Tuesday, March 12, 2013
Progress report on opening my own practice
I am not sure if my lack of blogging is a good sign or a bad one. It's been a week and a half since I started my new practice and I finally am getting this chance to come up for air. It's been an uber hectic and very draining time, but I am happy to report that the end of the week was significantly better than the beginning.
Here are some things I am learning.
1. Starting a business is really, really hard
I did my best to make my business as simple as possible, mainly because I understand my own deficiencies when it comes to business-related activities. Of course, being in a leadership role of a practice for the past 16 years helps me understand incredibly confusing concepts like accounts receivable, budgets, paying bills, and avoiding going to jail for spending all the collections on lottery tickets and reporting it as "research." I purposefully designed the business to require as little accounting as possible, and in general I think I accomplished that. People come in to see me, pay me by swiping their card on the nifty card-reader on my iPhone, and I email them the receipt. That's not the hard part (aside from people touching the "skip signature" button with their hand while they are signing).
The hardest part of starting a business for me is knowing what overhead items are necessary and what are not. Building the office took a month longer than I expected and cost twice as much. Yet I signed "yes" to all of the things that added cost. Some of them were necessary, like doing the things needed to comply with the Americans with Disabilities Act, compliance with electrical code, and having furniture. But where to draw the line? I want the office to send a message of "professional, yet welcoming," which means it can't look cheap but doesn't look posh either. I want the office to be consistent with my logo, a door opening that says "come on in," and "welcome." But everything adds cost, and mounting cost is tough when delay in opening means I am earning nothing.
Everyone is willing to give advice, but most of the advice given has little foundation in my reality. People say "it will all work out," or "you'll do great," reassuring me that I don't have to fret about things. It's as if I can sit back and relax while things "work out." The reality is that the reason they will work out is that I will spend most of my waking hours (and some while I'm not awake) working, worrying, thinking about details, and trying to plan for a very uncertain future.
2. EMRs have gone over to the dark side
I wrote about it in an earlier post, about how hard I had to work to figure out my EMR system. Well, I never really figured that EMR out, so am in the midst of deciding where to go next. The problem I see is that instead of transforming health care by simplifying the process (what I imagined in the early EMR years), electronic records have been transformed by the system to add a complexity that was not possible without computers. "The system" thrives on complexity and documentation of that said complexity in complex ways. It is job security to EMR vendors, hospital administrators, insurance and HHS employees, and the armies of medical billing staff over our great land. Computers can turn difficult tasks into easy ones, but EMR has taken easy tasks and made them incredibly complex.
This has been much clearer now that I don't care about documentation for the sake of payment, and am not trying for "meaningful use." I just want to document so I can give good care, using the EMR in a meaningful, useful way. Yet, to enable a seasoned veteran of EMR (16+ years of use) to simply document a visit required hours of training. After they bragged of the way I could send lab results to a patient portal (complying with meaningful use) more than one vendor explained apologetically that they were unable to print a letter with those same results. Adding problems and medications is another simple task made complex, not to mention finding them on the list after they've been entered.
3. Walk, then run
I had a crisis last weekend. I was so frustrated that I wasn't giving people the care I imagined. It seemed all the work over the four months prior to opening the practice amounted to a bunch of wadded up balls of paper around the trash can. I tried a lot of things that didn't pan out. I learned a lot about what doesn't work. While there is value in knowing what works (a lot of value, actually), it doesn't help deliver the goods when it comes to actual patients. And the plans I made showed their flaws once they were put to the test, giving me the task of re-solving problems I thought already had a solution.
Upon further reflection (and common sense from a person willing to listen to my anxiety) I realized the source of my frustration: me. I wanted to have the practice working perfectly from day 1, something that my patients never expected. It turns out that it's not the business with the best plan that succeeds; it's the business that responds best when their plans are flawed. There was no way to predict everything that would happen when I saw actual patients, and so we've spent the first week and a half finding ways to make our practice fit reality, not trying to force reality to fit our plans.
So, what will this week bring? I think things are starting to fall in place and we are getting a system set in many areas. But I also think that I don't know what's coming. Some things that worked for the first 2 weeks will show their flaws and perhaps better solutions will appear.
The head count: 35 families, and 73 patients signed up so far. The total signed up or on the wait list is up to 250, and there are big prospects on the horizon. We are slowing down a bit this week, focusing on building the systems that will let us manage a bigger patient population. That's what it comes down to: I left my practice because I felt like I was too busy to give good care. Now I need to resist the temptation to grow the business too fast. I want to make it worth the wait.
I explain to people when they ask about paying $30-$60 extra per month that if all they were getting was me as I was in the old practice, they'd be wasting their money. I intend to give them far more than that.
One of the high points of the week was seeing a person in their 30s who has very high blood pressure, but was too busy with school and a job to get it taken care of. The hassle of calling a doctor, waiting in the office for hours, and getting very little time for the money paid kept them away from care they needed. I told about the $40 monthly charge and was greeted with a grin. The smile widened when I mentioned that the basic chemistry profile I was ordering would be an additional $4.50. I'll do a follow-up this week, with an EKG, but there will be no charge for that and nobody's had to use my waiting room yet. Perfect. It's what this is all about.
Stay tuned ...
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.
Contact ACP Internist
Send comments to ACP Internist staff at firstname.lastname@example.org.
- QD: News Every Day--'Dollars for Docs' database up...
- A modest proposal to unfetter the Second Amendment...
- Fortunately I only slept with diagnosis, I avoided...
- QD: News Every Day--Aspirin associated with lowere...
- New privacy rules may distract doctors from patien...
- The pathogens of Cupid's arrow
- QD: News Every Day--Diabetes' rising prevalence dr...
- Baby boomers' poor health will haunt them as they ...
- Happy misfortune and house calls
- QD: News Every Day--Emerging superbug prompts warn...
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.
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, 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 Richmond, Va., 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
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.
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.
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.
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
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)
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,
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
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.
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.
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.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.