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A home office private practice
Written by Jennifer Bremer, MD   

A career at an academic hospital seemed inevitable. After Princeton, I attended medical school at the University of Chicago, did psychiatry residency and child psychiatry fellowship at Massachusetts General Hospital and then affiliated with the University of Chicago Hospitals. My education was peppered with exposure to the academic greats and the opportunities that affords. However, my path suddenly veered when my daughter was threatened by a serious medical concern. Prioritizing increased time at home but wanting to continue to care for my patients, I transitioned to a home office private practice. My child was soon fine. However, mystifying some mentors and colleagues, I continued on this new career path. 

Tremendous advantages for clients were apparent. Patient outcomes simply were vastly better. Admittedly selection bias played a role. Clients functioning at a higher level were more likely to tolerate the setting - no insurance, mandatory prompt arrival, willingness to enter a home. However beyond this, even clients who had previously been followed by me at the hospital grew remarkably better.

Psychiatry practice from a home office
I still wonder why.  I see no research directly addressing this.  I hypothesize that clients paying from their own pocket invest more into appointments and follow recommendations more closely. Or, perhaps, the utmost confidentiality in this setting with only the doctor reaps benefits.  No administrators access records.  No insurance agency reads paperwork -- without direct client input.  Clients communicate with insurance agencies and submit receipts themselves. Perhaps this allows tougher issues to come up more readily.  Or, maybe the easy atmosphere of a warm, clean home with good coffee offers nourishment that the sometimes sporadic comforts of academic settings do not.  

The home office offered a safer place to take on concerns.

Boundary issues not an issue

Those issues that I anticipated would prove problematic simply did not. Boundary issues have not been an issue.  Clients consistently respect my privacy and home.  In order to offer good coverage, I routinely offer clients extensive contact information including cell/work phone, home phone, e-mail address, vacation numbers.  I ask clients to call promptly for any concerns, questions, side effects, or new symptoms.  I even emphasize that I never get annoyed at a call. Yet, I have not received frivolous calls.   The calls are appropriate and allow prompt attention.  Sometimes clients do call me with unrelated medical concerns because I am more available than their other doctors.  But this adds to my awareness of their general health, so I do not see this as a problem.  Clients have called me concerned about lipid levels or headaches or seizures, all of which were useful to know.   And, my work bears on these issues.   Of course, I do refer them then to call primary care physicians, as appropriate.  

In solo practice the sometimes perplexing calls from others’ clients in cross-coverage are completely avoided.  And, it is wonderful to cover only very familiar patients.

Keeping up to date 

Staying cutting edge also has proved surprisingly easy.  The home office clinician has advantages prior generations of doctors couldn’t dream of.  The Internet offers easy access to top experts worldwide -- via publications, Internet lectures and e-mail addresses. Access to the medical school library buildings is simply no longer necessary.  Grand rounds and other educational lectures often are online. There may even be advantages to Internet education as it allows the viewer to backtrack and repeatedly review complicated material or to skip over parts that the clinician already knows.  Educational websites like Medscape or professional physician resources like NetDoc consolidate resources.  And virtual communities like Facebook, Linked In or Twitter allow readily increased communication with remote colleagues.

Even juggling office paperwork now is smoother with the advent of I-phones, blackberries and financial computer programs. Recently I have further eased paperwork and opened lines of communication with my professional blog (http://drbremer.blogspot.com). On the blog, I offer my perspective on data and provide patients with links to medication information guides, recommended books, handouts on asthma monitoring, blood pressure norms, growth charts, mood charts etc.

Conveniences of home

Home office appointments are congenial.  While my office is near the front door allowing a slightly more formal atmosphere, patients know they are entering a home and seem grateful for the hospitality.  The home office offers a warmth which is not always present in hospital settings and which I do not see subtracting from therapy’s benefit. They pay promptly and on time without any billing service.  Generally, patients attend appointments on time and pay for missed ones without complaint.  During winter, clients frequently take off snowy boots even when I tell them there is no need.  Before a rare client eats in the office, he or she inevitably asks if I mind.  Similarly, I can offer more human kindness in a variety of ways.  When an elderly patient was in bankruptcy, I could treat her with no charge without a second thought.  I have the option to offer sliding scale fees as I see fit.   And, when a client called in tears with a family emergency, she  could come immediately and see me -- not a covering doctor -- as I am always “at the office.” Or, when my eating disordered patient was faint with orthostatic blood pressure, I readily can use my family’s juice or food prior to sending her for medical attention.

Of course, the endless flexibility and increased home time -- which motivated the home office setting in the first place -- are as priceless as I’d hoped.  These have allowed me to maximize both my time in clinical care of patients as well as parenting. No time is wasted on a commute, administrative meetings or non-essential paperwork.  Days off for appointments or vacations are readily scheduled, without a need to juggle others’ schedules.

Downsides do exist

Naturally, there are downsides.  There is no easy back up.   The set-up would not suit a far-flung traveler.  The ability to have consistent phone contact is a must.   There is no informal collaboration with a colleague between appointments.   And, while the avoidance of the hospital’s overhead allows a good income, there is additional stress in managing malpractice insurance and in having an income which can vary from month to month.  And, there is no administrative team to help with the endless bureaucracy of being a doctor --  keeping medical licensure up to date, prescription certificates current or continuing medical education hours recorded.

About the Author

 
Dr. Bremmer is a psychiatrist based out of her home in Chicago, Illinois.  Dr. Bremer's blog touches on a host of topics, from parenting to pharmacotherapy to general psychiatry.

 
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