanctuary where it's just quiet.

Q: How has this change impacted your overall mental health and your job satisfaction?

A: I tell people it's like a dream practice. It's sustainable. I think that's probably the most important thing. All the other positions I had, I felt they just were not sustainable -- like something was going to break. Either I was going to make a huge mistake and be brought down because of sloppy medicine, or I was just not going to be satisfied.

Q: What do you think were the most significant obstacles that stood in your way as you worked to recover from burnout and enact this new practice model?

A: I think No. 1 is fear, because you know that as independent and self-sufficient a lot of doctors feel they are, in reality, our training is very regimented and it's very hierarchical. It's almost paramilitary in a way.

It's all kind of laid out for you, and so to do something that is off the grid, something that is completely unfamiliar, is quite an obstacle for physicians to get over. It's just so much safer to say, "Well, I am going to go work at the clinic that is being managed by somebody else and the billing is being managed by somebody else and I am just going to get my paycheck." It's the model we know.

I think just that getting over that fear of failure was a big, big step.

The other thing is there's so much regulation in medicine. Every single act we do, it seems we have to make sure we have permission to do that. Even if you are doing a test that's waived, you have to get a license and permit and you have to do all these steps every year to say that you are in compliance. We also worry about the dangers of technology, like HIPAA (Health Insurance Portability and Accountability Act) violations and hacking and ransomware.

We made a decision -- and my wife is an attorney by training, so she has the background to recognize the potential pitfalls and liability in this type of business -- we made a decision that we're doing something different here so we need to make sure we are doing everything by the book.

Q: Now that you've been able to find a better personal balance for yourself, what advice do you have for others who might be facing similar struggles with burnout?

A: For me, it was really about looking at my priorities -- and I am married, so we had to look at our joint priorities. What is it that we value in life, and what is it that we really want to accomplish? I think a lot of people don't ever ask themselves those questions.

Once you figure that out, then you have to try to figure out how to make that happen.

It's given us a lot of flexibility to pursue our interests, and I think that for people who are thinking of how to get out of their dead-end position or that trapped feeling, they just need to figure out what is it that they want to do and then start learning how other people have been able to accomplish that.