After 18 years in practice, Dr. Herman Ayvazyan felt burned out. Paperwork, overwork, insurance hassles -- these had taken the joy out of medicine, a career he chose when he was 12.

With 3,000 patients in his solo practice in East Providence, Ayvazyan, 50, would start his day with hospital rounds and then hold 15-minute office visits with 25 to 30 patients, while handling 30 to 50 phone calls a day. It was exhausting.

So when MDVIP, a company that helps doctors set up concierge practices, approached Ayvazyan, the doctor thought he had found an answer.

He'd already considered everything else. He had tried to recruit a partner from among residents completing Brown Medical School training programs, but few were interested in primary care, preferring more lucrative subspecialties.

He could see no way to simply reduce his patient load; if he were to cut it in half, how would he choose which half to eliminate? And if he moved into a job at the Providence VA Medical Center or in administration, as some of his colleagues had done, then all his patients would lose him.

At least with MDVIP, he could provide good care to a portion of his patients.

So Ayvazyan put out word that his practice would change -- that he would only keep 600 patients, and those who still wanted him as a doctor would have to pay $1,500 a year.

He knew he would have to part with most of his patients. But it proved much harder than he expected. "When you see the patients and talk with them, and you understand their financial situation and how difficult it was for them to afford [the concierge service]. . . . I had this 90-year-old lady who sold stock so she could pay it. I just could not stand it."

Many of his patients had been with him throughout his 18 years in practice. "They're like your family. You gotta tell them they cannot come to see you because they cannot pay the fee. It just doesn't seem right. . . ."

"I just could not leave them."

Before opening the concierge practice, he told MDVIP that he could not go through with it. According to the company, Ayvazyan is the first among MDVIP's more than 100 doctors to change his mind in that way, but the company let him out of his five-year contract.

Then, Ayvazyan sent letters to all his patients telling them that he'd decided to leave things as they were.

"I've never made so many people happy," he said. "Everyone was coming in in tears. It was like coming back from a deathbed."

So what now? What about the burnout? Ayvazyan says he's trying to hire a second nurse practitioner so he can get a little more time off. But otherwise, he doesn't want to change anything. He feels rejuvenated by the process of considering and rejecting the concierge model, and by his patients' reactions.

"I'm really happy," he says. "I just love making a difference in the patients' lives. I feel like I have a very large family."