American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, December 18, 2012

The potential danger of success

"This could be big," he said after I told him about the company who wants me to cover their 100+ employees. I pay him to give me the stark reality of things, but his optimism made me uncomfortable. "You've got to go for this. I know you don't feel ready for it yet, but this could really be huge for your business, and I don't think you should pass this up."

I sighed. Yes, this is a victory of sorts (still only theory, not reality), but what if I can't deliver? What if I fail?

"You know," a colleague told me during another phone conversation, "You are the buzz of the medical community right now. We talked about you for half an hour at lunch today ... and it was all good!" He went on to use phrases like "our only hope," and "the way out," to describe the potential for my practice model.

"No," I thought, "I am not Obi-Wan. I'm not your only hope." I sighed. I don't want that kind of pressure on me before I even see my first patient. What if I fail?

Even worse: What if I succeed?

One of the main things that separates good clinicians from the rest is the ability to think through contingencies. When I order a test or prescribe a treatment I have to consider the possible outcomes: if the test shows X, then we do Y; if it shows not-X, then we do Z. Or, here's the plan if you get better on the medication, and here's the plan if you don't. The more contingencies I can anticipate and plan for, the more direct the path to the ultimate destination: resolution (or management) of the problem. I find that my experience in thinking through contingencies serves me well in my current job of building a new and innovative practice.

Obviously, if I fail to get enough patients to support the business, things could get really tough. I have bills to pay and the evil overlords of college tuition to placate. The fear of this failure has driven me to spend a large part of most days over the past two months working. I don't want to fail and I will bust my butt to prevent that outcome. The question is not simply, "Can I succeed?" I must also consider the possible consequences of success, and plan how to deal with them. When I consider those consequences it quickly becomes clear how scary they could be.

Consequence 1: getting overwhelmed
This is the easiest danger caused by success to anticipate. When I open the practice, I may be met with an overwhelming number of people wanting to sign up. If I open the doors too wide and too many patients become my patients at once, I could have trouble keeping up with demands.

It's like a restaurant that opens up to a flood of patrons before it is ready to handle the volume. The result is poorer quality food and longer waits, which could doom the ultimate success of the business. This is one of the reasons I was nervous when I was contacted by the business about becoming their "company doctor." I don't want to put out a poor quality product.

The solution for this is to open the practice slowly, or have a "soft opening." As much as my former patients are banging on my doors to open up, I may be tempted to let people in before I am able to give care that is worthy of their trust.

Consequence 2: getting distracted

I had the husband of a patient pay me an off-handed compliment after hearing my presentation about my new practice: "So when you become real successful in this, how long will it be until you don't have time to see patients anymore?" I appreciated use of the word "when" rather than "if" in his question. He not only saw the merit in the idea of what I was doing, he saw the potential for building a big business on this idea.

My answer was simple (and perhaps somewhat over-confident): "Never," I said. "I am leaving my old job so I can do what I love: see patients. I am not going to allow this business to take me away from the very reason I started it."

Others have suggested starting a franchise, writing books, or making money as a consultant for practices who want to follow my path. I hate this, not only because I haven't seen a single patient or gotten a single check (and thus have the practice equivalent of vapor-ware), but because I see this as a real possibility.

The solution to this will largely depend on the people who I end up working with. If I hire well (which is not an easy thing by any stretch), then I can delegate to people worthy of those tasks. But I am not a micro-manager (unlike most docs), so my temptation will be to get lazy and put too much in the hands of people who haven't shown they deserve that trust.

Consequence 3: kicking the hornets' nest
Let's say I dodge consequences 1 and 2, have a thriving practice and a bunch of money coming from consulting and from my show on Oprah's TV network (giving Dr. Oz the heave-ho in the process). It's a roaring success, the money is coming in, and doctors are leaving traditional practices in droves to emulate my incredible business model. I've been able to dump the administrative tasks to others, leaving me to see patients and scoff at the pittance demanded by the tuition gods. That would be a dream come true, wouldn't it?

Not necessarily. One of the most common criticisms I hear for what I am doing (and one I often bring up to myself) is that it is not generalizable to the whole of health care. I am cutting back my patient load from approximately 4,000 patients (the number I carried in my old practices) to 1,000. That is one of the keys to this type of practice: keep patient volume down so patients get more time.

So what happens if this business model takes off and a significant percentage of primary care doctors "abandon" 75% of their patients? It turns a shortage of primary care providers into a crisis. It turns direct care practices into a real threat to the viability of the entire system.

It would create a huge backlash. Direct care would have enemies, and those enemies could do things like requiring doctors to accept Medicare and/or Medicaid to have a license to practice. I've heard it suggested already, and it terrifies me.

This is one of the main reasons I've become increasingly focused on a new goal: to grow my practice back to the same size it was in the old system. I would have to do so using my "organic medical home," hiring dietitians, home visiting nurses, social workers, counselors, and other professionals to manage aspects of my patients' care, allowing me to increase my overall panel size (and perhaps even lowering my monthly fees).

If primary care physicians can have a profitable business without selling their souls, if patients can be given more access to care, better care, and save money, and if all of this can be done without threatening to destroy the system itself, perhaps some specialists will become envious and come back to "real medicine."

Wouldn't that be cool?

Yes, this could be big. Now I have to decide if that's a good thing.

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
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.

And Thus, It Begins
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
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 Infection Prevention
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.

Everything Health
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.

Glass Hospital
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.

Gut Check
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.

I'm dok
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.

Informatics Professor
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
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
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.

MD Whistleblower
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.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
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).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
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.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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