Surviving the Demise of Solo Practice: Mental Health Practitioners Prospering in the Era of Managed Care

Throughout his career, Nicholas Cummings has always kept at least one eye on the future of behavioral health care. With admirable vision, he has been at the forefront of important trends, and he has consistently tried to alert his fellow practitioners to the realities that lie ahead. One senses his frustration with those who ignore his wake-up calls, but he, Michael Pallak, and Janet Cummings (psychologists all) have edited Surviving the Demise of Solo Practice, offering practical guidelines to those who acknowledge that the days of the "old guard" are gone.

While not the first of the how-to-live-with-managed-care books, this one virtually promises success. The introduction calls it a "road map to prosperity" for those who "seize the moment."

The book contains 16 chapters, four written by Nicholas Cummings, who, as founding chief executive officer of American Biodyne (now Merit Behavioral Care), became a mentor for many of the other 13 contributors. Eight contributors are current or former employees, and their perspectives are derivative of his leadership and teachings; he is exalted in almost every chapter. Even the introduction, which he presumably wrote or cowrote, invites us to let him take us "comfortably and knowledgeably" through new territory, as he "deftly delineates the paradigm shifts required."

The reverence that Nicholas Cummings has inspired is present throughout the book, and although it provides a connecting thread, this tone is strong enough, at times, to undercut the credibility of some of the ideas within. The starting point, it seems, for all the contributors is that Cummings is right about everything; this attitude is reminiscent of how some of Freud's disciples venerated him.

Although Surviving the Demise of Solo Practice is described as geared toward "new and established practitioners," the primary audience is clinical psychologists. All but one of the contributors are Ph.D.s or Psy.D.s. Several chapters deal with issues of concern only to that profession. Most of these very readable chapters recount the writers' personal experiences as managers, entrepreneurs, and informatics experts. Interwoven throughout are references to Cummings' "catalytic" model of psychotherapy, in contrast to the traditional "dyadic" model. His perspective reflects current research and realities, and it merits attention.

Charles Browning's chapter on practice survival strategies and Michael Pallak's on outcomes measurement techniques seem most helpful to the clinician. Some contributors use unfamiliar terms, and readers may be confused in distinguishing integrated delivery systems from provider hospital organizations, or community accountable healthcare networks from regional group providers. The final chapter, by Janet Cummings on management of suicidal patients, offers interesting clinical vignettes, but the author bases her approach on an obscure model of suicidal ideation. The only reference cited is a film she produced; whether there is any corroboration is unknown, but it again highlights the uncritical editing that is the book's main vulnerability. The book concludes with three appendixes, listing information systems vendors, psychometric instruments, and Internet addresses, all of which may be useful to readers.

Keeping in mind the perils of unanimous agreement when it comes to the changing behavioral health care environments, one can find much of merit in Surviving the Demise of Solo Practice.

Dr. Moldawsky is a psychiatrist in the department of psychiatry at Kaiser Permanente in Downey, California.