Why solo doctors are here to stay

Others build teams, we build collegiality I joined the Primary Care Solo Doctor MIG within the Ontario Medical Association founded by Dr. Cathy Mastrogiacomo in 2018. We have more than 400 members. Some I've met over dinners, others on Zoom. But mostly through our own virtual “Doctor's Lounge,” a chat group of 60 people, using WhatsApp to share practice tips, difficult problems, learning billing codes, and providing collegial support . . . on a daily basis! This engaging little group is representative of the “real” solo doctors today, mostly female, very diverse in ethnic makeup and personality, smart, funny, caring, involved, and yes...terribly stressed at times. The group is egalitarian and mentor one another out of an abundance of talents. In short, not the “Lone Ranger solo docs,” or “Straw Man solo docs” used by those who think we ought to go. Read: The perils of patient portals: lost in translation We attract diverse and vulnerable patients Many of my fellow solos, like me, are multi-lingual, serving ethnic and a high proportion of immigrant families. We know both the ethnic and medical culture our patients came from. We see people who missed out on decades of primary care in their places of origin, others bearing trauma from war and poverty. We talk directly as doctor and patient, not through a lost-in-translator. Teams target “vulnerable populations.” But the vulnerables are too diverse, too spread out. Solos are not looking for targets. We attract like magnets; patients stick to us and we stick by them. I have a few homeless patients who lack internet access, so I text. I knew them and their families before they lost homes. I provide mental health counselling for others who cannot afford or access care, just because we have a history, and have a more meaningful conversation than if I sent everyone to a team social worker. Being able to say, “we have a history" is something hard-won and earned, not something easily replicated or substituted by a “team.” Read: ‘Radical Love:’ Toronto hospice takes new approach to help Toronto’s homeless Solo offices operates on trust over process, personal knowing over infrastructure. My receptionist of 20 years has cumulative knowledge of our patients, enabling her to make critical calls about who is really sick, picking up on who is “not like themselves lately.” People need to ask her only once to get things done, knowing a single person is accountable, not multiple people who forward messages to the next person, or delegate up or down the chain of command. Solos outperform teams A large and well conducted survey was done by the Westview Primary Care Network in Alberta, on 89,000 patients and 10 practices, conducted over four cycles in a nine-year span from 2007 to 2016. When they compared eight practices which adopted the “collaborative team-based care” PMH model, against two solo practices which chose to remain solo, they were surprised: “Results . . . the 2 highest scoring clinics were solo-practice clinics that did not participate in the collaborative team initiative, and the lowest scoring clinic was the clinic with the largest number of physicians” “Conclusions . . . future research should identify . . . factors that explain solo practices outperforming models of team-based care” What?! Solos outperform teams?! And why not. Personally I am not surprised, as a solo doctor with the lowest “outside use” in my FHO of 27 doctors (a FHO is not a “team” by AFHTO definition, but comprise of solo and group practices sharing calls not patients). Number 2 and 3 are also solos. My HQO reports shows very low emergency use. So I am baffled (and offended) when I hear people accuse solo doctors leaving patients stranded when they take holidays, or send people to ER after-hours, as if to imply solos are incapable or irresponsible. We cobble our own teams Some refer to solo doctors as a “uni-professional” model of care. This is misleading. Just because we don't have an in-house physiotherapist, nurse, or social worker does not mean we lack partnerships. We do use our own list of trusted allied health professionals, just no big meetings. It would be nice to have access to admin support, social workerw, IT expertise, and resource navigation, but they don't have to move in with us! I even worked with an NP, investing two years paying and training her in primary care. It ended suddenly when she was hired out by a team with a much higher salary and benefits fully funded by the government, which I cannot match paying by myself. Key funding question Which brings me to ask my colleagues and my government: “Do you support preferentially funding team based doctors, over solo doctors?” and, more to the point, “If Ontario invests $60 million over two years in primary care, should 100% go to teams, and 0% to other family doctors?” Preferentially funding some doctors over others, in any system, puts adverse pressure on the less-funded doctors. So preferentially funding team doctors makes it harder for solo doctors to hire staff competitively and work efficiently. This entrenches two classes of doctors, those co-located in a team and have preferential access to money, resources and help, and the unattached solos who can't access the same. Two-tier doctors, two-tier patients Teams should be measured by how well they serve their communities (such as addiction or homelessness), not by putting the solos out of business using a combination of preferential funding and nice-sounding ideology. If the successful launch of teams is coupled with the conversion or extinction of solos, we will lose even more doctors in this era of widespread doctor shortage (if not to attrition, then to provinces which are more solo friendly). Losing solo doctors in the healthcare work force puts greater strain on us all. But the biggest losers are the patients cared for by the solo doctors. If a two-tier disparity is created between teams and solo doctors, a similar gap opens up in healthcare access for disadvantaged patients of solo doctors. We should promote equity, not widen inequity. Rally for teams vs. rally for all? The politically savvy among us, may realize that it's relatively easy for our government to commit to funding a dozen or two teams, then consider their “fix” done. This allows governments to avoid the more challenging (and impactful) course bringing reforms and benefits for the entire family doctor workforce. If NPs and PAs are to be assimilated into the future of primary care, avail them equitably to team doctors and solo doctors alike! Vision for a diverse family medicine I look to a future where solo doctors co-exist alongside team doctors, equitably resourced and valued, not denigraded nor downgraded as “less.” Solo family practices should be presented as a valuable and viable career alternative. Even if counted as part of a “team,” many of us will still proudly proclaim ourselves as “solo,” practising with small office values, efficiency and quality. Diversity is great for the healthcare landscape, as it is for any ecosystem. Doctors work best and thrive in environments where we feel most fluid, negotiating a personal optimal balance between autonomy and support. We are not all the same. Some solo doctors may decide to join a team. Some team doctors may tire of meetings and team culture and aspire to “go solo.” Teams may benefit doctors in early and late career, where co-location helps one to mentor the other. But it's not for everyone, and not for me. An invitation to collegial support In the meantime, let us value one another's work and vision, even if they are different and divergent from our own. The future is too uncertain to put all eggs into one single basket of vision, (i.e., the Patient Medical Home). Let's keep talking and reaching out to one another as colleagues. For those practicing in a solo or small office in Ontario, consider joining The Primary Care Solo Doctors MIG (add us to your OMA account under “Groups”), or email adamchen@live.ca to join our WhatsApp “Doctor's Lounge." Dr. Adam Chen is a family doctor based in Oakville, Ontario.

Why solo doctors are here to stay

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