Doc Bailey was a classic country doctor right out of Hollywood's casting stereotype.  Growing up in a small town in Arkansas, he was the only physician in town, so of course he was in solo practice.  Wasn't that the way doctors worked?  Most of us first encountered Doc without Mom in the room during the annual sports physical at the high school cafeteria, which was unnerving enough on its own, but made a little more so because he did not remove his ever present cigar when doing the exam.

A lot has changed.

But thinking of Doc reminds me of one of the enduring issues in the physician segment of healthcare. 

What is the role of the very small practice?  Can it survive?  Should it survive?  If so, how does it survive?  If not, what should physicians in small practices do?

This is a theme that we will explore from time to time, and from multiple angles, in this space, but first let's start with some data.

The Center for Studying Health System Change is a non-partisan research organization that has conducted an extensive survey of physicians four times over the 13 years and the fifth iteration is underway.  There is a treasure trove of data there.

The chart below is from the HSC survey and shows the number of physicians that practice in a one or two physician setting.  Roughly one third of all physicians fit in this category and another 15% are in a three to five physician group.  So about half of all physicians are in a practice where everyone can have dinner together at one table.  There are a lot of implications for physicians and the healthcare industry as a whole in that one little factoid.

But, as the chart shows, things are changing, at least for one side of the house.  While the number of primary care physicians in the small practices has been relatively stable over the past decade, far more specialists have moved to a different setting.  In fact 12% of all specialists left the very small segment during this time.  About one-third of those that moved went to a larger group setting.  25% went to a medical school, 25% went to a hospital-based practice, and the rest were scattered into various other settings.

There are lots of questions that naturally spring from this set of data.  Why did specialists change so much more dramatically than primaries?  Will these trends continue and where does it level out for the specialists? 

Then there are questions behind the questions. 

• For example, some ask if there is a quality difference between small and large practices.  See here.
• Clearly, there are economic issues when practice size is considered, both for the practicing physician and the industry as a whole.
• Increasingly, some payers wonder if contracting with very small practices is even worth the hassle.
• And of course, at a very personal level physicians have preferences on the setting in which they want to work.

In our continuing quest to help physicians control their own destiny, we look forward to poking into this subject in future posts.  More important, we welcome your thoughts on the subject, be you in a practice large or small.