Lessons NOT Taught in Residency: Surviving Private Practice

Disclaimer: This post focuses on my experiences with ONE specific Private Practice clinic in a fairly Affluent, predominantly White, area. It is not a commentary on the clinic itself nor to say that all Private Practice settings are the same.

Traditionally, most medical training programs are primarily centered in so-called ‘academic’ centers. Training hospitals and clinics are great in that they generally have the most up-to-date research and often take care of the sickest of the sick or the most complicated patients. Sure there are the pros and cons of working with training physicians, but often times being in these institutions opens the doors for knowledge and opportunities sometimes lost to suburban/rural or distant areas, despite continuing medical education, or CME. But one thing that comes with these often state-backed/not for profit training programs is that a large population that is catered to is the non-insured, the indigent, the “lower socioeconomic class,” or, in short, a majority of a Medicaid population.

This is NOT a political post, I could get into my own thoughts on why I believe it’s important to care for those that are underserved and how that directly impacts the population I care about and the future – obviously children, but also immigrant families – but it’s more a commentary on how we are trained as Doctors. As a medical student and as a resident, I had mainly patients supported by social programs like Medicaid or CHIP. Fast forward to now, as I end my very first Locum Tenens job (yay!) and also my very first Attending job working in a Private Practice Pediatric Clinic, where Medicaid is NOT even accepted…

  • Problems, are different! Over the 300+ patients I’ve seen only working 2-3 days/week for the last 3 months, I’ve only seen 3 kids or 1% with obesity (BMI >95%ile). In training, it was the reverse with a majority of my counseling sessions focused on nutrition and weight loss. In my affluent private practice community, I found that, if anything, many kids were on the polar opposite and needed help gaining weight. Was it, possibly, because at the same time, I saw about 200x more prescriptions for ADHD medications? Is this a reflection of ADHD over-diagnosis in this population or under-diagnosis in my residency population? The AAP recently started a podcast called “Pediatrics on Call” which addresses the sometimes not as obvious fact that many diagnoses are given prematurely or not enough across races – does this also include across different insurance plans or socioeconomic classes? I have seen only 1 patient out of the last 300 with hypertension and pre-diabetes, how is this even possible?! Residency taught me that, well, everyone was developing it! Now, I have seen simultaneously an astonishingly higher percentage of self-diagnosed depression, anxiety or mood disorders. Is this because the culture catered to in private practice sector causes more of these problems? Talks about it more? Or because it’s not talked about enough in the Medicaid population, where, arguably, there are often many significant barriers and life chances that should amplify mental illness here as well? I had a brilliant eye-opening talk with one of my mentors, a prominent surgeon in Houston, “You need to see Medicaid to see the complicated cool things.” Definitely agree with that.
  • What is cultural competence? I have been trained extensively in the concept of ‘Cultural Competence,’ possibly moreso than some of my colleagues. My undergraduate college in San Diego, CA was focused on Social Justice and inequalities including a mandatory class titled “Dimensions of Culture” in which my Puerto Rican PhD Candidate T.A. would often discuss the nuances of vernacular in describing race: “White” vs. “Caucasian,” “Colored” vs. “Person of Color.” In medical school, I learned that in New Orleans, LA people do things different: They “make groceries,” or only care about “where did you go to high school?” When I moved to Houston, TX I found out that there are some Hispanic/Latino cultures that truly believe dunking their child in rubbing alcohol is the best natural remedy for illness, that’s what grandma did afterall… But, have I been trained in the culture of the Stepford Wife? The realm in which money isn’t a question? Where lululemon and flat whites dominate? I’m not used to “money doesn’t matter.” I’m not used to, “Oh, they own this entire company,” or “You see that huge building? Yeah that’s them.” I’m not used to, “They went to the specialist anyways before even coming to see us.”
  • “Doctor, I’m here for your help. But, if you don’t do what I want, I’ll find someone else that will.” The reality is, simply put, that money is important in private practice. And patient satisfaction leads to money. Especially in the time of COVID-19 when revenue has taken a large hit in the entire Pediatric market, money matters. Private practice, is all about patient satisfaction. Sometimes this gets dangerously close to the principles of medicine and “doing no harm” but also is supported by patient “autonomy.” I have been trained to do the right thing, and I constantly try to check myself and practice this way. This may mean NOT prescribing antibiotics, it may mean NOT giving in to a patient asking for lab testing, it may mean I recommend something that someone does NOT like. However, this has caused problems. I have recommended a newborn baby I was concerned about being SEPTIC go to the Emergency Room, mom refused and they went home. I have recommended AGAINST antibiotics for a virus, mom gave ‘leftover’ antibiotics anyways. People transferred to other clinics, maybe due to other things – I never ever said I was perfect – but sometimes I’m sure because I didn’t give them what they wanted. What were the consequences of not fulfilling desires materialized by Google and Pinterest searches? I was almost prematurely terminated due to losing business. Now, I am in no way, shape or form saying this does NOT happen in Medicaid populations or in medical training or that these challenges are not more complicated, but private practice medicine is certainly far more consumer-driven.
  • Guidelines vs. Necessity. I follow AAP and CDC Guidelines. This goes for routine screening, standard vaccination schedules and counseling methods. I’ve learned that in private practice, if it doesn’t pay, it’s not a good business deal to spend time with some of these issues. If there isn’t reimbursement for the time or the screening, is it truly necessary? Truthfully, maybe it isn’t necessary to get a cholesterol level on an otherwise very healthy 10 year old – or maybe a familial condition is missed. Maybe a teenager will be forthcoming with personal issues in front of their parents – or more likely, herein lies the nidus of problems like teenage pregnancy, mental health issues or school-wide vaping epidemics. But, i’ve learned that a guideline, is simply a guideline, and great care isn’t always the same as profitable care.

In the end, I DID enjoy meeting this population and taking care of their children. Families were in general nice. I learned just as much about cultures and Pediatrics here as I did with my ethnically diverse population in previous training. But I acknowledge fully that I wasn’t ready for some of these issues in Private Practice. I wasn’t ready to make decisions based on what would keep people happy, otherwise I could put myself out of business. I wasn’t ready to face totally different medical diagnoses that were seemingly separated by the question of whether or not someone had private insurance. I was taught to deal with those that don’t have much, but not for those that have seemingly everything – now don’t get me wrong, this has huge advantages and it was really nice knowing that most of the time my patient was going to get the help they needed because money wasn’t an option. I wasn’t ready for some of the overly educated or privileged that found their Google searches backed by their advanced degrees to be more significant than my decade in medical training. My training designed me as a provider for those that often needed significant guidance and help, not those that wanted me to guide them only when they wanted to be guided.

Now, the elephant in the room which I will only mildly address is the racial/socioeconomic differences found in predominantly private practice vs. Medicaid populations. This is, to many of us (especially people of color and medical professionals), an obvious connection and problem. Race/demographics is possibly the biggest contributing factor to the above statements; however, I have intentionally not addressed this specifically here due to the ‘colorblind’ issues many struggle with that will lead to an automatic refusal to entertain the rest of the post. I have learned moderation and non-extremist viewpoints is the only possible way to encourage change.

I am aware that NOT all Private Clinics or suburban populations are like this. I am aware that I had a very specific focused view on this one small homogenous population. But, I am also very starkly aware now of how these differences were not things I expected in medical training. All I know is that now I have dipped my toes into this Brave New World, and am ready for the Next.

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