Family Practice Spectrum

Family Physicians and Nurse Practitioners -- A Perfect Team

One upstate New York family practice has found collaborative practice a way to remain independent.

Lyndia Flanagan

Only one private family practice is left in Endwell, N.Y. Jonathan A. Harris, MD, one of three family physicians who started the practice in 1977, laughingly refers to it as "the last of the Mohicans." Everybody else, he says, has sold out to somebody.

A different route
Ironically, Endwell Family Physicians started out as a hospital-based practice funded in part by a grant from the Robert Wood Johnson Foundation. When the interests of the hospital and the primary care practice diverged, the physicians bought the practice in 1980. Even though many in the community expressed doubts that the practice could stay independent, the physicians were eager to take on the challenge.

By 1985, they were beginning to deal with managed care, Harris recalls, and "learning how to balance the conflict between being the patient's agent and being the insurance company's agent." With a thriving practice today, the partnership has managed to strike that balance. When Endwell Family Physicians observed its 20th anniversary last year, there was much to celebrate.

Strong collaboration among doctors and nurse practitioners has been one of the secrets of success for Endwell Family Physicians.

A major asset
What's the secret of their success? Early on, according to Harris, the doctors learned the value of working with nurse practitioners. In 1978, a nurse educator at the State University of New York in Binghamton made the physicians an offer they couldn't refuse: She volunteered to work for six months free to demonstrate the benefits of employing nurse practitioners.

The physicians considered the experiment a great success. Not only did they hire her, three years later they hired one of her students; and, as the practice has grown, they've continued to add nurse practitioners to their provider roster. By teaming with nurse practitioners, they are able to see more patients and offer more cost-effective care. Today, seven family physicians, eight nurse practitioners and two physician assistants serve approximately 40,000 patients.

What makes the practice particularly unusual is that the nurse practitioners maintain their own patient panels. Their relationship with the physicians is one of collaboration -- a mode of practice that has been the subject of heated debate elsewhere. Patients schedule appointments with the nurse practitioners in the same way they do with the physicians. The nurse practitioners evaluate, diagnose and treat, including writing their own prescriptions. They consult with the physicians when they encounter a problem that they cannot resolve. It can be as simple as a skin rash or as complicated as a hospital admission.

"They share their expertise as we do ours. It has been a very effective practice." Jonathan A. Harris, MD

"We work together," Harris says. "They share their areas of expertise as we do ours. It has been a very effective practice."

Availability
Endwell Family Physicians prides itself on making sure that the needs of its patients are always met. When the providers realized, for example, that they were referring their patients to other sites on weekends, they decided to open their own weekend walk-in clinic in December 1996. "We were getting a lot of phone calls on the weekend from patients who needed to be seen by a provider," Harris says. "Sometimes, we also found ourselves trying to treat people for things that we really weren't comfortable treating them for on the phone." With the addition of the weekend clinic, patients have access to the practice seven days a week until 9 p.m.

The practice also has established a company to conduct clinical drug trials, which has turned out to be "a nice side business," says Jonathan A. Harris, MD.

The decision to open the weekend clinic has proved to be a wise one. "We've actually more than doubled our guesstimate of the volume of patients we thought we would see in the walk-in clinic," Harris says. He also readily admits that the ability to schedule evening appointments and to offer care on the weekends is one of the practice's stronger selling points. "To make it in this business today, you have to make patients feel that they come first," Harris says.

The right work environment
The partnership has worked hard to build a sense of trust and cooperation among staff -- not an easy task given that there are more than 80 full-time and part-time employees. It has taken a number of steps, including the following, to foster a supportive work environment:

• The providers share a common office -- a large open area with 15 desks. They do not bring patients into this area; it's strictly a work space. What is the advantage of this arrangement? "It brings all of us together so that it's easy to talk to each other and understand what goes on, and it fosters a group spirit," Harris says.
• The three senior partners each assume responsibility for managing one dimension of the practice: the physical plant, finances or personnel. Harris is quick to point out, however, that they do not micromanage, but work closely with department supervisors and the office manager.
• In an effort to avoid conflicts between the front and back offices, individual departments meet routinely with their supervisors, and then the supervisors meet to talk about common problems.
• To make sure everyone feels actively involved in the practice, the entire staff meets once a month to talk about practice issues and to bring people up-to-date on what's going on.
• Every effort is made to offer competitive compensation packages to all staff.
• Special measures are taken to make sure the providers don't burn out. The partners, for example, have seven weeks (35 practice days) of vacation each year. No one is allowed to accumulate vacation for more than one year -- it's use it or lose it. If a provider is not on call, that means he or she is not on call. "You operate at such an intensity all the time that you need to be able to get away," Harris says. "If you can figure out how to play and have avocations that occupy your brain, you live longer and can do what you do better."

"To make it in this business today, you have to make patients feel that they come first." Jonathan A. Harris, MD

In this type of work environment, it is much easier to fulfill the practice's commitment to provide the best possible care in a pleasant, respectful and friendly atmosphere. "When people come in our office, they're greeted by smiling staff who thoroughly enjoy working here," Harris explains, "and it creates an aura that makes people feel good about coming here."

New venture
While meeting the challenges of successful family practice, Endwell Family Physicians has also managed to diversify. In 1991, the partners set up a separate company to do pharmaceutical clinical research trials. "We knew someone in another community who was doing this kind of work," Harris says, "and we thought it looked both interesting and profitable."

The company, which maintains one office at the practice and another one off-site, employs 10 research coordinators. It is, according to Harris, a "nice side business" that has proved to be very rewarding. Among other things, it has given the physicians an opportunity to gain extensive experience with a number of new drugs coming to the market.

Future plans
What does the future hold for Endwell Family Physicians? The practice now has about 21 percent of the market. Its goal is to capture 30 percent within the next five years. To handle the additional patients, the partners hope to hire three more family physicians over the next three years. They admit that it won't be easy to compete with the larger systems, but they hope to maintain their edge by providing very high-quality care at reasonable costs.

The existing facility, which includes a level-two lab, has been enlarged. This is the practice's third renovation of the building. The practice is also shopping for a computerized patient records system.

The practice's collegial environment helps smooth interactions among the staff as well as making patients feel welcome and at ease.

While the practice has no plans to expand the nature of its services, it continuously explores different modes of treatment. One partner is certified in acupuncture and also does some psychotherapy with hypnosis. "We're interested in providing services that seem to meet a need and make sense, so we're willing to take a look at what is out there," Harris says.

To help other family physicians thrive in private practice, Harris offers these tips: make sure your partnership is clearly defined; develop an effective management style and stick to it; strive to provide high-quality, patient-centered care with maximum availability; enlist nurse practitioners as part of your team; employ adequate office support staff; and protect your personal time.

Editor's note: The other family physicians at Endwell Family Physicians are Bruce T. Bowling, MD, Pamela J. Cook, MD, Victor A. Elinoff, MD, James C. Holler, MD, John S. Perry, MD, and Duncan Sze-Tu, MD.

Lyndia Flanagan is senior editor of Family Practice Management.

Copyright © 1998 by the American Academy of Family Physicians.
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