Christopher Garofalo, MD – Walking Away from Employment: A Practice Owner’s Playbook

Dr. Christopher Garofalo joins Dr. Michael Jerkins for a wide-ranging conversation about a transformation few in medicine are tracking closely—the slow disappearance of the physician-owned practices, and what it means for the doctors and patients left in its wake. As a family physician, longtime private practice owner, and advocate inside organized medicine, Dr. Garofalo has watched the ownership model erode from the inside, and has a clear-eyed view of how policy, private equity, and the insurance industry have reshaped what it means to practice independently.

Dr. Garofalo walks through the levers physicians rarely realize they can pull: how simply showing up in advocacy circles translates into tangible wins like prior authorization reform, why direct primary care is quietly rebuilding a relationship between doctor and patient that insurance long ago broke, and how policies restricting physician ownership of hospitals and surgery centers have quietly tilted the field toward consolidation.

The episode also takes on the harder structural questions underneath the trend lines: What happens to access and cost when monopolies and vertical integration replace independent practices? Why has the dental profession protected ownership while medicine surrendered it? And could AI tools and new financing models finally make private practice viable again for the next generation of doctors?

Throughout the conversation, one truth anchors the discussion: practice ownership is not nostalgia—it is infrastructure. Restoring it is how physicians regain autonomy, how patients regain access, and how medicine regains the room to be practiced the way it was always meant to be practiced.

Here are 5 takeaways from our conversation with Dr. Garofalo:

1.  Challenging the Myth of the Solo Practitioner

The perception that physicians must operate independently to succeed is outdated. Dr. Garofalo emphasizes the power of strategic partnerships and supportive systems in private practices. By collaborating with others, physicians can enhance their resilience and motivation, leading to more sustainable and innovative practices.

2. The Power of Showing Up

Dr. Garofalo illustrates how consistent participation in advocacy efforts can transform potential opportunities into real change. By attending local medical society meetings, he was able to influence policy changes, such as insurance regulations. This demonstrates that being present and engaged can unlock new avenues for reform and progress.

3. Practice Ownership as a Lever for Autonomy

Owning a practice provides physicians with significant leverage and freedom, countering systemic constraints, and reducing burnout. Dr. Garofalo argues that ownership is not just entrepreneurial but essential for maintaining moral and clinical independence. This allows physicians to regain control over their schedules and clinical decisions, ultimately benefiting patient care.

4. Removing Primary Care from Insurance Constraints

Dr. Garofalo advocates for direct primary care models, where the financial and administrative burdens of insurance are minimized. This approach allows for straightforward billing and improved physician satisfaction, making high-quality, patient-centric care more accessible and sustainable.

5. The Future of Practice Ownership for Specialists

Specialties like endocrinology and rheumatology are well-suited for independent practice due to the flexibility of direct care models. Dr. Garofalo highlights the potential for specialists to reclaim autonomy and innovate outside traditional hospital systems, signaling a shift towards more physician-led, patient-focused practice structures.

Transcript:

Dr. Michael Jerkins:

Today on The Podcast for Doctors (By Doctors), we are joined by Dr. Christopher Garofalo, a family medicine physician in North Attleboro, Massachusetts, who also practices obstetrics and co-owns his private practice alongside four physician partners.

Dr. Garofalo is deeply active in physician advocacy at both the state and national levels. Nationally, he serves as an AMA delegate for Massachusetts and is a member of the AMA Private Practice Physicians Section.

In Massachusetts, he sits on the House of Delegates, serves as treasurer in his district, and is a member of the Committees on Finance and Legislation and the Board of Trustees. For the past eight years, he has chaired the Committee on the Sustainability of Private Practice, working to build and protect an environment where physician-owned practices can thrive.

Welcome to the podcast.

Dr. Christopher Garofalo:

Thank you very much, Michael. I appreciate the invitation, and it’s really an honor to be here with you. Thank you.

Michael Jerkins:

Absolutely. Even from your introduction, listeners can tell how much extra work you put in to help move things forward for physicians and practices. Can you tell us a little bit about how you find the time to own a practice while doing all of this advocacy work? And what really drives you to advocate for physicians and their practices?

CG:

I have the time to do this because, as you mentioned, I have four physician partners who all co-own the practice. I don’t know that I could do this if I were a solo owner. They’re all wonderful, and we divide responsibilities within the practice. We don’t all have to wear every hat—we just have to wear some of them.

One of the hats I wear is advocacy. That’s part of what I do for the practice. I’m always talking to my partners about upcoming meetings or discussions I’ll be having with organizations like the Division of Insurance. I’ll ask them what issues they’ve run into recently with prior authorization so I can bring specific examples to those conversations.

My family is also very supportive. My wife is a family physician as well and owns her own direct primary care practice. She doesn’t have much interest in advocacy herself, but she’s incredibly supportive of the work I do.

I came to advocacy a little later than many of my peers. In the AMA House of Delegates, you’ll see people my age—in their mid-50s—who have been involved since medical school or residency. I didn’t get involved until about 12 years ago.

I became increasingly frustrated with the direction medicine was heading and how difficult things were becoming for both patients and physicians. One day, I simply decided I needed to do something about it.

I responded to an email from the Massachusetts Medical Society and attended a local Bristol North Medical Society meeting. I became a House of Delegates representative, and things grew from there.

Honestly, if it weren’t for the advocacy work I do, I don’t know if I would have stayed in medicine as long as I have. As frustrating as things can be, advocacy has been incredibly rewarding.

MJ:

That’s really great. One thing that stands out to me is that you simply showed up. Just showing up created opportunities you probably couldn’t have anticipated. Once you got involved, it sounds like the path became more tangible. For people on the outside, it can be difficult to see how they can actually make a difference.

CG:

It really can be.

Recently, the Division of Insurance in Massachusetts held a series of listening sessions, including one focused on prior authorization. They wanted to know what they could do to help physicians.

Some of your listeners may have heard that this month the governor announced new regulations around prior authorization. These changes won’t solve everything, but they are meaningful.

For example, we will no longer need prior authorization for medications used to treat diabetes, asthma, and congestive heart failure. So medications like GLP-1s prescribed for diabetes won’t require prior authorization anymore. We’ll still need it when they’re prescribed for obesity or weight loss, but not for conditions where the treatment is clearly indicated.

That’s a very tangible example of how advocacy can make a difference. The Division of Insurance asked physicians how the system could work better, and they listened.

MJ:

That’s great. I’d love to hear more about your journey after residency and how you became a practice owner. Did you go directly into ownership, or were you employed first? Tell us a little about that path.

CG:

Sure.

I graduated from the University of Massachusetts Medical School in Worcester and completed my family medicine residency there as well.

After residency, I took a position with a hospital system in Attleboro called Sturdy Memorial Hospital, now known as Sturdy Health. I worked in a family medicine practice alongside family physicians, internists, and a rheumatologist.

I stayed there for five years.

When I moved to the area, I needed a primary care physician myself. I found a local private family practice and became a patient there. During my first few visits, my physician kept asking me why I was working for the hospital instead of going into private practice.

I told him private practice seemed difficult and challenging. He replied, “Well, I’m doing it. When you get tired of working for Sturdy, let me know.”

About four years later, during my annual physical, I asked him if that offer was still on the table.

He said yes.

So I left Sturdy and joined his practice.

To be honest, there was a specific reason I decided to leave. At the time, we were seeing a huge influx of new patients because of Romneycare. Our office served as the primary family medicine referral site for patients coming through the emergency department who didn’t have a primary care physician.

That was great in some ways, but I had already built a full patient panel. It became increasingly difficult to balance caring for established patients while also meeting the needs of all these new patients.

I started being encouraged to stretch follow-up intervals. For example, patients with diabetes who should have been seen every three months were being pushed out to four months or longer.

I met with the chief financial officer and explained the problem. I told him I was struggling to provide appropriate care to my established patients while continuing to absorb large numbers of new patients.

His response was, “Some care is better than no care.”

I tell that story all the time because I walked out of that meeting knowing I needed to leave.

I didn’t believe that statement. Some care is not necessarily better than no care when it means delaying necessary treatment for existing patients.

What he really meant was that some of my established patients would need to wait longer so we could accommodate more new patients.

So I left.

I joined the private practice and have remained there ever since. At the time, there was a single owner who gradually brought physicians into partnership over the years. It took me five or six years before I became a partner because I wanted to make sure it was the right fit.

Looking back, I wouldn’t do it any other way.

MJ:

I love that story. Once again, you advocated for both yourself and your patients. It sounds like that decision has had a tremendously positive impact on your community.

We speak with a lot of early-career physicians—residents, fellows, and young attendings—and it often feels like employment is viewed as the default path.

Interestingly, the dental profession is experiencing something similar. The ADA recently reported that about 92% of dental school graduates spend their first 10 years as employees. Many eventually become practice owners, but ownership is no longer the starting point for most.

How do you see the future of practice ownership for early-career physicians?

CG:

We’ve seen a seismic shift in physician ownership over the last decade or so. Depending on the survey, physician ownership has fallen from around 75% to roughly 25%. That’s an enormous change.

There are many reasons for that, which I’m sure we’ll discuss. But I do think the pendulum is beginning to swing back.

I’m hearing more and more physicians coming out of residency who want independence and ownership. At the same time, health systems are starting to recognize that they don’t manage outpatient practices particularly well, especially primary care practices.

Specialties that are procedure-based and closely tied to hospitals may be different. But primary care has always been a challenge for health systems. They often talk about primary care being a loss leader, but that doesn’t account for the value primary care physicians generate by referring patients for imaging, specialty care, laboratory testing, and other services.

Even so, many systems continue to struggle.

I think we’ll also see growth in direct primary care and direct specialty care models, where physicians either charge a membership fee or operate on a fee-for-service basis without relying on insurance.

That can be difficult for physicians coming straight out of residency, but I think it will become more common because more established physicians are making that transition.

The insurance environment has become increasingly difficult. Every few weeks, it seems like insurers introduce another reimbursement cut, additional audits, or new AI-driven downcoding initiatives.

Whether intended or not, the message physicians receive is that they’re not wanted.

Physicians respond to incentives just like everyone else. When conditions become too difficult, they leave.

That’s one reason maintaining a healthy private practice environment is so important.

I often tell my employed physician friends that private practice creates choice. Without it, your options become moving from one large health system to another.

Choice matters.

Whether you’re a solo owner, a partner in a group practice like mine, or even an employed physician within a physician-owned practice, those options create leverage and flexibility.

Being employed by physicians is very different from being employed by a large health system.

MJ:

It’s choice for physicians, but it’s also choice for patients, which is becoming increasingly limited depending on where people live and what insurance they have.

I’d love to go back to direct primary care for a moment and walk through the basics for listeners who may have heard the term but don’t fully understand it.

And I’d also be interested in your perspective on a common criticism: that direct primary care may reduce access for some patients who don’t have the ability to pay out of pocket.

CG:

First, full disclosure: my wife owns a direct primary care (DPC) practice.

She actually used to work in our practice. She’s a family physician and was employed part-time with us. About three years ago, she left—not because of any issues with the practice, but because she simply couldn’t deal with the insurance side anymore. She said, “I can’t do this anymore,” and opened her own direct primary care practice.

The basic DPC model is that patients pay a subscription fee directly to the physician. Often, it’s a solo practice. My wife is literally the only employee in her office. She shares space with another DPC physician. That physician has a medical assistant who has been with her since before she transitioned to DPC, and that relationship works well for them.

My wife started her own business, patients sign up directly with her, and they pay a monthly subscription fee. The average cost for direct primary care is about $85 per month.

Direct primary care is different from concierge medicine. In concierge medicine, patients typically pay a much higher monthly fee, but the physician still bills the insurance company. In direct primary care, the physician has nothing to do with insurance. My wife isn’t in any insurance networks. She doesn’t take Medicare or commercial insurance. Patients pay her directly and receive essentially unlimited primary care services.

To make that model work, physicians often provide a wide range of services. I have friends in Massachusetts who practice DPC and perform joint injections, suturing, and many other procedures. In many ways, they function like an urgent care center for their patients. That helps patients avoid urgent care visits because their physician can address many of those issues directly.

One of the biggest advantages is time. You’re not limited to 15-minute visits. You can spend an hour or even an hour and a half with a patient if needed.

When you have that kind of time, you can often work through diagnoses more thoroughly. You don’t necessarily have to say, “I heard a murmur, but I’m not sure what it is, so I’m going to refer you to cardiology.” You can spend more time evaluating and managing problems yourself. You can also help patients develop treatment plans rather than simply treating them and moving on.

Patients can come in for minor illnesses as well. They don’t have to go to urgent care for every cold or minor issue because they have access to their physician.

One of the things patients value most is accessibility. They don’t call and get an appointment three weeks later.

Even in our office, we pride ourselves on keeping same-day appointments available. I can’t tell you how many times over the past few years patients have told us, “Thank goodness you got me in today.”

Patients will use urgent care when they have to, but most would rather see someone who knows them. Whether the urgent care is staffed by a physician or an advanced practice provider isn’t really the issue. They want continuity. They want to see their doctor.

You also asked about the downsides.

I acknowledge there are downsides, but I think the access discussion is more complicated than people realize.

Most patients can afford $85 a month. They’re often already spending money in other areas of their lives. That’s not a judgment—it’s just reality. Many patients on Medicare or Medicaid can make it work because they save money elsewhere in the healthcare system.

For example, many people now have very high deductibles. If your deductible is $6,000 per year, there’s a good chance you’ll never actually meet it. That means you’re effectively paying out of pocket for much of your care anyway.

With DPC, patients can often get labs and imaging at dramatically reduced cash prices. A complete blood count might cost $5. A cholesterol panel might cost $10. A CT scan might be a couple hundred dollars if paid in cash.

Many patients would rather spend a couple thousand dollars per year on their physician, labs, and imaging than spend that same amount—or more—toward a deductible.

High-deductible plans have actually made the DPC model more attractive for many patients.

Massachusetts is somewhat unique because it’s such a highly concentrated insurance market, and residents are required to have insurance coverage. In other parts of the country, people may have no insurance at all. In those situations, cash-pay models can become even more appealing.

If you’re paying cash, would you rather go to a hospital system that charges inflated rates because they have to maintain a standardized fee structure, or would you rather go to a DPC physician who can offer transparent pricing?

That said, there is one very legitimate concern.

My wife went from managing a panel of roughly 1,500 patients to about 150.

That’s where the access issue becomes real. If large numbers of physicians move into DPC models, there will be fewer physicians available to care for the broader population. That’s a valid concern, and it’s something we need to address.

But when it comes to cost, people are often willing to pay for what they value. If they value time and access to their primary care physician, many are willing to pay for it.

That doesn’t mean everyone can, and some patients will be left behind. But many of those patients are already struggling in the current system. They can’t afford medication copays or other healthcare expenses.

Another advantage of DPC is that many physicians purchase medications at wholesale prices and dispense them directly. Patients can often obtain medications for a fraction of what they would pay at a traditional pharmacy.

MJ:

There are definitely a lot of benefits.

You mentioned earlier that you think the pendulum may be swinging back toward practice ownership, and I think there are several reasons for that. One is that many employed physicians are frustrated. They want more control over their schedules and more control over how they care for patients.

If the alternative is reducing clinical work, leaving medicine entirely, or taking a non-clinical role, then independent practice can actually improve access because that physician is still caring for patients rather than leaving the workforce altogether.

Given your advocacy experience, I’d love to hear your perspective. If you had a time machine and could go back to 1996 instead of 2026, what policy or advocacy changes would you prioritize? What could have been done differently to prevent some of the consolidation and decline in physician ownership we’ve seen over the past few decades?

CG:

One of the biggest issues is that most states have laws prohibiting the ownership of medical practices by non-physicians.

Despite that, we’ve seen a tremendous rise in private equity ownership.

The way many organizations work around those laws is by putting a physician’s name on the ownership structure while private equity effectively controls the operation. In reality, the private equity group is making the decisions.

If I could go back 30 years, one thing I would change is enforcement.

Laws are only as effective as the willingness of regulators and elected officials to enforce them. If legislators and regulators had been willing to say, “No, we’re not going to allow this level of consolidation and vertical integration,” I think we’d have a much more competitive healthcare marketplace today.

More competition would benefit both physicians and patients.

The second issue is vertical integration itself.

We’ve allowed situations where insurance companies own physician groups, urgent care centers, pharmacies, and other parts of the healthcare ecosystem. We have antitrust laws designed to prevent monopolies, but too often those laws aren’t enforced.

Recently, we saw an encouraging example in Oregon, where the state’s private equity laws were upheld in a dispute involving an emergency physician group and a private equity-backed organization. Cases like that suggest we may finally be seeing some of these laws enforced.

I think we need more of that.

Frankly, I think some of these highly integrated healthcare organizations need to be broken up.

If they had never been allowed to consolidate to this extent in the first place, we’d likely have a healthier system today for both physicians and patients.

In the Boston market, we’ve repeatedly heard promises that consolidation would lower costs and improve care. Then five years later, costs haven’t gone down and care hasn’t improved.

At some point, we have to acknowledge that the evidence doesn’t support those claims.

The data are there. People know this. What has been missing is the political and legislative will to say no. And that’s difficult for a variety of reasons.

MJ:

I think many people would be surprised to learn that insurance companies are now among the largest employers of physicians in the country.

At the same time, there are laws that prevent physicians from owning hospitals, which is another major barrier. If attorneys can own law firms and plumbers can own plumbing businesses, why can’t physicians own hospitals?

I understand the arguments that have been made against it, but I think we’ve seen how those policies have played out.

CG:

I agree.

That was actually another item I would have included on the list of things I’d change.

The Affordable Care Act brought many benefits for patients and physicians, but restricting physician ownership of hospitals and certain facilities has had some unintended consequences.

I understand the concern. The argument was that physicians might have financial incentives to keep patients in beds or direct care in ways that benefit themselves financially.

But I don’t know who thought large corporations wouldn’t have those same incentives.

MJ:

Exactly. Are corporations somehow not self-interested? That’s literally why they exist.

CG:

Exactly. I don’t get that. I think some of this is a presumption that physicians are rich, greedy people who are just there to take money from patients. You’ll find that anywhere. But when you allow that perception to drive your policy—when that really isn’t what the data shows—that becomes a problem. And when those myths get put into policy, that’s what harms patients. It’s what harms physicians. That’s what led to preventing physicians from owning hospitals. If you allowed physicians to own outpatient centers and hospitals, I think you’d see a very big difference. Those physicians are interested in taking good care of patients. You don’t go into this profession to not do that. Are there bad apples? Yeah. Are there things we could do better? Absolutely. But you have to lead with the data, you have to lead with the information.

MJ:

Yeah. I wanted to ask about direct primary care—I’ll move off it eventually, I promise. There have been some proposals to allow insurance reimbursement for direct primary care subscriptions. Some plans say, “Hey, we’ll actually reimburse for direct primary care.” Do you think that ultimately undermines the model, or is it just an inevitable future for insurance companies to allow that?

CG:

In some places—if there are self-funded employers, for example—some direct primary care physicians will contract with an entire employer. They may bring three hundred patients to the table, and that can be beneficial for both. Obviously, the problem is that as a physician, if you suddenly lose three hundred patients, that’s tough. But that is a model. A lot of people in Massachusetts are working toward it. They’re trying to reach these small employers who are being literally crushed by healthcare costs. It’s upwards now of twenty-five to thirty thousand dollars a year for a family plan in Massachusetts. Employers can’t afford that anymore. They can’t afford to pick up half or three-quarters of it anymore.

So I think if it’s done right—if you don’t go to a model where every visit gets reimbursed and the physician has to send in a super bill every time—it works. If the employer pays X amount up front per month, per employee, and those employees get all the care they need, that sticks with the DPC model and still works. Now, again, I’m not a direct primary care physician, so you may hear differently. But if you stick with the basics of the model, I think it works well, even scaling it up like that.

MJ:

Makes total sense. We’ve talked a lot about primary care and private practice. Given where you sit—advocating in these rooms for practice sustainability, which I’m very passionate about; that’s one reason we exist, to help support independent practices—where do you see, in the specialty or surgical subspecialty space, a renaissance or an increase in practice ownership? Are you seeing any trends outside of primary care?

CG:

Yes. A lot of it is in the non-procedural specialties—endocrinology, rheumatology. Rheumatology does do some procedures, but obviously a joint injection is very different from needing a surgical suite for a cholecystectomy. But nephrology, too. There actually is direct specialty care—DSC—and it’s becoming more common. I just had a physician in endocrinology who recently left a practice in a neighboring state and was looking to rent space from our office. She’s going to open her own direct specialty care office. So that is becoming more common.

I think if you took the handcuffs off the procedural specialists—because ambulatory surgical centers are part of that, and you can’t own that, you can only build on what you have—if you took the handcuffs off, I think you’d see the procedurally related specialty physicians move more into private practice.

That said, there was a really good GYN doc who specializes in endometriosis care. He was in Waltham, part of a big hospital system, and about six months ago he made the leap and said, “I’m going to leave the system and open my own practice.” I haven’t had a chance to speak with him yet, but I’ve heard he’s going to be hiring another GYN to work with him. So it is happening—I wanted to give him enough space to do this at the start.

It can be done. Physicians are doing it. They’re realizing they can do it. That’s one of the things I want our younger colleagues to realize because, like you said, they’re just not exposed to this anymore. Everyone they work with works at the hospital. But we can do it. We need to find some way to get that message out to them. It is happening. It’s dribs and drabs, but—just like anything else—it’s going to hit a critical mass at some point. Because, like you said, for a lot of physicians the option is, “I’m going to go work for pharma. I’m going to go work for someone else.” It really is becoming a breaking point where physicians are just—I can’t do this anymore. I’m burned out. I can’t take good care of my patients. The moral injury experienced by physicians in trying to take care of their patients is getting to a level that’s unsustainable.

MJ:

I agree. I love the work you’re doing to support this effort. I feel very strongly that if we can financially support doctors—obviously it’s a very complicated issue, and we’re not going to solve everything at once—but letting someone be less financially stressed allows them to practice the way they want to. And when a doctor can practice the way they intended, patients benefit. We’re not all doctors, but we’re all patients. So this is a public good effort as well. But I’m preaching to the choir.

CG:

I think that’s a really good point. One of the things is that in Massachusetts they’ve floated an idea—they want to put a lot of money, several million dollars, into paying physicians’ medical school tuition if you go into primary care.

Now, it’s interesting—the old is new, the new is old again. When I went through medical school, they actually had something called the learning contract. When I went to UMass, I deferred two-thirds of my tuition. I paid a third and deferred two-thirds. If you went into primary care and stayed and practiced in Massachusetts after residency, that two-thirds was essentially forgiven. The problem is that amount—way back then, thirty years ago—was set at a certain level and hasn’t been addressed since. So it’s not as valuable to physicians nowadays.

I was actually talking to one of our Mass Medical Society advocates at the State House, and they said, “My goodness, we’re going to have this great program.” And I said, “Whoa, whoa, whoa, hold on—let me give you another perspective.” Let’s say the average medical debt is two-fifty, two hundred and fifty thousand, and half of that is forgiven or paid for by the system. Every medical student, every resident still knows that the delta between what they’re going to make over a lifetime as a subspecialist versus what they get paid as a primary care physician is huge. So paying off medical school is not going to be enough. It may be helpful.

This gets back to your point about how we get physicians into practice. I would contend those millions of dollars would be better spent as a loan or a gift—something to set physicians up in their own practices when they leave—rather than paying off their medical school. Because that’s going to help us turn the tide. That’s the point. It’s not that we don’t want to pay off medical school tuition; it’s whether that money could be spent better somewhere else. And I would contend it could. We need to find ways to put physicians into private practice.

MJ:

Yeah, I think it would be a very interesting study—I’m not sure if it’s happened—but there are schools that are tuition-free now, and it’d be interesting to know: has that changed the specialty they’ve chosen? I don’t think so. So that’s an interesting thought experiment, to your point. I think some states, like Florida, have programs where they’ll—I can’t remember if it’s a grant—but they basically provide some seed money for these private practices in areas of high need, to facilitate choice and innovation and things like that.

CG:

I wasn’t aware of that. That’s interesting—I’ll have to look into it. The AMA House of Delegates is meeting in Chicago in a couple of weeks, and I’ll see a number of my colleagues from Florida. I’ll have to ask about that.

MJ:

I’ll be there. I’ll be at the House of Delegates, and I’ll be at the FMA meeting next week.

CG:

Oh, okay, great. Well, I’ll have to look for you at the HOD meeting. But you’re right—those are the kinds of ideas we need to put forward if we want to encourage private practice. My wife and I took out a HELOC to open her practice, which was doable, but first of all, not everyone can do that. And second, sometimes if you’re going to have a bigger practice—my wife still works part-time in her practice—if you’re going to be full-time, you probably need more to start with. So investing the money into physicians at that level is going to be really important.

MJ:

Yeah. One of the things we’ve found helpful is that when we’re lending money for a startup, for example, many times we mandate that some of those proceeds pay for a practice consultant. That way you’re not doing it on your own. Some of our experience has been that physicians try to have the smallest startup cost possible—so they don’t pay anyone for the front desk, don’t pay anyone for labs, “I’ll do all my phlebotomy”—and that cuts down on potential revenue. All that to say, it’s worth it to have someone who has experience in the consulting world. Not everyone’s created equal there, but in general, to advise on some of the stuff we’re not trained on in residency or medical school, it more than pays for itself in my experience. So that’s a resource that’s probably underutilized.

CG:

Agree. I know there are a lot of people who advocate for—do we need to teach more business in medical school or residency? I used to think that would be really important, a great idea. I’m not so sure about that. My wife has opened a DPC practice.

She’s a very intelligent person, but she was not a business person—and her practice is thriving without an MBA. So I think it can be done. Now, again, a direct primary care practice is very different from opening a practice that’s going to charge insurance; that’s a little more involved. But I’ll tell you, literally across the block from my office in North Attleboro, there’s a pediatrician who left Sturdy probably four or five years ago and opened her own private practice pediatric office—which is almost unheard of—and she is doing wonderfully.

I don’t know if she hired a practice consultant; I don’t remember hearing about that. Even if she did—again, it can be done. She’s doing it and loving it, and she didn’t get an MBA. She hasn’t gone to any little course like that. She did it all on her own. I’m not saying she didn’t have help—I’m sure she did; her husband is the office manager and has a little more business experience. But it can be done, and you don’t have to get an MBA.

You don’t have to spend eighty grand on an MBA. But having a consultant—it doesn’t have to be someone who’s going to charge you six figures, but someone to guide you a little—I think is a really good idea.

MJ:

And I think for doctors, we’re generally smart enough to learn whatever we have time to sit down and learn. The problem is we don’t have the time. But once you’re put on that path—you have a mentor, a consultant—you kind of see what’s possible, and then you devote some time to it and we can learn it.

MJ:

I fully believe, like we talked about, that unfortunately in academic training we’re not given the opportunity to see the diversity in which you can practice and see patients. Some of that obviously isn’t on purpose—just the way the system is structured. But I hope the message, to your point, is getting out that there are options.

MJ:

I think trainees are starting to ask more questions about other possibilities. Maybe it’s a combination of wanting to pay off some debt initially, and then they get experience and go do their own thing. That’s the analog in the dental space—that’s what we’re seeing right now—and I think something like that could happen here.

MJ: The one thing I always find fascinating: you mentioned twenty-five percent of physicians are in private practice or practice ownership, which of course is a steep decline. But what’s so interesting to me is that as an absolute number, that’s more than all of dentistry—all dentists, regardless of practice scenario. Yet we always talk about the entrepreneurs in the dental space as a much higher percentage, but as an absolute number it’s less.

MJ:

And if you go to a dental school, industry is in the dental school. Industry is in the residencies; they hear from accountants, practice consultants. I’m not saying that’s necessarily a good thing, but the exposure is there—whereas in the medical space, it’s just so alien at this point that we have an uphill battle on raising awareness. I’m on my soapbox—I realize I’m supposed to be interviewing you. Apologies.

CG:

No, I think you’re right. We’re supposed to not be business people, not be wanting to make money; we’re supposed to be altruistic people who do this for the good of society—and we still do that. But as I tell my patients, look, I’ve got to keep the lights on. If I don’t keep the lights on, I’m not helping anybody.

CG:

There is a fine line, and you can certainly debate: do physicians make too much, do they make too little? But the reality is—in my office, we have one person we hire who does just prior authorization. That’s a five-physician, three-NPP practice. I love the person who does that, but she would be so much better off in a different role if we didn’t have to do that.

CG:

The money is there in the medical system. It’s just so maldistributed—pick the ways: private practice versus facility fees for hospitals or systems, subspecialist versus primary care. It’s such a maldistribution. It’s there, it’s just not being put where we really need it.

MJ:

Totally agree. I know we’re rounding third and heading home. We end our interviews—well, technically all of them—with a rapid-fire round. Essentially I’ll say a statement and ask whether you think it’s true or false in your opinion. I say “rapid,” but it’s almost exclusively not rapid—we talk about all of them for an extended amount of time—but we’ll try.

MJ:

So, true or false: in ten years, the number of doctors in private practice will be more than it is today.

CG:

True.

MJ:

Why do you think so?

CG:

It’s going to reverse itself. I think more physicians are realizing that systems don’t manage them well, systems don’t do well, and physicians want their autonomy back. They can’t continue to practice in the moral-injury setting that many of these health systems set up for them. And they’re going to find out—you know what, I may think it’s tough to open a practice, but God, it’s got to be so much better than what I’m doing now.

CG:

I had a guy come in two weeks ago, thirty-one years old, doesn’t have health insurance in Massachusetts because his job dropped insurance—it’s a small business—and somehow he missed the window to sign up. But I’ve been taking care of him for ten years. There aren’t a lot of thirty-one-year-olds who come in for a routine physical.

CG:

He came into my office to get his annual checkup and said, “What do I pay?” I gave him a cash price, I gave him a discount, and I said, “Come in, pay it, and we’ll take care of you.” He came in, paid it, and we took care of him. Patients and physicians will realize they can do so much better for each other if you remove all the insurance barriers.

CG:

And I know fee-for-service gets a really bad rap, but the way people think about it may not be the best thing. If you literally bring it down to direct patient pays physician, physician serves patient—that is fee-for-service at its purest. That works in a lot of ways. Not for everything, but it does work.

CG:

Particularly in primary care, I think removing it from the whole insurance system is one of the ways it’s going to go. That’s partly why you’re going to see a lot more physicians in private practice—because they’ll be untangled from the whole web of the system.

MJ:

Yeah, that would be a crazy shift that I think ultimately patients would win. Next true-or-false statement: true or false, AI-enabled tools will make it easier to own a practice.

CG:

True.

MJ:

What are some of those tools that make it easier?

CG:

AI tools make it easier by helping automate some of the work. For example, writing your notes more easily. If you’re in a practice like a DPC practice, you don’t have to write notes for billing—but you still have to put together a medical record, right? And if you can do that by having AI in your room listening to you and the patient, that helps. Using AI to make sure medications get sent off for refills will be helpful too.

CG:

AI is not going to replace physicians, but physicians who don’t utilize AI will go out of business—just like physicians who haven’t utilized electronic medical records don’t really exist much anymore. You really can’t do that. So I think AI will be part of it, and I’m sure it’ll also do things we don’t even think about yet.

CG:

But utilizing AI to reach out to patients—some of the automated systems now, checking in. My wife can set up a message to get sent to a patient three days after their visit: “Hey, are you doing okay? How are things going?” I think some of that is going to be helpful.

MJ:

I totally agree. Last true-or-false statement: true or false, you would choose family medicine today over any other specialty.

CG:

True. I can’t imagine doing anything else. When I first started med school, I thought maybe I wanted to be an ophthalmologist—I’d done some eye research as an undergraduate. Then I got to med school, really started to think about it, and said primary care is more my thing.

CG:

I do better thinking about lots of different things—not at a huge depth, but across a wide range of topics. And I love that, because I can take care of most of what my patients need.

MJ:

I’m the same way. Med-Peds, like I said—distant cousins of family medicine—have very similar personalities. Well, I really appreciate this. We have one final question we ask every guest: what is one thing you’ve recently changed your mind about?

MJ:

We’re in a setting of more information than we’ve ever had access to, yet I sometimes find more information doesn’t necessarily lead to more free thinking—it just reinforces our current thinking. So I like to ask: what’s something you’ve actually changed your mind about?

CG:

I’ve become more convinced that primary care needs to be removed from the insurance system. In some ways I’ve always thought that. I’ve been saying for years—and others have said this too—when you fill up your gas tank, do you charge that to your insurance? When you replace your wiper blades, do you charge that to your car insurance? And everyone looks at you and goes, “No.”

CG:

Well, that’s what we’re asking primary care to do, and we need to remove it. I say to people, “What if every time you filled up your gas tank you charged it to your car insurance—what would happen?” Oh my God, it would go through the roof; I couldn’t pay for it. That’s what we’ve done with primary care.

CG:

For a long time I recognized that, but I thought, well, we can make it work—you change this, you change that. But over the past six to twelve months, I’ve become convinced that primary care—regardless of whether you’re DPC, concierge, solo, or six people—is going to need to be removed from the insurance system as a whole in order to really save it.

MJ:

I think we could do a whole episode on just that topic—I’d love to dive deeper. I appreciate your time; I know you’re a busy person. Where can listeners find you online or follow more about your work and advocacy?

CG:

It’s interesting—I don’t do a lot of social media. I do a lot on Facebook; I’m of that generation. When Twitter came out—well, X now—I looked at it, signed up, tried it, and said, until someone can tell me how this is better than Facebook, I can’t do this. I don’t have the bandwidth, as they say.

CG:

So, I’m on Facebook, I post a lot, I’m in a lot of the physician groups there, under my name. People can find me and message me. I don’t do LinkedIn—I have a profile, but I haven’t been on there. I know people say you should be branding yourself, this and that. I just want to take care of my patients and advocate; I don’t need to do that.

CG:

But people can reach out and find me—you can look up where I practice, find me on Facebook, where I do all my advocacy. Or come find me in Chicago.

MJ:

Okay, that’s great. Well, Dr. Garofalo, thank you for your time. This has been awesome—hearing your perspective—and I’ll see you here next week.

CG:

All right, thank you very much. Take care.

MJ:

You can catch The Podcast for Doctors (By Doctors) on Apple, Spotify, YouTube, and all major platforms. If you enjoyed this episode, please rate and subscribe. Next time you see a doctor, maybe prescribe this podcast. See you next time.

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