“Time off? Surely you jest,” wrote C.K. Hebdon, MD, in response to Physicians Practice’s query about going on vacation. Hebdon is the owner and sole physician at the Center Performance & Longevity in Salt Lake City. An addiction medicine specialist, he says there is no other nearby specialist who can cover his clinic when he leaves, so he rarely takes time off from his practice.

“And if I take a day off, I’m punished by having to fit in that day’s patient load into the surrounding days,” he notes. “Monthly visits and prescriptions must be maintained.”

In Physicians Practice’s 2018 Great American Physician Survey, 29 percent of respondents reported they’re the only physician at their institution. Those doctors are opting for the flexibility and increased freedom to spend more time interacting with their patients, a perk that often comes with a small private practice.

But for solo practitioners, that freedom comes with the responsibility of ensuring revenue levels are maintained and patients can get the medical help they need, when they need it. That can cause solo practitioners to avoid taking time away from the office, which can lead to burnout.

“The fear is, if you’re not there, then you’re not making money,” says David Hicks, DO, who runs West Coast Family Medical Care in Clearwater, Fla. “But your health is more important, and I think burnout is a huge thing for solo practicing physicians.”

Matthew Bates, the managing director of healthcare practice for Huron, a global management consulting firm, relates the story of a solo practitioner who drives to all of his vacation destinations. The doctor plots his course so he constantly has cell phone coverage in case someone at his office needs something.  

“That’s incredible dedication. But he’s 40-something, and he says he’s burning out,” Bates says. “His marriage is struggling, and he’s disconnected from his family. He’s not sure how much longer he can keep going with that lifestyle.”

On the rare occasion Hicks goes on vacation, he carries two cell phones and two smart watches that can make and receive phone calls. That way, he’s always accessible. “I never go anywhere without them,” he says. “Not that they ever ring, but if they do, I have them. They’re just part of me.”

Being completely unavailable to the office isn’t an option for most solo practitioners. Even so, they can strategize ways to physically escape the daily grind and maximize the mental break they get while away. It all comes down to a foundational strength of solo practices: relationships.

Relationships with patients

Erinn Harris, MD, is the entire office staff at Harris Internal Medicine, her micro direct primary care practice in Tyrone, Ga. She maintains regular clinic hours, but when she’s not in the office, it’s closed. Because she and her patients have a relationship built over one-on-one interactions, they understand her need to take time off. They’re even forgiving when she has an emergency and has to close the office suddenly.

That type of patient relationship is common in traditional payer-based practices, too. Because they’ve gotten to know each other over time, patients see those physicians as actual, real people with a personal life. Patients recognize they can often place demands on their physician’s personal time, so they’re usually understanding when their physician wants, or needs, to take some time off.

Deborah Winiger, MD, who runs North Suburban Family Healthcare in Vernon Hills, Ill., says the relationships she has built with her patients cause them to naturally be more respectful of her time when she’s out of the office, so they tend to avoid calling her outside of office hours. When they do, they keep the call brief.

Part of that is the nature of a solo practice. Patients know that if they leave a message with a solo practitioner’s office, they’ll get a call back the next morning, which isn’t always the case with larger group practices.

Most solo practitioners work hard to accommodate their patients before they leave the office for an extended time. They give patients plenty of notice that they’ll be out of the office, and they often load up extra patients in their schedule before and after vacation.

“Even if I’m gone for the week, revenue for the practice tends to not be down that much, because I end up working harder on both ends of the vacation,” Winiger says.

Established relationships with staff

Life goes on even if a doctor isn’t in the office seeing patients. In his experiences working with healthcare practices, Bates says the majority of phone calls to medical practices don’t require physician attention. The most common reasons for calling are about scheduling, billing, or the nurse desk-matters staff can handle. But for those that require a medical professional, physician assistants (PA) or nurse practitioners (NP) play a crucial role.

“Most of my patients are used to seeing the NP or PA, so it’s not a big deal for them, and it works out really well for me,” Hicks says. “If I want to go on vacation, they have full licensure and the ability to write all the scripts, so I don’t have to worry about that.”

Instead of seeing about 70 patients a day, of which Hicks would see close to half, the office cycles through about 50 when he’s not there, meaning the practice can still earn revenue while he’s away. It’s less than normal, but a more manageable loss of income than if the practice were closed. That also means fewer patients have to wait to be seen or referred elsewhere for care.

But there are limitations to what an NP can handle, Winiger says. “Invariably, something always happens when you’re gone. That’s just the nature of medicine.”

And when those “somethings” happen, solo practitioners need a plan in place. That’s where other local providers can help.

Relationships with other docs

If Harris leaves the country for vacation, she tells her patients about another direct primary care physician nearby who they can see for urgent needs.

That’s another strategy for temporarily cutting the ties from the office: If there are other physicians nearby who provide the same services, solo practitioners can ask them to cover urgent cases.

“In markets where there are other doctors who can cover, what we typically see is an on-call/emergency reciprocal setup,” Bates says. “They’ll refer their patients to another doctor in town who they’ve built a relationship with while they’re gone. Many solo practitioners share call schedules. Then they might agree to use that same structure of sharing patients to help support time off.”

That means the solo practitioner going on vacation now will have to take on more patients when that coverage doctor goes on vacation later. That can make for some busier than normal days as payment for taking a vacation. But solo practitioners understand that cost, and because solo practitioners are usually able to give plenty of notice about a pending vacation, patients don’t expect to be seen while they’re gone. The result is that the additional load isn’t too heavy for the covering doctor. Instead, it tends to be emergency cases or patients who insist they can’t wait until their physician returns.

Before Ronald Krauser, MD, retired from Arthritis Associates of the Main Line in Paoli, Penn., he shared weekend call duty with a local rheumatologist group. The two rheumatologists from that group also covered for him when he took vacations.

The key to a good coverage relationship is flexibility, Krauser says. “I could call them at 5 o’clock and say, ‘Listen, I have to be out of the office the next two days,’ and nobody ever said anything except, ‘OK, we’ll take care of it.’”

Electronic Health Records (EHRs) now allow doctors who cover for a practitioner to have basic patient information at their fingertips. “In the old days, if I was a paper-based doctor, there was no way to get that chart unless I give them the key to my office,” Bates says.

Figuring out how to enable access to that EHR for the covering doctor should be part of any vacation planning, he says.

Relationships with technology

In fact, technology can assist solo practitioners who want to take time off in several ways.

When Harris took off four weeks for maternity leave, patients continued calling her for lab orders or prescription refills. She says fulfilling those needs wasn’t as difficult as she thought it would be.

Physicians can access medical records remotely via cloud storage, so they can order prescription refills and specialist referrals remotely. They can also order X-rays-or even have a patient send a picture of a rash via text or email for a quick telehealth visit. Harris estimates she can handle 90 percent of patient needs over the phone.

“It works out pretty well,” Harris says. “I’m able to handle a lot of things while I’m out of the office.”

Remote working is still working, but it gives providers the freedom to not have to come into the office. Telehealth visits allow physicians to quickly process the one or two urgent items that come in and then log off rather than having to go into the office for a full slate of patients.

Relationships with locum tenens

If all else fails, there are locum tenens physicians. The obvious problem is that the solo practitioner must pay them, so it eats into the bottom line. Plus, it costs time to train locums on office processes.

“Getting a locum tenens is sometimes a pain in the rear because you have to train them on your EHR system,” Hicks says.

Relationships on this smaller end of the practice-size spectrum are especially important, says Alexi Nazem, MD, MBA, a hospitalist with Weill Cornell Medicine in New York City and CEO and co-founder of Nomad Health, an online platform that allows doctors to interact directly with the people who are going to hire them. “If you can build a great relationship with a locum tenens, that doctor can repeatedly cover for you.”

But solo practitioners are often priced out of the traditional locum tenens market, Nazem notes. There aren’t many solutions to that, except perhaps using less expensive agencies or online tools to find a locum tenens.

Another alternative: Hire a retired or semi-retired area physician to cover for you. Ward Paine, MD, is one of the rare solo practitioners who doesn’t answer the phone on vacation. He says he takes vacations to spend time with his family, so he stays away from the phone and office work.

Besides running his own clinic in Morgantown, W.Va., Paine also provides services at the local hospital and a nursing home. When he leaves for more than three days, he hires a semi-retired doctor to help cover the nursing home patients on a locum tenens basis. “He’s someone I know and trust, so I feel comfortable with him,” he says.

Relationships with regular vacations

In a facility with 12 other doctors, taking time off is easy. In a solo practice, you have to be more purposeful, Bates says. “It can’t just be, ‘I’m not feeling good today. I’m going to call in sick.’ You have to plan. It’s harder.”

Let your patients know that you’re planning on being out of the office by posting messages on your front door, on social media channels or practice website, and on the voicemail system. Block out your schedule for that period of time as far in advance as possible and figure out an on-call process and emergency coverage.

It’s more likely that cities and towns that have only one provider will be in a rural area, and for those residents, it’s not unusual to drive to the next town for any number of reasons, including seeing a doctor. Referring them to a physician in the town over while you’re out of the office is part and parcel of living in a remote area, Bates says.

“Telling patients that they will have to drive to the next town over is OK in rural America,” he says. “I think rural Americans are comfortable with that, and they adjust to that.”

In the end, you just have to plan to take time off, and then do it, Winiger says.

“Plan ahead and make it happen,” she says. “And know that even if a patient might be upset because you’re not there that minute, the world won’t fall apart, even though sometimes it feels like that.”

Tips for taking a break from the office if you’re a solo practitioner:

• Find area physicians who can cover for you.

• Make sure you have flexible and up-to-date contingency plans in case of an unforeseen emergency.

• Provide the covering doctor with access to your EHR system.

• Remember you can connect remotely or call staff if necessary.

• Plan to work harder before you leave and after you return to make up for the patients who missed you when you were out.

• Expect that your practice will bring in less revenue while you’re on vacation. Some of the preparations mentioned above can help offset that loss.

Dave Schafer is a freelance writer based in Columbus, Ohio.