Reflections on Almost a Quarter Century in Practice

This week marks my 24th year in private practice. Wow, how things have changed. I still remember seeing many kids with chickenpox in the office, as the varicella vaccine had only been recommended for a few years at that point.¹ Beta-blockers in heart failure were just beginning to move from the contraindicated list to standard of care.² Warfarin was the only choice for outpatient anticoagulation since direct oral anticoagulants were not available until 2010, when dabigatran hit the market.³ The Institute of Medicine’s “Crossing the Quality Chasm” report had just been published,⁴ and the groundbreaking “Future of Family Medicine” report was still three years away.⁵

Professionally, I’ve gone from being part of a small, independent family medicine practice with anywhere from two to four doctors to being part of a larger primary care practice with more than 60 doctors spread across 20 locations. I’ve witnessed stacks and stacks of paper charts (we originally had one computer in the office that we’d use for billing) to now my daily joy — the electronic health record. And, of course, let’s not forget that by 2001 only four “Star Wars” movies had been released! These past 24 years have given me some gray hair, but hopefully some wisdom too.

Obviously, not everything is perfect in family medicine today, but a couple positives stand out to me.

First, I think the emphasis on team-based care has been good. Allison, my medical assistant, is a reliable partner in helping me take care of patients. Michelle, the RN care manager I work with, supports patients with complex needs in ways I cannot. Both of them use their training and skills to drive better outcomes for our patients. It’s not all on me, and that’s a relief.

Second, speaking of outcomes, I think the emphasis on quality improvement has been good. That doesn’t mean I agree with all the metrics. So many of them have drivers well beyond our control, from social determinants of health to specialist practice patterns. But ultimately I’m a believer in the idea that improvement starts with measurement. We need to stay engaged in quality measurement because it’s up to us to tell the story of what’s important to us and our patients.

In a few weeks, I’ll be heading to FMX, the AAFP’s annual meeting, in Anaheim. I’ve written before about how much I look forward to this event, but the “why” behind my excitement has evolved over time. At first, when I was just out of residency, I went purely for the academic recharge — nearly a week’s worth of practical, evidence-based clinical education. As I got older and the doldrums and frustrations of daily practice crept in, FMX became a rejuvenating reunion with colleagues. Commiserating about our shared trauma from the difficulties of running a practice offered solace and hope. Now, as I’m in a different phase of my career, my focus has shifted from building things to giving back. I love seeing the energy and enthusiasm of our younger colleagues.