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Thursday, March 12, 2015

How to avoid being a dumb-ass doctor

It's been two years since I first started my new practice. I have successfully avoided driving my business into the ground because I am a dumb-ass doctor. Don't get me wrong: I am not a dumb-ass when it comes to being a doctor. I am pretty comfortable on that, but the future will hold many opportunities to change that verdict. No, I am talking about being a dumb-ass running the business because I am a doctor.

We doctors are generally really bad at running businesses, and I am no exception. In my previous practice, I successfully delegated any authority I had as the senior partner so that I didn't know what was going on in most of the practice. The culmination of this was when I was greeted by a “Dear Rob” letter from my partners who wanted a divorce from me. It wasn't a total shock that this happened, but it wasn't fun. My mistake in this was to back off and try to “just be a doctor while others ran the business.” It's my business, and I should have known what was happening. I didn't, and it is now no longer my business.

This new business was built on the premise that I am a dumb-ass doctor when it comes to business. I consciously avoided making things too complicated. I wanted no copays for visits (and hence no need to collect money each visit). I wanted no long-term contracts (and hence no need to refund money if I or the patient was hit by a meteor or attacked by a yeti). The goal was to keep things as easy as possible, and this is a very good business policy.

Despite this, I've increasingly had to educate my gluteal muscles over the past two years. I am not allowed to abdicate my responsibility as a business owner any more. It's hard, as I have never been one who likes to attend to the numbers after the decimal point or the fine print in the contracts. My ADD screams when these things come into my visual fields, hitting me with the uncontrollable urge to play “Candy Crush Saga” or watch “American Idol.” I want to turn my mind off whenever confronted with minutia. It's taken a while to decondition this Pavlovian response. I am getting better at it.

The good news is that I actually want to get more organized and on top of the business. I am starting to enjoy spreadsheets, budgets, and even task managers. No, I'm not ready for my membership card for Pinheads International. I'm still not able to look at fine print without high doses of caffeine and antiemetics. But things are moving in the right direction.

So how does one avoid being a dumb-ass doctor? Here are my tips for doctors wishing to retrain their buttocks:
1. Don't ever forget that it is your business. No matter how much employees are invested in the business (and mine are as good as they get), nobody cares like you do and nobody pays the price you will pay if things fail.
2. Don't try to change overnight. I've learned these lessons over the past two years; they weren't there in the beginning. I've had to go through the process of change, which has come out of my desire to do best for my patients and still make a reasonable income.
3. Speaking of income, if you start a business like I did, don't forget to pay yourself. It's cool to get new gadgets or fancy task management programs (heh), but they don't pay your mortgage or your kid's tuition. There are plenty of ways that I want to grow the business, but that must wait until the cash-flow lets me do it.
4. On the other hand, don't skimp on things that will let you grow the business or improve service (which means you keep your patients). It's OK to borrow money if it helps bring in new patients and/or retain your present patients.
5. Hire staff that believe in your mission. I can't stress this enough for this kind of practice; my nurses are very dedicated to my practice and bend over backwards for my patients because they relish the chance to take care of people.

All this being said, here are some dumb-ass things that I avoided:
1. I kept it simple. The business of medicine is a morass of rules, codes, and disclaimers. It's way too much for docs to deal with. I don't charge copays. I don't expect people to pay more than 1 month at a time. I don't file insurance. I don't nickel and dime people for charges if I don't need to.
2. I didn't plan too much. I got all bent out of shape in the first few months we were open, as I wasn't doing everything I imagined doing. I realized (after being politely called a dumb-ass by a friend) that it would take time to figure out how to do all of the stuff I hoped to do. We've prioritized what is most important to our patients: access, and have been working to improve the process and quality since then.
3. We didn't grow too fast. This partly comes out of the fact that I was a dumb-ass, deciding to build my own EMR system, and was hence too busy doing that junk to focus on growth. To be fair, the system is the central way we are working to improve our care quality, so it's not all bad. But growing too fast will decrease the quality of care patients are getting.
4. I didn't pay a whole lot in advance for a consultant to give me a business plan I'd just abandon. This business is so new, it would've taken a person with a crystal ball to view into the future and anticipate what would happen. I am very glad I didn't waste the money.
5. I've enjoyed the chance to do what I want. We have fun in our office. We laugh at ourselves and each other. Despite all of the stress of starting a business, it all seems worth it when I think about what I left behind.
6. I accepted and embraced the reality of my dumb-assness. Doing so has lowered my expectations and made me more open to learning and listening to others. Those aren't easy things for us docs to do (I often wonder if “MD” stands for “Major Dumb-Ass”).

That last one is probably the most important one to learn. I have to learn how to learn and that I need to learn.

Ironically, I am grateful for my old mistakes that drove me from my old practice. Without those mistakes I'd still be on the hamster wheel of codes and data, making my patients angry and giving them lousy care. I am now nearly up to 600 patients, have 2 nurses, and am proud of what we do. I am also excited about our future, which is something most docs (and patients) cannot say.

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.

Auscultation
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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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