Monday, June 24, 2013
It feels dangerous to write this, but ... my practice seems to be working.
I am now running and hiding from lightning bolts, meteors, or stray arrows shot in the air by a Scottish soldier. I am also expecting a raid on my office by the IRS, CDC, and BBC tomorrow morning.
But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving. We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from uncle bouncy. While we've started to discuss when we will hire another staff person (probably a nurse), neither me nor my nurse Jamie (may her name be ever blessed) feel overwhelmed at this point. We can handle this volume, which speaks well for the future when we actually have a fully-working system.
The past few weeks have been totally consumed by my need to have an underlying system of organization. After fighting valiantly against the idea for the first two months, I succumbed to the necessity of building my own IT system and have been seeing the many benefits of that decision. Despite being totally obsessed with how data tables connect and whether I've left a parenthesis off of a script I've written, I now have a place to put data, have a pretty decent task management system, have an integrated address book, and have discussed integration with my phone system vendor, my secure messaging developer, and a lab order/result integration vendor. I've also found some strong local tech talent who gets what I am doing and yet doesn't simply see the market potential for my software.
The reality is, my whole focus is on the practice model, and that model seems to work. As my business and medical care management systems click into place and become more functional, growing the practice should not be a problem. We continue to get several new patients signing up every day, and now the reluctant spouses of established patients are joining (which is a very good sign for both my practice and for their marriages).
Let me appease the gods and state clearly that this is by no means a sure thing. There are many, many things that could go wrong. A successful start-up requires not only a good idea and hard work; it also needs requires luck (or at least to avoid bad luck). I could get cancer, my building could burn down, or our city could be overrun by a mob of psychotic llamas. We all know the llama apocalypse is happening; it's just a question of when, not if. So I accept the fact that I am, to a great extent, in the hands of the fates (and llamas).
That being said, it is encouraging to see the first stage of the practice running reasonably well. The key will be to keep doing what I am doing: working, working and working. In some ways, the satisfaction of my patients should not surprise me, as the care they got from the health care system sets the bar very low. I am frustrated because I am not yet building care plans for patients or calling to check up on people as much as I would like, but that's not care that any of my patients are used to getting. They are used to being ignored unless they are sick. They still wonder if they can make an appointment, when I would gladly talk about their problem on the phone. They are simply happy that we still have an average waiting time of about 30 seconds.
Having been under high pressure over the past few months, my recent success makes it very tempting to take a deep breath and slow down a bit. Am I simply setting goals of care higher than they need to be? I think about these things while in the shower. I'm not sure why the pelting of my head with water makes me think better, but it does.
While wetly contemplating my obsession (and whether this was a sign of strength or stupidity), I remembered a physician worked under during my residency at Indiana University: Dr. Larry Einhorn. Dr. Einhorn is credited for the use of Cis-Platinum therapy in testicular cancer, a treatment which made a lethal disease in young men largely curable, even at very advanced stages. He was one of the group who cured Lance Armstrong of his advanced cancer, and was already quite famous when I was there nearly 20 years ago. This group of docs was not only amazing in their clinical and research skills, they were very good teachers and treated us residents with kindness and respect. It was truly an honor and a pleasure to train under them, and I strongly considered oncology as a career because of them.
One of the attendings told me that what made Dr. Einhorn so great was that he didn't stop at the first breakthrough. He didn't say, "Hey, this cures 75% of advanced testicular cancer! I am going to name this the Einhorn treatment protocol and be real famous!" Instead, he focused on refining and improving the treatment to where, while I was there, the cure rate was well over 90%.
That's not a character flaw, that's the definition of character. While I am nowhere near in accomplishment to that of Dr. Einhorn, I am tempted to listen to the happy patients, the complements from colleagues, and the band of groupies that gather on the handicap ramp each morning for my autograph. I am tempted to think I've accomplished something before the job is done. I am encouraged by the fact that I can handle 300 patients with just a nurse to help. I am encouraged by the fact that I am recovering from nearly having my practice impaled by "meaningful use certified" EMR products and may actually have a system that really improves care.
But I am a long way from where I initially planned to go, and there will always be more I can do. The foundation is laid, but foundations are generally unacceptable (and uncomfortable) places to live. So, I take a deep breath and dive back into all the work I have ahead of me. I hope things continue to improve, but I won't count on it. People have told me "You'll do it. I am confident you can make it work." But their assurances don't include the footnote that says: "As long as you continue to work most of your waking hours, and avoid doing something really dumb." That's no slam dunk.
And don't forget about the llama apocalypse.
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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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).
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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.
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Other blogs of note:
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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.
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.
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