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

Wednesday, April 16, 2014

Going gets tough

Sorry for the long gap between blog posts. I have been distracted by the volume of work that I have had to do. Is that a good thing? Yes. Is it a bad thing? Certainly.

I recently heard an interview of Mark Cuban, the owner of the Dallas Mavericks basketball team, billionaire entrepreneur, and one of the “sharks” on the show (that I have never watched) “Shark Tank.” Apparently, the show involves entrepreneurs the opportunity to pitch their “next big idea” to propel with real money who can fund the business and ensure its ultimate success. The interviewer asked Cuban what the biggest mistakes entrepreneurs and business owners make are. His answer was that most small businesses or start-ups fail not because they lack a good idea, but they simply don’t execute on the good ideas they have. A good idea, even brilliant and ground-breaking one, is not enough to ensure success.

I have lived this. I know it is true. I believe strongly in the idea behind my practice:
• that doctors should work for patients, not payors;
• that communication, not documentation, should be the center of care;
• that rewarding doctors for healthy patients who do not need expensive procedures is a better business model than the opposite.

I see the look in people’s eyes when I explain how I do things: a look of both understanding of what I am doing, and complete confusion over why such a better business model as mine is not dominant in our country. I have heard repeatedly that I will succeed. The concept at the core of my business is too sound to fail. I’ve learned to ignore this kind of talk.

This kind of talk used to really bother me. How could I get praise for an idea (much less one that is not originally mine)? I felt that this kind of praise simply gave me more pressure to succeed without helping me get to that point of success I so coveted. I am not so bothered by them now, instead choosing to simply ignore them. The words of Mark Cuban spoke to why listening to them is so seductively dangerous: no matter how good of an idea I have or how hard I work, the secret of success is in the execution and implementation of the idea, not in the idea itself.

This has been borne out in recent events. In December we seemed to hit our stride. Everything seemed to be working well and Jamie and I felt like we had finally figured out how to do this new practice thing right. January was a banner month here at the office, with a flood of new sign-ups and a surge in our office revenue. February was similarly successful, but brought with it a sobering realization: We were falling behind. I had planned on hiring another employee to help us stay ahead on things, but the fear of messing up our chemistry, the dread of training someone new in a system (which we were inventing while we were doing), and the increased cost of that employee’s salary made me hesitate.

Normally I see hesitation and caution like this as a good thing. A good idea will still look good tomorrow, so sleep on the big decisions (my Dutch ancestors are now standing and applauding). But in this instance my hesitation allowed us to get overwhelmed by the work we needed to do. We felt like we were getting more and more behind, with more on our plate than we could handle. The quality of care started to suffer, and for the first time ever we heard complaints.

This made it clear that the risk of hiring someone and bringing that big internal change in our office ecosystem was far outweighed by the risk of not hiring someone and letting our accomplishments be washed away in the work created by our success. So when I was contacted by Jenn, a nurse from my old practice who both Jamie and I got along with well (notwithstanding her propensity to be a bit too “spunky” before 9 a.m., in my opinion), I jumped at the chance to bring her in. This week is her first full week of work, and we are already wondering how we made it without her. Now Jamie and I actually have time to work on things that need to get done, rather than just field the flood of new patient requests, lab results, pharmacy requests and computer glitches.

My goal is not to have fodder for good blog posts. My goal is not to impress people with my great ideas. My goal is not to get pats on my back or praise from my colleagues. It’s not bad to have any of those things, but the goal I have is much bigger, and is long-term. I want to be part of the proof that we can do better than to give people the sickness-centered, treatment-heavy, over-priced, and chaotic care most Americans are getting!

Proving something, however, is far harder than explaining it in a way that sounds sexy. So that is why I’ve become more quiet. My focus is to build a sustainable business that will grow, sustain me and my family, offer excellent service, and serve as a template for others to do the same. We are not there yet. We have made a good start, but the goal is to finish well, not to start well.

Here are my goals as we move ahead:
1. Build a highly organized system that handles my patients’ medical needs effectively and efficiently.
2. Build a record system that focuses on care quality, not on E/M compliance, ICD and CPT codes, and defensive medicine.
3. Give patients access to that record, and give them the ability to update and edit it as needed. Since most of my updates are made by me asking them what has happened, why not have them do it directly?
4. Integrate communication tools with the collaborative records.
5. Integrate task management tools with these records as well.
6. Go through patients systematically and see who is due for care, then reach out to them.
7. Find ways to grow without diluting the personal care they have gotten over the past year.
8. Find other ways I can save money for my patients, such as dispensing of prescriptions (at wholesale), negotiating prices for radiology tests and other procedures, and working with specialists to create a “cash economy” where they are paid cash up-front in exchange for a discounted price.
9. Increase the number of services I offer to better meet my patients’ needs. Dietary education, exercise plans (and perhaps memberships), counseling services, and other things that could improve the quality of care my patients receive.
10. Working with small businesses to save them money and give their employees care that is not excruciatingly expensive and annoying.
11. Building a community within my patients that will let them interact (anonymously or in person) so they can help each other. Having “group visits” for patients with similar needs, for example.

There are lots more buns in the oven at this point, and which direction I go will be largely determined by what my patients tell me. The bottom-line is that, while I am happy/proud/relieved to have made it to this point, the hard part may still be ahead.

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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