Thursday, November 29, 2012
Learning to fly
This is my new office. I signed the lease for this property yesterday, another big step in the process of getting my new practice off the ground. I should feel good about this, shouldn't I? I've had people comment that I've gotten a whole lot accomplished in the four weeks since I've been off, but the whole thing is still quite daunting. Yes, there are days I feel good about my productivity, and there are moments when I feel an evangelical zeal toward what I am doing, but there are plenty more moments where I stare this whole thing in the face and wonder what I am doing.
I walked through the office today with a builder to discuss what I want done with the inside; it quickly became obvious that there was a problem: I don't know what I want done, and nobody can tell me what I should do. Yes, I need a waiting area, at least one exam room, an office for me, a lab area, bathrooms, and place for my nurse, but since I don't really know which of my ideas about the practice will work, I don't know what my needs will truly be. How much of my day will be spent with patients, how much will be doing online communication, and how much will be spent with my nurse? I want a space for group education, but how many resources should I put toward that? I also want a place to record patient education videos, but some of my "good ideas" just end up being wasted time, and I don't know if this is one of them.
I come across the same problem when I am trying to choose computer systems. I know that I want to do that differently: I want the central record to be the patient record, not what I record in the electronic medical record (EMR). I want patients to communicate with me via secure messaging and video chat, and I want to be able to put any information I think would be useful into their personal health record (PHR). So do I build a "lite" EMR product centered around the PHR, or do I use a standard EMR to feed the PHR product? Do I use an EMR company's "patient portal" product, or do I have a stand-alone PHR which is fed by the EMR? I have lots of thoughts and ideas on this, but I don't really know what will work until I start using it.
Here's the real rub in all of this. There's a large group of patients waiting for me to open my doors and take them in as my patients. These people will need excellent care and all that goes into providing that care. I am confident in my care as a doctor, but the doctor is only a part of the equation; there are referrals, labs, and other care-coordination services that need to be done. If people are going to be trusting me enough to pay a monthly fee in exchange for better care, I have to deliver on that.
This must become a viable business. I quit my other job, and now will rely on this new business to support me and my family. The incredibly low overhead of it all helps a lot, but the final say of any business is this: do I offer a service that is worth what I am charging? Decisions like how to redo the office, or what computer systems to use have a twofold impact on this: they impact the quality of the care, and they cost money.
It feels like I have been given the task of learning how to fly in three months. But instead of taking flying lessons and flying in the conventional way, I have to build a whole new kind of airship from the ground up. I need to design it, build it, and then learn to fly well enough to take passengers. My ideas were good enough to take this challenge, and I have lots of smart people willing to help me, but I will be the one who has to make it fly.
Some of this is ego. I wouldn't have quit my old practice for a new way of doing things if I didn't have the confidence to pull this off, much less write about it for thousands of people to see. So when people give me advice, my ego wants to assure them that I know what I am doing. I want to say, "Well, that may work for you, but I am doing something different." But then there's the small fact that I don't really know what I want, so I should at least listen to any advice I get.
In the end, all that matters is that I give good enough care for my patients that they are willing to keep me in business. Keeping that reality in front of me as the center of my focus will give me the best chance to get this baby off the ground. Once I am flying, it will be much easier to know how to improve it from there.
In the mean time I just pray that I don't crash.
After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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One of the most popular anonymous blogs written by an emergency room physician.