When You Close a Practice

by Dave Schuler on February 10, 2014

You know, I’ve been mulling over the phenomenon of physicians’ “closing their practices”, i.e. not taking new patients, and I think it has some interesting implications. Doesn’t the practice mean that

  1. Either physicians
    1. Don’t care to seek efficiencies in how they deliver care or
    2. Are convinced that greater efficiencies in how they deliver care while preserving the standard of care are impossible and
  2. Physicians who’ve closed their practices either
    1. Don’t expect their pay to increase or
    2. Expect to increase their pay by raising their rates.

I suppose an elderly physician, foreseeing his or her retirement, might conscientiously limit her or his practice but my anecdotal experience suggests that’s pretty rare. I’d be interested in other explanations.

Update

Here’s what the AMA has to say about the ethics of the issue:

There are two bases for physicians’ prerogative to choose whom to treat. The first is a general privilege held by all members of society that accords individuals a right to choose with whom to associate. Physicians do not give up their freedom of association merely by becoming professionals. But they do assume certain obligations that place limits on their choices in the context of serving patients. The second aspect of the physicians’ prerogative stems from the notion of professionalism. Physicians are granted enormous autonomy within the context of the patient-physician relationship and this autonomy includes the freedom to choose whether to undertake the treatment of a particular patient. However, this autonomy is not designed to further physicians’ self-interests. Rather it is a necessary element of assuring patients the best possible care. Since medical professionals are trained in a complex body of knowledge, and non-professionals are not able to judge how that knowledge should be applied in particular cases, physicians are often accorded the freedom to make medical decisions on their own—or autonomously. The purpose of the exercise of autonomy in this context is not the furtherance of the physician’s interests, but those of the patient.There are two bases for physicians’ prerogative to choose whom to treat. The first is a general privilege held by all members of society that accords individuals a right to choose with whom to associate. Physicians do not give up their freedom of association merely by becoming professionals. But they do assume certain obligations that place limits on their choices in the context of serving patients. The second aspect of the physicians’ prerogative stems from the notion of professionalism. Physicians are granted enormous autonomy within the context of the patient-physician relationship and this autonomy includes the freedom to choose whether to undertake the treatment of a particular patient. However, this autonomy is not designed to further physicians’ self-interests. Rather it is a necessary element of assuring patients the best possible care. Since medical professionals are trained in a complex body of knowledge, and non-professionals are not able to judge how that knowledge should be applied in particular cases, physicians are often accorded the freedom to make medical decisions on their own—or autonomously. The purpose of the exercise of autonomy in this context is not the furtherance of the physician’s interests, but those of the patient.

On what grounds can the prerogative to choose be curtailed? First, it may be limited by factors such as legal requirements not to discriminate, or requirements for emergency care. Second, the autonomy generally granted to the physician should be limited to the extent that it may only be exercised in patients’ interests and, therefore, there are cases where a physician should decline to take on the care of a patient. limited by factors such as legal requirements not to discriminate, or requirements for emergency care. Second, the autonomy generally granted to the physician should be limited to the extent that it may only be exercised in patients’ interests and, therefore, there are cases where a physician should decline to take on the care of a patient.

{ 13 comments… read them below or add one }

Tim February 10, 2014 at 9:01 am

I actually used to do medical ethics research work, and this topic is interesting from a number of angles.

Note that the last line you quote says “patients’ interests” (identifying patients as a group), whereas almost the professional code of conduct for physicians relies primarily on one-on-one interactions (ONE doctor to ONE patient). The original AMA Code of Ethics was actually organized by reciprocal relationships: Doctor-Patient, Doctor-Doctor, Doctor-Society.

The last one is what physicians are using when closing practices, OR opening a ‘closed’ concierge practice. These practices charge a fee – sometimes nominal, like $100-200/annually, and sometimes $500 a month or more – to get you on their ‘list’ of patients. This puts their practice out of the hands of the vast majority of Americans, though the urban middle class might see this as worthwhile, particularly at the low end.

In exchange, patients are promised more options for visit times (including a promise of same-or-next-day visits), a personal relationship with their physician, and so on.

This is ‘allowed’ professionally because of that last line: Docs can say that it is in the interest of the patients they have to charge that fee, which then gives docs the flexibility to more time with patients (rather than the 20-patients-a-day in 15 minute increments that’s becoming the norm for primary care in this country).

It also means that having insurance isn’t the guarantor of access that it used to be.

Dave Schuler February 10, 2014 at 9:08 am

If I haven’t made my own views clear in the post, I think that the practice is unethical for most physicians most of the time.

PD Shaw February 10, 2014 at 9:30 am

My family doctor is no longer taking new private insurance patients, but he referred me (the odd one out in the family) to one of the other docs in their practice. I think he wants more face time with the patients and I think economizing would require him to sever his relationship with the medical school and he likes mentoring. I would not describe his appointments as leisurely, or terribly personal, but he seems to take his time when there is a student in the room.

Trumwill February 10, 2014 at 9:40 am

The physicians I’ve known about who have closed their practices either did so because:

a) They’re gliding to retirement. A lot of doctors are getting up their in age (one of the factors behind the allegedly impending physician shortage) and/or have enough money that they don’t have to go along with the latest shakeups in how they are expected to practice medicine.

b) Are closing their practices simply because they have a full plate and taking on a whole lot of new patients means that they’d be giving the short-shrift to their current patients (longer wait times, less face time, etc.).

I’m not sure if (b) counts towards what you’re talking about, though, since that’s long been extremely common. Patients build a full practice and then stop accepting new patients.

Trumwill February 10, 2014 at 9:55 am

Physicians build, I mean.

Tim February 10, 2014 at 10:13 am

Dave, I agree that there are serious ethical issues; but there’s a broader one as well.

We simply haven’t trained enough primary care physicians to have adequate care for everyone in the country. Something has to give, and one of the things that will give is physicians being accessible to all.

It’s a sad state of affairs, and an entirely avoidable one (if we had started planning about a decade ago, or more).

PD Shaw February 10, 2014 at 10:15 am

@Dave, did your friend receive referrals to other practitioners? It would seem to me that it would be an implied obligation of refusing a patient, or requiring a patient to see someone else as a precondition to performing services in the first place.

Dave Schuler February 10, 2014 at 10:25 am

No. As it turns out I have some meager contacts in the area which I’ve turned to without an enormous amount of success. The practices they’ve suggested are closed, too.

IMO closing a practice incurs certain ethical obligations that I don’t see being honored.

steve February 10, 2014 at 1:04 pm

There are different kinds of closings. Most of the ones of which I am aware, happen with primary care docs who have too many patients. Accepting more new patients could risk abandonment of already existing patients. In those circumstances I don’t think there is a real ethical problem for the doc. The kind of closing for which I think there are some ethical issues are the ones where they refuse to take any patients with the wrong kind of insurance or no insurance. While I dont think you are morally obligated to take every patient with no insurance, which in theory could lead to negative income, I know we didnt take an oath to get rich. If taking some patients of lesser means results in a bit lower 6 figure income, I think that is what comes with the profession. My practice accepts all comers. To be fair, I can guess I can afford to be a bit self-righteous about this since i am older and have saved enough to retire already.

I suspect that the above piece (will try to read original later) is more about dealing with individual patients. Sometimes you need to terminate a relationship with a patient because you are just incompatible with them. That happens in any kind of service profession. The rules for doing so are pretty carefully laid out (a constant topic in the CME courses).

As to your friend, I would try visiting one of the urgent centers as a patient. If he has insurance like you said, and is a decent person, it is likely that he will be able to get a contact. Lots of the urgent care centers are staffed by PCPs who are covering part-time.

Steve

PD Shaw February 10, 2014 at 1:33 pm

Its a bit of a collection action problem, since I don’t think I personally care too much about someone closing their practice, so long as alternatives are available. I’m not familiar with the situation Dave as described, and I was going to ask some local doctors over the weekend, but it seems to me that physician groups have gotten larger and when they have more work than they can provide they invite someone else into their group.

On further reflection, I think our family doc didn’t want to accept certain types of managed care (HMOs or PPOs), so I guess he was open to new patients, but didn’t want those with more expansive responsibilities with respect to the insurance side.

steve February 10, 2014 at 3:05 pm

PD- The trend right now is to get big. Practices are merging and being bought up. You can invite people to your group, but that doesnt mean they will come. Several groups in my area have been recruiting, unsuccessfully, for over a year. They all want to go to the big cities and/or spouses are a problem.

Steve

PD Shaw February 10, 2014 at 4:25 pm

@steve, I’m just musing on the effect of an increase in groups, effectively reducing personal responsibility.

This is a pretty good medical ethics column that reflects on the challenges of a pending shortage of general physicians, and the ethical obligations of the physician to ensure healthcare for his/her community and the physician’s personality responsibility to family and self.

PD Shaw February 10, 2014 at 4:29 pm

This paragraph in the link touched on the dynamics of groups:

“Evidence presented at the 2008 meeting of the Assn. for Medical Education in Europe suggests that duty-hour limitations have generated a “shift mentality” among residents. Moreover, the current emphasis on team-based health care delivery may be creating a reduced sense of personal responsibility to patients among young physicians in training today. This threat may be real, but it should not deter dedicated physicians from maintaining practices that they can manage effectively.”

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