THE LOCAL MEDICAL DOCTOR (LMD) HAS COME A LONG WAY

The Indiana University School of Medicine in the 1960’s was in Indianapolis, the capitol city in the geographic center of the state. Its main objective was to train physicians who would ultimately practice in Indiana, but it also functioned as a referral center where doctors around the state sent their patients for specialty care. Unfortunately, the residents, interns, and some faculty of the medical school had a very low opinion of the physicians practicing out in the communities. When a patient with a serious problem was referred to the school for care, the attending staff called the referring doctor “the LMD—local medical doctor,” and chronicled all the errors the LMD had committed in his care of that patient. 

It was very belittling, in my mind, because the local doctors were portrayed as barely competent and not capable of diagnosing complicated cases. They had to be bailed out by he “ivory tower” physicians in the big city. These LMD’s, however, had largely the same educational opportunities as those who were claiming to be experts. I thought it was disrespectful of physicians who were doing the best they could with limited resources. This shaming was so common I know it had the long term effect of discouraging doctors from choosing primary care and rural locations as a place to set up a practice—the opposite of the desired result. 

Academia has long held a dim view of private practitioners. They think of them as just being in it for the money and that they are money-grubbing. Nothing could be farther from the truth. Money, or lack thereof, is the reason so many doctors are leaving private practice. This mini-post serves, then, as an introduction to information on private practice, and the many reasons  why a lot of doctors are still trying to make a go of it. 

Money is a big factor, yes, but not in the sense that primary care doctors are being paid too much and getting rich. On the contrary. Medicare reimbursement is lower every year, and has reached the point of ridiculousness. So it’s not money. Many psychosocial factors play in to staying in private practice. The number one psychosocial reason is autonomy. The ability to be your own boss, work at your own pace, and decide who is and who isn’t your patient, is a huge privilege. Plus, not being bound by productivity quotas where someone looks over your shoulder to be certain you’re earning your keep. 

Second is the ability to develop deeper relationships with your patients and get to know them better. As well as being able to tailor patient care in the way you choose; not by some strict protocol you had no part in developing. Thirdly, you have the flexibility to create your own culture and run your practice in a traditional manner. It’s your business and should have your personality stamped all over it. And last, maintain your practice communication, continuity, and advocacy just as you always have; you “do your own thing.”

Still, you have to make a living and pay overhead, and that has become harder and harder for private practitioners. You can control costs somewhat, but the reimbursement for services rendered is totally out of the physician’s hands. Medicare controls that. Medicare pays only the amount they approve and nothing more, regardless of the charge. They, then, control a practice’s revenues which are more limited every year. 

So, the so-called LMD out in a rural area, does his best to stay in business. Over the past 60 years, the image of the floundering, hapless, barely competent, disheveled country doc has been replaced by the residency-trained, knowledgeable, engaged physician who chose to practice in small-town, USA because he/she wanted to make a difference for the locals. No longer is there a reason why academia should look down on the LMD. If anything, they should be looked up to with respect and admiration for the myriad of problems they encounter, the breadth of knowledge required to perform competently, and the capability to provide the variety of services they do. 

Reference: Buchfuhrer J, Bose N. What Keeps Rheumatologists in Private Practice? Hint: It’s Not The Money. Medscape 2025 December 24.