Conscious Choice: Bigger is Not Always Better Served

November 2001

Bigger is Not Always Better Served

by James Faber

Joseph Lee is an Illinois State licensed traditional Chinese medicine practitioner with an office in Westmont. Lee has no staff. Instead, he handles every aspect of his practice — from answering the telephone and setting up patient appointments to treating and billing his patients — on his own. A typical work day lasts about twelve hours, but Lee wouldn’t have it any other way.

"It’s a lot of hard work, and the hours are long, but I can’t complain because there are patients to treat," says Lee. "If you have patients to treat, that’s something to be grateful for."

To Grow or Not to Grow

At one time or another almost every business is confronted with the decision whether to grow larger or remain at its current size. This decision is no different in the healthcare industry; many integrative care practitioners face this very dilemma.

There is no doubt that the integration of conventional and alternative medicine is the wave of the future in healthcare. In 1998, an entire issue of The Journal of the American Medical Association was dedicated to alternative medicine. It included the results of a study conducted by David M. Eisenberg, M.D., of Beth Israel Deaconess Medical Center in Boston. The study showed that four out of ten Americans used alternative medicine therapies in 1997, while total visits to alternative medicine practitioners increased by almost 50 percent from what they were in 1990. In fact, they exceeded visits to all U.S. primary care physicians.

With such growing demand for more healthcare options, especially for ailments that conventional medicine has traditionally failed to treat successfully, integrative care practitioners have found more opportunities to join larger practices, often within a hospital setting. Yet there remain many who prefer to operate within a smaller practice. We asked some of them why they’ve made that choice.

Feeling Safe and Comfortable

Dr. Connie Catellani is an integrative, internal, and family medicine physician practicing from a small home office in the Chicago suburb of Skokie, Illinois. Dr. Catellani has one assistant to help with the administrative tasks, and also works one day a week at WellSpring Integrative Medicine Center in Evanston, Illinois.

According to Catellani, working in a small practice provides several benefits to a doctor or practitioner, but perhaps the biggest benefit is to the patient. One advantage Catellani says a patient has in a smaller environment is the feeling of being in a more relaxed and comfortable atmosphere than a larger office affords.

"The few times I’ve been to doctors’ offices, I’ve been personally struck by how impersonal it feels," says Catellani. "It can be disheartening to be in a crowded or less-than-clean waiting room with a harried staff, then be squeezed into a tiny room to wait for a long time only to be seen very quickly then rushed out. I think all of these things may take away from the quality of care."

This relaxed feeling, combined with the fact that Dr. Catellani is able to spend more time with each individual, also helps the patient to more freely discuss their problems and concerns.

"If people don’t feel like they have to say everything to the doctor in three minutes or less, I think I’m able to get to the bottom of what’s really bothering them much more quickly and efficiently than when they’re in a tense situation typical of a doctor’s office," she says.

Lee feels an important aspect of a smaller practice for him is the opportunity to get to know his patients. The more the doctor or practitioner becomes invested in the patient’s care, the more the patient benefits.

"I think the patient is better served in a smaller environment because the doctor or practitioner deals with the patient in more of a closed system," says Lee. "If you have to see a hundred patients a day, there is simply no way you can know the patient well."

Dr. Nicholas LeRoy is a chiropractic physician with a degree in Oriental Medicine and the director of the Illinois Center for Progressive Medicine in Chicago, which consists of an assistant and four other practitioners.

Dr. LeRoy also feels that being in a smaller practice enables him to have more intimate interaction with his patients. At the same time it eases the stress of having to see as many patients as possible, which is typical in some larger practices.

"I normally spend an average of one hour with each patient," says LeRoy. "In a larger practice, there’s pressure to see more individuals. I like the fact that I’m not pressured into seeing a lot more patients."

Another advantage of working in a smaller practice, according to LeRoy, is the direct control he has over patient care. When LeRoy began to combine different treatments such as diet therapy, herbal therapy, and a variety of different diagnostic tests, he found that he didn’t need to rely on the other practitioners as much.

"I find that there’s an advantage when I coordinate the treatment myself," says LeRoy. "Rather than losing some of the coordination of care, by doing it myself, I have better control and I understand better where my patient is going with therapy."

According to LeRoy, in at least one of the larger centers where he has practiced, when a patient would get referred to one of the allied practitioners, the original referring doctor was not able to effectively track what was happening when the patient was not directly under his care. The situation would then become further complicated when the allied practitioners began making referrals among themselves.

"In a busy clinic, it’s almost impossible to keep track of therapy that’s being directed by the allied practitioner," he says.

The "Bigger" Advantage

While working in a smaller practice does have many advantages, there are also some disadvantages. Handling insurance is often a complication that small practices prefer to avoid. Dr. Catellani and Joseph Lee both require their patients to pay for services up front, which may turn some people away.

"I think it’s certainly possible to lose some patients whose insurance never reimburses anything," says Catellani. "I’m sure that influences them not to come to a practice like this." At the same time, she points out that if the average person who goes to an HMO gets twenty minutes for a new visit, and seven to ten minutes for a follow-up, her average new visit is an hour to an hour and a half, and the follow up is forty-five minutes — so although the prices seem high compared to an initial HMO visit, the price per minute is actually less expensive.

"I think that the vast majority of people who do this kind of care feel like there is a bigger investment in time and money for the patient initially, but over the long run, the payoff is amazing."

The payoff Catellani speaks of is fewer visits to the doctor, which is her bottom line — enabling people to maintain their own health.

"The thing I tell people who are hesitant about the cost is that my goal is to make it so they hardly ever have to see me," says Catellani. "My hope is that after a patient has worked with me for six months to a year, I won’t see them because they won’t be sick anymore. Or if they do get sick, nine times out of ten they’ll be able to handle it by themselves."

Lee claims money is not as much of an issue with his patients as is the success of the treatment itself. "Most of my patients have seen other doctors, but for whatever reasons the treatment hasn’t worked, so it’s not a matter of money, but, does it work?" says Lee. "If you’re suffering enough, you’ll worry about the money later. If the treatment doesn’t work, it doesn’t matter if it’s free or not."

Dr. LeRoy is a primary care physician for HMO Illinois, and PPO provider for Blue Cross/Blue Shield, but with all other insurance companies, his patients pay cash at the time of service. As a courtesy, LeRoy then submits the claim to the insurance company, who may then reimburse the patient. "It’s better for cash flow that way," he says. "It’s difficult when you’re in a small practice if you’re waiting for an insurance company to pay."

Another disadvantage to smaller practices is public perception and name recognition. Some patients assume a larger practice is more credible, while smaller practices also have a more difficult time accessing the public. "Patients have a tendency to look at large facilities and think that the care they’ll receive there is going to be better than care from a single individual or several individuals who are working on their own," says LeRoy. "The large practices are also able to do more advertising and get more visibility. When you’re in a small practice, fewer people know who you are and where you are."

Drs. LeRoy and Catellani have both been part of larger practices in the past, and as much as they enjoy practicing in a smaller setting, there are still particulars they miss about being part of a larger group.

"The best part of being in a large practice was the camaraderie and the opportunity to interact with people who were doing similar things on a day-to-day basis, and to be able to compare notes on different clinical situations that were challenging," says Catellani.

The interaction between colleagues is something that LeRoy also misses. "I’ve found that socially, a large practice provides many opportunities to interact with a variety of practitioners and people," says LeRoy. "You don’t see that as much if you’re on your own and in an individual practice."

On the other hand, Joseph Lee has been invited to join larger practices, but is not interested. Lee says there were too many conditions, and he felt he would have ended up spending more time talking to other practitioners than treating his patients.

Is Smaller Better?

There are many factors to consider before making a decision on which type of healthcare is appropriate. Some people prefer a large center with many integrative practitioners, while others may be more comfortable in a smaller setting. In the end it’s all about having the freedom to choose the best possible care. To Lee, that freedom is an integral part of a smaller practice.

"If you work within an organization, they may have a set of rules that may or may not agree with your concept of healing," says Lee. "If you’re on your own, at least you can do what you feel is best for the patient."

Resources

Joseph Lee, 630-325-9888

Dr. Connie Catellani, 847-673-5300; at WellSpring, 847-733-9900

Dr. Nicholas LeRoy, 312-456-3000, ext. 210

Recommend this page to a friend

Top Ten pages recommended to friends: