Before I start I would like to thank the people that called, e-mailed, or wrote to express their support after reading about my plans. That column, which, among other things, expressed my frustration with the current structure of medical economics and the effect of this structure on health care delivery, caused the greatest response of any of my columns by far—apparently touching a nerve in many physicians. The support, which came mostly from senior physicians who remember how things used to be, was very helpful during the times when fear threatened the confidence of my convictions. The letters helped me realize that I am not doing anything that has not been done before; in fact, quite the opposite—I am doing what always was done before.
And so, more than a year ago I began. I found an empty shell of a space overlooking a wooded lot, signed a 5-year lease, and sketched plans for the layout of my new office. My residency rotations and personal experiences with psychiatrists gave me some idea of what I wanted, including a nice view, enough room for a couch and chairs, and an exit hallway that bypassed the waiting area to provide a greater degree of confidentiality. I bought a few Web domains and learned to make a Web site, eventually choosing fdlpsychiatry.com over dsmv.com for my main Web presence. My wife (now my business partner) applied her skills in business, decorating, and marketing, just as we had proposed more than 20 years ago during one of those "what if" discussions when stressed but excited couples try to look beyond medical school. Before too long, I was sitting at my new desk, excited that it was mine, and worried that nobody would make an appointment and help me pay for it.
A variety of work
I planned to find a regular source of income that would pay the bills while I waited for the practice to build to a sustainable level. Conveniently, I live a few miles up the street from the Taycheedah Correctional Institution, Wisconsin's only maximum security women's prison. Many states, including Wisconsin, are at a crossroads for providing mental health services for prison inmates. An aggressive effort is under way to improve the quality of mental health care in the prison system, and one outcome of these efforts is the need for more prison psychiatrists.
I had mixed feelings about taking such a position; my perception of prison medicine was not entirely complimentary, admittedly a perception that was not based on anything that I could specifically identify. Perhaps the negative perception was a natural reaction to considering a mysterious and closed place that contained the people that society chose to avoid. At any rate, the prison position turned out to be a godsend, because it allowed me to set my own schedule and to work whatever number of hours I wanted to work. These are 2 wonderful elements in any job, but particularly helpful when setting up a solo practice. For my purposes, the prison work fills Monday and Friday.
I would like to write about my prison experiences at some point, but to do so will likely require permission from multiple levels of bureaucracy. For now, suffice it to say that the work is incredibly challenging. Picture your most frustrating patients with Cluster B features, multiply by 400, and then divide by 3 part-time psychiatrists. There will be more psychiatrists coming, but I expect that the demands of the patients will grow to fill the number of appointments available, given the abundance and nature of Axis II diagnoses.
Wednesday has become my favorite day—the day each week when I leave town for Milwaukee to lead a group of first-year medical students, and to sometimes visit with former colleagues still in residency. I also teamed up with a psychologist who has a significant solo practice in the area and whose philosophy about third-party payers matches my own. His patients are a different population from those of my solo practice; they are spending time and money for weekly psychotherapy, and so I think it is a fair observation that they tend to have a higher commitment to getting help and a greater desire for insight into their conditions.
Tuesday, Thursday, and Saturday mornings are reserved for my private practice, and I initially planned to drop one of the other positions when my practice demanded more time, but I enjoy different aspects of each area and I am reluctant to give anything up. I also need to set myself apart from the competition, a group of 5 psychiatrists in the local health network, and so I offer appointments on evenings and weekends. I consider such a schedule to be one of the features necessary to get patients to try someone new, especially when potential patients are so familiar with the competition: there are only 3 other independent physicians in town, and so the county's entire population walks through the doors of the local hospital/clinic megaplex for essentially all of their health needs. I realized at the start that the playing field was not level and that I had to provide something better and emphasize the differences.