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Friday, February 5, 2016

Wisdom from a toddler

Feb. 5 is the 3-year anniversary for my practice. Yes, my practice is now a toddler.

I could say the cliché things about it seeming like yesterday, yet like it has been forever since I worked anywhere else. I guess I just did … so there's that. But more to the point is the reality that I actually survived. Many expressed confidence in me when I started doing this, while many others expressed supreme skepticism over whether or not this type of practice could actually work. To both of those groups of people I say: keep waiting to make your final judgment. The practice, while profitable and now growing steadily, is still not near to the point I need it to be. It's heading in that direction, but there are no guarantees; I still could mess this thing up.

So what have the past 3 years taught me? What pearls of wisdom can I give to doctors considering following my journey away from the sick-care symptom that is quickly burning doctors out?

It is much, much better.

This is a huge understatement. There is no comparison of life in this practice and my previous existence.

I was on a collision course with burn-out when I left my old practice. I was seeing 25-30 patients per day, spending a distressingly large amount of my time away from my patients, documenting and submitting data so I could get paid. I was feeling less and less able to give them the good care I was capable of. I was making people wait for 30, 60, and even 90+ minutes to have a few minutes with an increasingly depressed and distracted doctor.

Our EMR system, one which I had championed for many years, was becoming increasingly difficult to work with, focusing more and more on meeting documenting requirements and “meaningful use” criteria, and significantly less on improving care and ease of use. I was certainly sad to leave my patients and set out on this new project. I didn't really know what I was moving toward, but I was not sad to leave the system which made it impossible to give these people the care they deserved.

My new practice has surpassed my expectations. Now up to over 650 patients and with 2 1/2 employees (1 is part time, not sawed in 2), there still isn't a wait when people come in to be seen, and I still have much more time with them than I ever could have had. A “busy” day now is when we have more than 8 patients coming to the office. I get far more hugs, many more delighted customers, and people are evangelizing their friends and family so much that I've hardly spent anything on marketing. We rarely hear complaints, and when we do we fix problems as quickly as possible.

My nurses are happier too. They are far more engaged in direct patient care than they ever were in the old system. The reality is that in the old system they were simply “support staff” who enabled the doctors to see as many patients (and make as much money) as possible. Since we are paid each month based on how happy we keep our customers, they are on level playing ground with me in being profit-centers for the business. Their willingness to save people money, to quickly handle problems, or even to fill out paperwork people need for their care, is 1 of the main things that keeps people paying each month. Both Jenn and Jamie say that I've spoiled them forever, and they'd never be able to go back to the old assembly-line type of practice.

Patients are better customers.

I've read some doctors who balk at the idea of patients being called “customers.” The truth is, it is absolutely wrong to consider them as customers in practices like the 1 I left 3 years ago. If you define customer as being the person who pays for the product sold, the true customer in most of healthcare is the insurance company or government payer. Considering patients as customers in most practices is like dairy farmers considering cows as their customers: they are interested in keeping their cows happy and healthy, but only because they make more money that way.

But now, working in a practice where I am paid by the people I treat, I see that they are far better customers than the third-party payers. I also see that I am a far better doctor when I consider my patients as my customers. The reason for this is simple: it aligns my business motivations with what is truly best for my patients. Having patient customers motivates me:
• to be more efficient
• to be responsive to their needs
• to save them money whenever possible
• to keep them well (which allows me to grow my number of customers)
• to listen to what they truly want from me.

So what about the idea that the customer is always right? Will this make me more prone to give antibiotics or addictive drugs when doing so would be inappropriate, to tell people hard truths, or to avoid controversial topics that may upset them? While such behavior may turn away some people (and I'm sure it has), it tends to turn away those who I don't want as my long-term customers.

Plus, the assumption that people don't want doctors who insist on doing the right thing is 1 which paints them in a very negative light. It assumes poor judgment on the general population, which I think is wrong. When I go to get my car fixed, I want a mechanic to listen to me, but I won't tell them how I think the care should be fixed. But should that mechanic ignore what I have to say, I'll likely find another when I next need help with my car.

The primary product I sell is accessibility.

Contrary to what most people would say, the epicenter of health care isn't at the doctor's office or the hospital; it is wherever the patient is between office visits or hospitalizations. To phrase it in another way: the best measure of the quality of my care shouldn't be how many office visits I have with my patients, but how few of them there are. If this is true, then the question is, how do we minimize patient visits without giving worse care? The answer is obvious: use different forms of communication and lower the threshold for which the patient can communicate with us.

One of the clearest examples of how bad our system has gotten is when patients told me that they waited to see me “until they got sick enough.” That's like waiting for my “check engine” light to go on before addressing problems with my car. Why not handle problems before they get big? Why not check people's blood sugar and/or blood pressure between office visits instead of waiting 3-6 months to see how things are going?

The biggest difference people see when they come to my office is that I am not afraid of my patients. I don't have nurses handling calls in a way that “protects” me from them (as was the case in my old practice). The quicker and easier we can handle problems, the better my practice works. If someone has poison ivy, they send me a picture of the rash and I treat it. If a person needs a note for school or home because of a virus with a fever or diarrhea, I give it to them without forcing them to come in and prove to me they have either (i.e. bring in the diarrhea). We can hear the history on the phone or via secure messaging, and then if the person needs to be seen, it is only to fill in the gaps of the history we already have.

This doesn't lower the quality of care, it raises it. People are more willing to communicate with us, and are less likely to let small problems fester and turn into big ones. Plus, they get a far more pleasant experience in the office, as the wait times are still close to 0 for most office visits.

I set off on this journey with the lofty idea that this practice model could change our system. While I still believe that fact, I am far less interested in preaching that fact and far more interested in doing what I've always wanted to do: give as good of care as I can for as many people possible. Three years behind me and even this business amateur hasn't messed this up. My practice is more fun, patient centered, simple, fulfilling, and personal than my old practice ever was. I also give much better care than I ever could, and I do so paying much more attention to saving people money.

To those who said this never could work, I say: so far it is working far better than I ever thought it would. To those who expressed implicit confidence in my success, I say: It wasn't ever a sure thing I'd survive, I did spend most of my savings to get through the first 2 years, and we still have to grow enough to make this thing sustainable, but doing so without diminishing what makes my current practice so much better than my old 1.

We are not there yet, but perhaps the goal is coming into sight. If it doesn't, I may just throw myself to the ground and scream.

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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