It fascinates me that at the beginning of my practice I was frightened about "making it." Very quickly, it became an issue of controlling the monster.
One option, other than the ER, is to cultivate a relationship with a good local urgent care group who has later hours than you. Our problem was that the acute patient would show up at 3:30, need lab and x-ray that we could not get back for 3 hours, and we just are not set up to deal with that. Maybe we would be willing to be a martyr and have no life, but the rest of the staff wasn't. Absent that, the ER is the only realistic solution.
Closing your practice, even if temporary, does help. My inner rebellious "child of the 60's" does have some issues with selectively closing it to patients with poor coverage, but the older businessman part has learned to slap him down. Still, the kid slips through occasional M'care/caid patients for whom I seem to have something special to offer.
The final fact is, your patients are better off with 85% than 0% of you. 100% is not a realistic possibility, especially as you grow older.
