Introduction

As more health care practitioners accept positions within large health care entities, such as hospitals, the number of physicians in solo practice is diminishing at a rapid rate. Solo-practice physicians are less likely to have a colleague to consult with and often go without a support system for the growing administrative demands they face in our complex health care system. The end result is that these physicians may experience more stressful work-place conditions — putting them at greater risk of errors and burnout, which in recent years has become a serious workforce issue.

The Washington Medical Commission (WMC) is evaluating the alarming rates of physician burnout and adverse events and their prevalence among solo physicians and is actively considering a variety of interventions aimed at reducing the potential for burnout among the state's licensed physicians. As a part of this effort, the WMC used the Gallup Q12 Employee Engagement Survey, which has been a commonly used standard for measuring employee engagement since the late 1990s, as the foundation of a solo practitioner survey. The WMC-adapted survey aimed to better understand the attitudes solo physicians practicing in the state have about their practices and practice settings. This summary of the project highlights research results and describes some of the strategies and tools that can help reverse the impediments and challenges associated with solo medical practice, and in turn potentially impact rates of errors and physician burnout.

Solo-Physician Demographics in Washington

In Washington, there are no significant differences in the overall demographics of physicians practicing in group-settings, compared to those practicing solo. Of the differences that do exist, the most notable are that solo practitioners are, on average, nine years older and tend to specialize in psychiatry rather than family medicine.

Burnout Across Specialties: Identifying Which Solo Physicians Are Most at Risk

There is ample data indicating that burnout among physicians is on the rise.1,2,3 Factors contributing to burnout include excessive caseloads, negative workplace culture, poor work-life balance or perceived lack of autonomy in one's work. Burnout among physicians may lead to unprofessional behavior and medical errors. Burnout can also affect the relationship and trust between physicians and patients. Figure 1 provides examples of national burnout rates in several specialties and the percentage of Washington physicians who are engaged in solo practice within these specialties.

Figure 1.

Burnout Across Specialties

Source: Medscape National Physician Burnout and Depression Report 2018, accessible at https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235#1.

Figure 1.

Burnout Across Specialties

Source: Medscape National Physician Burnout and Depression Report 2018, accessible at https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235#1.

A strong effort is under way among medical boards and the Federation of State Medical Boards (FSMB) to raise awareness of, and address, physician burnout. However, very little information is available about burnout among solo practitioners and the unique challenges their practices face when implementing the various strategies available to address burnout. For example, a solo-practicing physician may not be able to close his or her practice even for a day in order to attend a mindfulness seminar aimed at improving well-being.

In Washington, urologists (1% of Washington solo physicians) and cardiologists (2% of Washington solo physicians) are among the specialties least likely to seek professional help for burnout.

On the other hand, psychiatrists, who make up the majority of Washington solo-physicians, are statistically more likely to seek help (Figure 2).

Figure 2.

Specialties Most Likely to Seek Help for Burnout

Figure 2.

Specialties Most Likely to Seek Help for Burnout

As a part of its effort to better understand and address the issue of burnout among solo practitioners, and taking into account survey results, the WMC is making a special effort to reach out to psychiatrists.

But it is also reaching out to a wider cross-section of other targeted solo practices — including solo urologists, cardiologists, family medicine and internal medicine specialists — in order to provide broad support and resources across professional categories.

Solo-Practitioner Survey: Helping Determine Levels of Engagement and Motivation

Research shows that physician engagement and motivation are key indicators for positive outcomes in practitioner health, patient satisfaction, productivity and profitability.3,4 Using the Gallup Q12 Employee Engagement Survey, the WMC sought to learn more about how the engagement and motivation of solo physicians in Washington might be impacted by conditions in their practices and practice settings.

In the WMC survey, three key questions were asked of solo-practice physicians in an effort to better understand their level of engagement and motivation:

  • Do I have the opportunity to do what I do best every day?

  • In the last week, have I received recognition, praise or acknowledgement for doing good work?

  • Is there someone at work who encourages my personal and professional development?

Physicians whose answers to the questions (Table 1) regarding their level of engagement and motivation were generally negative would be, according to research,3,4 less likely to achieve higher satisfaction from patients and staff, or to sustain optimal patient retention and productivity.

Table 1

Solo Physician Attitudes Toward Practice and Practice Setting

Solo Physician Attitudes Toward Practice and Practice Setting
Solo Physician Attitudes Toward Practice and Practice Setting

Patient Safety and Malpractice Implications for Solo Practitioners

Patient safety and quality improvement (PS/QI) initiatives have rapidly proliferated through all fields of health care.5 Harnessing these initiatives provides an opportunity to systematically evaluate and disseminate best practices and to evaluate their effect in improving value for patients. However, small practices are less likely to participate in QI collaboration and may miss out on the benefits QI initiatives provide.5 As changes in health care continue to accelerate, solo practitioners who embrace opportunities to optimize value in their respective subspecialties are more likely to see improved outcomes for their patients and to reap the benefits of a thriving, fulfilling clinical practice.

Both institutions and individual practitioners view the threat of malpractice liability as a significant barrier to error reporting.6 The disclosure could have a double impact, leading the patient to file suit once informed of the error and providing admissible evidence to the plaintiff's attorney. Research shows that of physicians who report being sued, the great majority of malpractice lawsuits are against solo practices (70%) or single-specialty groups (64%) (Figure 3).6 Lawsuits in outpatient settings are commonly due to diagnostic issues, while in the inpatient setting, suits arise from surgical errors.6,7 

Figure 3.

Malpractice by Practice Setting6 

Figure 3.

Malpractice by Practice Setting6 

Strategies for Future Engagement

With the results of its solo-practitioner survey helping inform its decisions, the WMC is considering interventions to reduce burnout in solo physicians, focusing on strengthening organizational capacity for change, such as strong communication, leadership and innovation. A key factor in building effective strategies is understanding the unique challenges that solo practitioners face on a daily basis. One study, for example, noted that it was “really stressful to be a small independent practice because of all the financial stresses. They don't have a big staff to do a lot of the administrative work that needs to be done, and they don't have care coordinators. They might have a medical assistant or a practice administrator. Many didn't even have a nurse.”8 

One potentially promising resource for solo-practice physicians is continuing medical education (CME). Having a regulatory body provide dedicated CME for these physicians can help in subject areas where they may need support. Examples include:

  • Quality Improvement (QI): Understand QI and learn how to implement it to position a solo practice for success in a value-based care environment.

  • Regulatory Compliance: Understand common areas of concern for solo physicians regarding issues such as Stark Law and medical-record security.

  • Medicare Access and CHIP Reauthorization Act (MACRA): Learn about the unique challenges that solo physicians face in navigating the complexities of recent administrative changes to Medicare payment.

WMC data shows that insurance and paperwork requirements are the largest factors contributing to job dissatisfaction for Washington solo practitioners. Regulatory facilitators could help small practices make the system and workflow changes that are necessary to adopt new technology and improve quality of care for patients — by reducing or eliminating the additional work that is often seen with paper-based practices and outdated electronic medical records, for example.

Mentorships can also be a valuable tool, enabling solo physicians to deliver the highest quality of care while remaining financially viable. Mentorships among physicians encourage discussion and communication regarding best practices as a solo physician. Regulatory bodies can encourage these mentorships by holding meetings or facilitating conversations between solo physicians in different areas. A simple introduction of two physicians can create a mentorship opportunity. Mentorships can also be a conduit to on-the-job training. Connecting physicians with local community colleges and trade schools can create an opportunity for students in health care-related disciplines to work closely with a physician, while also helping reduce some of the administrative burdens solo physicians face.

Community health workers — trusted laypeople who help their communities achieve health and well-being — are another potential resource for solo-practice physicians. Community health workers are found in a wide range of U.S. settings, including in rural, urban and metropolitan areas. Although their roles vary depending on location, they generally serve as a liaison or intermediary between health care or social service providers and the community, facilitating access to services and improving the quality of service delivery. In the communities in which they work, they often form a larger partnership structure known as a community health team. These individuals and teams have been catalysts for improving health care and incorporating social determinants of health into health care. Regulatory structures can help facilitate this model by creating a blueprint for operational oversight. State medical boards can assist in establishing partnerships between solo physicians, clinics and community health workers to achieve quality, patient safety, utilization and cost objectives goals. These partnerships can help lighten the burden that solo practitioners carry in their day-to-day operations.

Conclusion

As regulators, we need to ensure that we are offering assistance and resources to solo physicians, who provide a valuable service, especially in rural and underpopulated areas. A lack of support for these physicians may escalate the decline of solo practices and impact access to and quality of care. State medical boards facing these circumstances in their states should consider interventions aimed at meeting the needs of solo physicians, with a focus on reducing their likelihood of experiencing professional burnout.

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About the Author

Jimi Bush, MPA, is Director of Quality and Engagement at the Washington State Medical Commission.