Hanging Out A Shingle

The Business Diaries - Part 1

Back in 2006, when Rachel and I founded Westside Family Medicine, we were blissfully ignorant of what it would entail. 

At the time, we were both working as teaching attendings at the Columbia Family Medicine Residency, with me in charge of the hospital service and Rachel on faculty teaching obstetrics and women’s health.

We had three little kids by then, and it was a pretty good life. 

The hours were reasonable, the work challenging and interesting, the teaching fun and often inspiring. Our colleagues were great, and there were a lot of benefits that came along with working for an big institution like Columbia.

But there’s something about perceiving a need that you are uniquely positioned to fill that shakes up the status quo.

In our case we looked around our neighborhood of Morningside Heights on the Upper West Side, and noticed a definite lack of good, affordable primary care for people with private insurance. Furthermore, when it came to Family Medicine in particular, there was nothing as far as the eye could see.

The difference between Family Medicine and primary care as it is practiced by other specialties is a subject for another time. But in a nutshell, Family Medicine is the specialty of primary care, whereas Cardiologists, Pulmonologists, or OB/Gyn’s generally practice primary care as a sideline to their main specialty. Even General Internists have a much more limited scope of practice that excludes pediatrics, women’s health, and sometimes even mental health.

This has implications on both sides of the equation. On the one hand, it means that a Family Medicine doctor won’t overly focus on one organ system; on the other hand it means that you can go to a single Family Medicine doctor for problems as varied as depression, shoulder pain, COVID, a pediatric checkup, or a pap smear.

The upshot is that you are less likely to be overtreated, less likely to be undertreated, less likely to be referred out for every little thing, and more likely to develop a deeper, more personal relationship with your physician.

In those days, urban Family Medicine was mostly limited to academic medical centers and Family Health Centers. But that left out a lot of patients - including all of those who got medical insurance through their employer. We wanted to bring Family Medicine to that group.

So we decided to hang out a shingle. 

This idiom originated in 19th century America, when professionals would paint signs on house shingles to advertise a new practice, usually run out of the home. It mostly pertains to medicine and law, but can be used to describe opening almost any kind of small private office or business.

I love the expression because of how well it describes the attitude. 

As far as most professionals are concerned, the hard work is in the schooling, the training, and the practice. If you are good at that, then the business part should be as easy as, well, hanging out a shingle.

Too bad it’s not.

I remember having dinner in Florida with my brother, Peter, an executive coach and management consultant, shortly after we decided to take the plunge. 

“Great idea,” he said, “do you have a business plan?”

“Of course we do,” I replied, “our plan is to see patients and have the money coming in be more than the money going out.”

“Very funny,” he said, and pulled out a pen. 

Over the next couple of hours we sketched out the basics, literally on the back of a napkin. I think I still have it somewhere. In fact, while I am not a big fan of business plans, I once had a summer job in venture capital so I am quite familiar with them. 

Compared with those V.C. business plans, I would say that while our napkin had the disadvantage of being short on details, it also had the advantage of leaving out the wildly optimistic projections.

In any case, not knowing what lay ahead was surely for the best. If we had known, we might rightly have concluded that we were totally unqualified for the job.

What did we know about payroll? Nothing. About medical billing? Nothing. About hiring, firing, and managing employees? Not much. About ordering supplies, managing inventory, and negotiating with suppliers? Nothing. 

How about setting up and maintaining computer systems for everything from electronic health records to VOIP phone systems to HIPAA compliant messaging systems? Nothing, and still don’t. Taking out business loans and lines of credit? Maybe a little. Acquiring and renovating office space? Well, there we knew a bit and had my interior designer mother-in-law, so there’s that…

The truth is we had lots of help, financial and otherwise. We both come from big families and are lucky enough to have a social network large and varied enough that whenever we had a question there was always someone to ask. 

And we had each other. Not to get too personal but Rachel and I tend to be on the same page about the big things; have very different but complementary strengths and weaknesses; and are extremely lucky that working together has deepened our relationship instead of driving us apart.

And ultimately, most of the things we didn’t know we were able to learn on the job, although sometimes at a price.

Let me know if you want to hear about the blunders, fiascos, and pitfalls in the various areas listed above, not to mention how we managed existential threats that we couldn’t see coming, like our falling out with the predatory startup Zocdoc, or the seismic quake of Covid (thousands of medical practices were forced to shutter under the stress of the pandemic).

So why persist? Lots of reasons.

For one thing, we wanted to bring Family Medicine to a new population of patients in New York and so we are doing. Our patients, many if not most of whom had never heard of Family Medicine, now understand and appreciate the model. And we love taking care of them.

For another thing, we like being independent. One consolation for having every problem dumped in your lap is knowing that nothing, other than your own creativity and willingness to bear the costs, stands between you and the solution. Or, to be a little less high-minded: we like having no one to blame but ourselves.

I don’t think we are the only ones who feel this way. Doctors are a pretty independent-minded bunch, trained to feel personally responsible for the outcome of every case. That mentality naturally extends to business, where private practice has been predominant structure for decades across most specialties.

So why is private practice disappearing? Why are independent doctors dropping like flies and becoming employees? Why is this process accelerating to the point that we feel like the last of a dying breed?

There are three main reasons, one of them old and perennial, two of them new and structural. 

Interested? I plan for that to be the topic of next week’s post.