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

Monday, January 13, 2014

Happy New Year!

It’s been a month since I wrote my last post—really more than that, since my last post was a little thank you note to my patients. While my silence was not premeditated, I have decided that it’s more important to do the walk than the talk. Really, I’ve just been too busy working.

How’s my practice doing? It’s working too.

I am now up to nearly 400 patients, and while my nurse, Jamie, and I have talked about hiring a new staff person, we seem to be hitting our stride in this different practice model and have not yet been overwhelmed. New patients are coming with regularity, some still coming from my old practice and many others through word-of-mouth from satisfied patients. Yes, people still seem very satisfied with the care they are getting from me. If they have medical problems that need immediate attention, they can come in and be seen. I frequently hear from patients in the office how happy they are that I am doing this kind of practice.

I’ve also stepped up my effort to coordinate care by calling specialists or sending them detailed letters explaining why I need them to see the patient. The specialists I’ve contacted are delighted with my efforts to make their jobs easier and to give better care. While it is still difficult to get them to adopt secure communication tools, I am getting a small number who I can throw curbside consults to, and who can give me updates on the patients from their computers or phones.

I’ve been working on adding new services as well. One of the first things I did when I opened the office was to negotiate a very inexpensive fee schedule from a lab that would bill me for the tests. Most docs mark up the tests and make a profit off of it, but I do very little mark-up of the tests, instead offering things like a CBC for $4.50 and a TSH for $8. I am now working on doing the same thing with an X-ray facility, giving them the opportunity to get guaranteed cash up-front (reducing their overhead) while avoiding the many traps of compliance with Medicare billing (which forbids providers from giving discounts to other patients that they don’t give to Medicare patients). I can attest: get into the cash-pay world and life becomes simpler and overhead is much, much lower. You can afford much cheaper rates. In the end, I hope to negotiate this kind of rate for other procedures, like echocardiograms, colonoscopies, and perhaps even minor surgeries. As my patient population grows, my credibility in negotiation grows as well.

What’s the thing that patients appreciate the most about my practice? Accessibility. If they need me, they can reach me. In fact, I just answered a question for a patient right before I wrote this sentence. One person had a child with flu-like symptoms on New Year’s day and was contemplating taking them to the ER. I told them to meet me at the office and I ran a flu test and took a quick look at them. No big deal; it took me about 10 minutes and I saved an ER visit. This kind of thing happens with regularity (not usually after hours, thankfully), and having an office that at most has one patient present, it’s easy to handle them quickly and efficiently. My only challenge thus-far has been to convince people to call me before they go to the ER or urgent care. Many of them still imagine their phone calls or secure messages are “bothering me,” despite my reassurance that this is exactly why I charge a monthly fee.

The past week has produced a couple of promising opportunities, one with a self-insured local business of 200 and one with a labor union of nearly 1,000 people, inquiring about my services. While both of these may not work out, the fact that I am getting these contacts encourages me that there are many such entities out there looking for an alternative to the agonizingly irritating and inconvenient world of American Medicine. My job is to work with these groups to give them what they need without compromising the quality of care I have been able to give. I need to grow, but grow in a way that lets me add new services, expand my staff to broaden the scope of my care, and allow for more investment into making a business and clinical infrastructure that will scale up without overwhelming me or my staff.

That’s probably the best thing that has happened: I’ve become much more patient with the process. I won’t dive at opportunities that offer revenue without taking the time to work out a plan. I am in no big hurry. My original goal was to grow this to about 1,000 patients, but the fact that I can handle 400 patients with one (beloved and highly capable) nurse and not feel at all overwhelmed, makes me think that it could go significantly higher than that. But it can only go there if I am careful to build it well, with much planning and care in implementation.

A Rob blog post would not be complete without a mention of (of course!) computers. My home-baked (and half-baked) EMR system is working reasonably well, and I’ve been able to pour much of my creative time and energy into building a much more stable “2.0” version of it. Since I had no good record system when I made the first one, it was put to use well before bugs were worked out (and before I really knew what I was doing). This new system is much more efficient, stable, and reflects some of the radical changes to my clinical thinking this new practice has allowed me to embrace. More on that later.

At the beginning of 2013 I stared into the great unknown of this new practice. I had no idea which plans would succeed and which were foolish dreams. The road was much more difficult than I expected, but also much more satisfying. I spent much of my time learning what doesn’t work, but in the end learned that most good ideas grow out of the remains of a hundred bad ones that didn’t survive.

Now, as I face 2014 I see great opportunity. My dreams are still big; I am more convinced than ever that this model of practice could be a game-changer for American health care. But my ambitions have grown smaller. I now enjoy the practice of medicine more than I have in many years, and am delighted by the same expression on the faces of my patients. It doesn’t suck to be a doctor any more, and it doesn’t suck for my patients to go to the doctor! My ambition is to keep that reality alive for me while making it available for more patients. I want them to be happy, and I want to be happy.

It’s nice to think it actually could be a happy new year.

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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Blog log

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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