Ever since re-starting to get more active on X/Twitter over the past few weeks, one particular discussion has been really interesting to me. It's the discussion surrounding independent medical practice for physicians. This is a major topic and likely the outcome of it will determine the environment in which doctors work into the foreseeable future.
But it is also remarkably complex. Anyone pretending that there is an easy solution likely doesn't grasp the actual circumstances.
In any event, I don't think a problem can begin to be solved until there is an understanding of the issues and barriers at hand. So, I'd like to share what I perceive as the biggest barriers to independent medical practice – defined as a physician run and owned practice.
Biggest barriers to independent medical practice
1. Student debt
Trainees graduate into practice with absurd amounts of debt. Take my story for example. This will only get worse as the One Big Beautiful Bill puts a cap on the amount of federal (and possibly forgivable) loans that medical students can take out. The last thing they want to do is take on more debt to start a practice.
2. High cost of building a practice
This ties into the first point. Building an independent medical practice is expensive. You need an office. Staff. You need an EMR. Supplies. Malpractice insurance. And you need some cash runway until you start to actually make a profit. This all adds up. This barrier typically limits independent medical practice to those with family money or some kind of connection to PE (at which point the practice is no longer “independent.”
3. Risk
I don't have data on this. But the risk of starting your own independent practice is actually probably a lot less than it seems. I'm willing to bet that most doctors who start their own practice actually stay in practice unlike most small businesses which shut down on average more than they stay open. Either way, with high student debt and a high cost of entry (and inherent consequences if the practice does not do well), this is a risk most doctors now choose to avoid.
4. Lack of exposure/education
Running a practice is not always intuitive. Back in the day, most doctors were in independent medical practice. Now the majority are employed. That means that trainees get less and less exposure to the business of medicine and are less comfortable than ever with running a practice. We tend to stick with what we see. So most new trainees who graduate stick to employed practice.
5. Increased regulatory hurdles
Regulations in medicine as a whole are a good thing. I don't think anyone is saying that we should be completely unchecked as doctors. But regulatory burden for doctors has increased exponentially. To the point where it is challenging to make sure all is being followed to the “T” while also being a full time clinician. Even those who could do it often don't want to and thus avoid independent practice.
So, where is the solution?
I don't have one. Honestly, I don't even really have the start of one. However, I do think that independent medical practice should be the future goal for all physicians. We have seen the detriment that private equity and employed based models can have on the quality of medical care. And I say this as an employed physician – I don't think all systems are bad, but many are or can become. So, as a group, we need to make this a priority.
The only thing close to a silver bullet that I can offer is financial freedom. If you are financially free, the risk and practice debt associated with independent medical practice doesn't seem as bad.
That's why on an individual level, achieving financial freedom through these basic steps is the best way that doctors can take back medicine. But, on a systems-wide level, there is still a whole lot of work to do…
I really want to hear what you think on this one! What are the biggest barriers to independent medical practice? What is your practice like? Why did or didn't you go independent? What is stopping you now? Is there a solution on the horizon? Let me know in the comments below!
