Wednesday, December 17, 2003

Less filling, tastes great

Yesterday I ordered some office furniture from Plummers, which is slightly more upscale than Ikea. Since my office is really small (an 8 x 8 foot room), I had to make sure everything fit and optimized my space. It isn't the cheapest stuff, but also not the most expensive. It still came out to about $1500 though.

A recent article in American Medical News talked about getting seed money to startup new practices, and the consultants in the article gave figures of up to $150,000 in startup costs for a solo family physician. Yikes! I'm more like this guy. It depends what kind of practice you want. I'd rather have one that's less filling (than tastes expensive).

Countdown: 19 days until target start date

Monday, December 15, 2003

Old fashioned values, 21st Century gear

Things are progressing as I slowly move towards opening my solo practice.

I started moving in a week ago, much to my pleasant surprise. I thought the acupuncturist might end up staying past his 30 day notice, but he did not. The sink fit, but the carpet got soaked from the installation. No matter, as that is going to be replaced.

The cable installers came today, and installation was a breeze. I assigned myself an email address to be used exclusively with the practice. I had originally thought that HIPAA required that any email communication had to be via a secure encrypted server, which meant going with a free service, like the ones offered by the California Academy of Family Physicians or by Medem. Or you could pay $50/month for secure email through RelayHealth.

The problem with CAFP's site is that it is not fully compatible with Macs (my platform of choice), so I and my Mac-using patients would be left out of some functions. Since I am in California, I hope that CAFP can fix the website to allow full functionality for Mac users. In fact, I'm going so far as to volunteer to be on an advisory committee on technology issues for CAFP to make sure that it eventually comes to pass.

Medem is advertiser-supported, meaning your free website has to display ads, unless you choose the non-sponsored version which costs $30/month. The email service is called an "online consultation" and permits physicians to charge a fee if they want to or not. My reading on the subject so far has been that very few patients are interested in paying for email communication (or phone calls) with their doctor.

RelayHealth looks like a great site and I have used their eScript prescription refill service at Kaiser. It works well. But they do charge quite a bit, basically $600/yr. If I ever consider hosting my own website, maybe I'll consider them again.

My interpretation of HIPAA is that while secure email is best, unsecured email is permitted as long as you disclose to the patient that this form of communication is not totally confidential, and that as long as they understand this and agree to this avenue of communication, then a physician is not going to be penalized for using regular email. We'll see how well things work.

How will I get patients in my new practice? I hear this question a lot.

Word of mouth, of course. I am getting more and more requests from people/friends as to when my practice will start, and what kind of insurance I will take. We had a Christmas party last weekend, and one friend said she already has 5 families lined up for me whenever I'm ready. I even handed out some homemade business cards my daughter made on the computer, just so people could get the word out.

One of my daughter's friend's father is a graphic designer who just recently left a big graphics design firm to start his own business (just like me!), and he offered to help me design something for free (although we eventually agreed we would barter his services for a complete check-up). He showed me his designs today for identity logos which blew me away with how professional they looked. To paraphrase an old movie line, "I could be somebody!" with business cards that looked like they belonged to a Fortune 500 company, rather than a one doctor operation in a small suburb. The hard part will be trying to decide among the 6 great designs he came up with and choose which one will represent me.

Email. Business cards. Logos.

It is all part of an image I will be trying to present to my target population. That of a caring, community-oriented, small-town family doctor who is also extremely accessible and technologically savvy. Old fashioned values, 21st Century gear.

Countdown: 21 days until target start date

Monday, December 08, 2003

What's in a name?

I got the keys to my new office today. I guess I should say, our new office. I am sharing a 4 room suite with a psychologist (my landlord) and a chiropractor, who each have one room. I have 2 rooms. Two *small* rooms: a 9'7" x 9'5" exam room and a 8 x 8 foot windowless room, which will serve as my office.

The pedestal sink I bought was incompatible with the plumbing fixtures, so the landlord and I made a quick trip to Home Depot to buy a cabinet style sink which looks just fine. There are holes in many of the walls where a bunch of cabinets used to hold large quantities of pungent and bitter-smelling Chinese herbs. The landlord said that he and the chiropractor both lost patients because of the smell, so he is glad that I am moving in.

The landlord also kept telling me how busy the previous tenant, an acupuncturist, was. But he chose not to renew his year-long lease, instead going on a month to month lease. That was what enabled me to take his space, because the landlord wanted a tenant with a long-term commitment. I'll try not to make that mistake when my lease renewal is due. This is assuming my practice is a success.

What to do next? I have to get furniture for my tiny office, and chairs. Bookshelves. I don't know how I'm going to be able to fit everything in my office, since I would prefer not to leave anything out in the common area, at least nothing of significant worth. I know my wife wants to have some say in the color of paint, and wall decorations.

A major project will be ripping up the carpet in the exam room to lay linoleum tile. This is to allow for easier cleanup (and a more sanitary environment) just in case someone has an "accident". After all, besides being my own nurse, receptionist, biller, and office manager, I also will be my own custodian.

I also have to figure out how to fit a refrigerator/freezer in to store my vaccines.

And business cards. And newspaper ads. And business stationary.

The phone installer is coming between 8AM-5PM tomorrow. Talk about a "narrow window". Good thing I have the whole day off. And the cable installer is coming next week to hook me up for cable modem internet access (which I've found to be faster than DSL for home use; plus I hate the local phone company that provides DSL service).

A lot of things to juggle. As a family physician, I am used to that.

The landlord asked me how I wanted my name printed on the signs outside. "No middle initial?" he asked after I told him. No, I preferred a simpler identity. First name, last name. M.D. But then I wondered what to put after that. "Which sounds better? Family Practice or Family Physician?" I asked him and his wife.

I had recently read about the American Academy of Family Physicians voting to rename the specialty "family medicine" instead of "family practice" ; and "family physicians" instead of "family practictioners".

"While it may be semantics to some, perception is everything," Lindholm said. "I specialize in family medicine. If our own colleagues in medicine don't understand that we're specialists, I don't think our patients can (understand), either."

It is something all family physicians have to put up with, I think. Our patients don't know what kind of doctors we are. Many assume I am an internist, or a pediatrician (when I see a child), or a general practitioner. This mirrors the findings of focus groups questioned by the Future of Family Medicine Project, which found that a third of patients who saw a family physician didn't know their doctor was a family physician.

The landlord and his wife both thought "Family Practice" sounded more familiar to them, so I told them to put that after my name on the sign. But now that I think about it, I would rather be known as a family physician than a family practitioner. Time to think different, just like my solo practice model.

So tomorrow morning, i will call the landlord and tell him to put "Family Physician" after my name. Because that's what I am. And proud to be.

Countdown: 28 days until target start date

Sunday, December 07, 2003

An end (and a beginning)

I did something yesterday I had never done before. I attended the funeral of a patient. Except that Charlie was not exactly a patient in the usual sense.

At Charlie's funeral, a crowded affair at his Mormon temple, I learned some things about this man whose life briefly touched mine. He was a devoted family man with 5 children, very active in his local community helping out with T-ball leagues, was very spiritual in his faith. He worked as a mortician, which struck me as somewhat ironic. The many stories and remembrances shared by his family and friends reminded me that we tend to lionize those who pass away, and yet I wondered if I could ever be as good as man as Charlie seemed. I suppose even the most accomplished person still has some regrets when he/she dies.

After a period of waiting, things seem to be rolling ahead again with my solo practice venture. The current tenant of my future office space is indeed moving out on time, and I hope to be able to start moving in starting tomorrow. I bought an inexpensive pedastal sink at the local hardware store for less than $100 to be installed in the one exam room, and a handyman is scheduled to install it tomorrow.

I had been told by the malpractice insurance agent that I had been approved for coverage last week, but still had not received the official notice yet. That was because they had mailed it to my future office address, and I did not have access to it yet. Luckily, the landlord held the letter for me which I opened today. Surprisingly, the annual premium was less than what I expected, about $5000 for the first year. It will go up gradually every year for 5 years, as I increase my patient panel (and presumed malpractice risk). I have to mail back a check and then I will be covered.

I finally received my EMR program last week, too, after ordering it a month before. First it was delivered to the wrong address. Then by the time I got the disc it turned out to be the version to upgrade the program rather than the software for a new installation. I have been playing around with it, but of course, I won't really know how well it flows until I start charting a real patient encounter.

I've ordered some hardware. A Palm Tungsten C loaded with Epocrates Pro, InfoRetriever and some shareware medical programs. I have a demo of Bluefish Rx, too, which is a prescription writing program. It allows printing and faxing of prescriptions, but I think it costs $20/month for the fax service. In the interest of keeping costs down, I think it will still be cheaper to handwrite prescriptions for a while. But the *Wow Factor* of being able to fax prescriptions from my PDA is certainly intriguing and fits into my model of a smalltown practice utilizing 21st Century technology.

I bought both a black and white laserprinter, and a multifunction inkjet color printer/fax/scan/copy machine so that I could save on some space, which I won't have a lot of in my new (small) office.

I hope to finally start moving in to my new office space tomorrow. Such is the natural cycle of life. Some things come to an end while other things begin anew.

Goodbye, Charlie.

Countdown: 29 days until target start date

Sunday, November 30, 2003

There is no medicine like hope

Charlie died last night. At home, in the presence of his loving family, peacefully.

He and his wife had seemed resigned, accepting of the inevitable when I met them 4 days ago at his home. Sitting upright in an armchair, hooked up to an oxygen tank, he was having a hard time breathing then, because of the mets to his lungs and the resulting fluid buildup in the pleural space. But he had been at peace, spending his time meeting friends and family who dropped by to say hello, and a final goodbye. The hospice team was wonderful, they said, and couldn't have been kinder. It occurred to me that Charlie was lucky in a way, because he had had a chance to say goodbye to those nearest and dearest to him before he died. How many people, I wondered, got a chance to do that?

That day I explained again the information I had found about the clinical trials on pancreatic cancer, and encouraged him to enroll in the study. Also, I told them that I had ordered a bottle of enzymes for him to try, but unfortunately it was "out of stock" and wouldn't arrive until the day after Thanksgiving. Charlie and his wife were very appreciative of my concern and efforts on his behalf, even though I wasn't his doctor, or even his friend. I just wanted to help him buy a little time, and have a little hope when there was little chance of either. I guess I didn't know it at the time, but I was trying to practice "chivalrous medicine". Coincidentally, the current issue of Family Practice Management has an article on this subject:

Chivalry is not merely a civil duty meant for young men of yesteryear. Rather, it is a lost art that physicians - both male and female - can practice today. Being chivalrous requires effort, self-sacrifice and giving of oneself without expectation. A chivalrous physician respectfully places patients' concerns before his or her own (within reason). Fundamentally, being chivalrous demonstrates to others that you are a person who actively pursues the moral high road and realizes your character, perpetually evolving, is linked to your deeds. Chivalry is simply acting with kindness.

I brought the bottle of enzymes by two days later, on Friday evening. Charlie had had a rough day and could barely speak because he was so short of breath. As I handed the bottle to his wife, she asked me, "What do you think?" And I said, "You've got nothing to lose." She nodded her head with a hopeful smile. "What do I owe you for this?" she asked. "Nothing," I said, and I meant it. "Thank you so much," she said as I left. "It's my pleasure." And it was. The next night, he passed away.

It occurred to me that I might have done a disservice to Charlie and his family by offering false hope when there was none, instead of allowing him to accept his eventual death without a fight. Normally, I don't believe in futile treatments. But there was something about Charlie's situation that made me want to try to help him no matter what. Probably because he was so young, a few years older than me, and I could identify with him more than usual.

I believe that even though I didn't help Charlie live one second longer, I still helped him with the only treatment I had left: Hope. As Orisen Swett Marden said, "There is no medicine like hope, no incentive so great, no tonic so powerful as expectation of something tomorrow."

This website on bladder cancer discusses end of life care and the value of hope as a treatment option:

Some practicing oncologists consciously uses hope as a treatment tool. In ancient times, when medical technologies were more limited, the physician's appreciation of the therapeutic uses of hope was much more refined than it is today.

Even if one has no difficulty accepting the prospect of death, human beings need hope. To hope for a miracle is something we are capable of doing until the very end. There is no such thing as false hope.

This is the kind of medicine I want to practice, medicine that doesn't end when pills and drugs and knives can't do any more good.

Charlie, I hope you're doing fine.

Countdown: 36 days until target start date

Sunday, November 23, 2003

Medicare: Opt in or Opt out?

I spoke with Charlie's wife today (see previous entry). He is hanging in there, helped with some steroids. But he is very weak and getting out of bed is very hard for him. They haven't pursued any other course of treatment, I suspect because it is all so overwhelming. I got info from the clinical trial using pancreatic enzymes, and while it looks like he could be a candidate, I'm not sure he can wait for them to reply if we sent in all the info now. His family is more or less resigned to the inevitable and are trying to enjoy their time with him.

So I went ahead and ordered some pancreatic enzymes myself ($300) and am having them shipped overnight. I believe it's worth a try, and if it buys him some extra time, then it would worth more than $300. I charged it out of my business charge account, so I figure I can write it off as a business expense even though I don't intend to ever make any money from this. I have arranged to go over to Charlie's house on Wednesday since I have never met him, and just wanted to say hello (and I figured that would be a good time to bring over the enzymes, too). Isn't this what being a doctor is all about? Helping others for the sake of helping, rather than financial gain. Wouldn't that be a wonderful world if it could work just like that all the time?

This is my final (regular) work week at Kaiser. After this week I am taking a "terminal vacation" until my final resignation day on Jan. 5th, although I did agree to work 3 days in December as an urgent care doctor to help handle the expected spike in colds and flus. I am looking forward to the end of this week very much, mainly because it is the beginning of the end for me. I'll be able to finally catch up on everything, without accumulating any new patients or labs or calls.

I'm in a holding pattern with my solo preparations. Awaiting to hear from the malpractice insurance company, so that I can tell the hospital credentialing department, so that I can submit my applications for participation in Aetna/Blue Cross/Healthnet, etc. I've been waffling back and forth over Medicare participation. I'm not so concerned about the low reimbursement; it's more the fear of being prosecuted for minor unintentional violations of one of Medicare's regulations.

From a 1997 article in Family Practice Management:

The Medicare reimbursement system for physician services is complex, contradictory in the dual worlds of fee-for-service and managed care, and dangerous for those who would ignore its pitfalls. Because the rules continually change, Medicare offers a full plate of management challenges for physicians who seek its benefits but also must guard against its threats. Although the prospect is daunting, preventing false claims is manageable when taken in small bites. Physicians who had to be good students to become doctors need only approach this system the same way.

And that's from a positive take on Medicare. There are lots of negative opinions on Medicare such as this. But I have to say, this "fringe" group of the Association of American Physicians and Surgeons (who are these guys anyways?) would seem more credible if they didn't also call for a halt to requiring new vaccinations.

On the other hand, I do want to help elderly patients with their healthcare. But not at the cost of my future livelihood or career. Maybe I'll be like Gordon Moore and just not charge Medicare patients. Which way to go? Opt in or opt out? I'm getting a headache.

OK. This doesn't look so good. Medicare's Resident and New Physician Guide is only 168 pages long. Migraine alert!

I asked one of my patients at Kaiser last week what he would consider to be a reasonable fee for a regular office visit (if he didn't have insurance). He said he thought $40-50 would be a fair price. And that seems fair to me, too. I have a hope that there might be enough patients in my local area who may or may not have insurance but feel that $50 is a fair price for a 15 minute office visit, too. And if I opt out of Medicare, perhaps that is not too much for seniors to pay? I could offer a senior discount. That is something I could not do if I accepted Medicare. Even if a Medicare patient wants to pay me more than the reimbursement limit of their own free will, I would be forbidden from accepting it. How much sense does that make?

Part of the reason I'm leaving Kaiser is for greater autonomy. I'm trading Kaiser's job security for professional freedom. It would appear that in accepting Medicare, I lose both security and freedom. Perhaps it's not such a tough choice after all. Now where's my Extra-strength Tylenol?

Countdown: 43 days until target start date

Sunday, November 16, 2003

Time = Medicine

I went into work today, even though the clinic is closed. This is a time when I can go in undisturbed and call patients back ("I didn't expect you to be calling on a Sunday, doc"), take care of abnormal test results, catch up on all my charting. But today I spent about 3 hours trying to help someone who isn't even my patient.

The parents of one of my daughter's classmates have a brother-in-law who was diagnosed a month and a half ago with a tumor, and it wasn't until a couple of weeks ago that a 2nd biopsy showed that it was metastatic pancreatic cancer. I got involved because he has Kaiser insurance, and his relatives were hoping that, as a Kaiser physician, I could help him figure out the best way to get action. I guess they felt like they weren't getting enough communication from his doctors.

I've never met Charlie. The only time I spoke with him about a month ago, he sounded pretty normal and he was grateful that I could answer some questions for him. My wife is a pathologist and she also reviewed his biopsy slides as a favor, but she could only confirm his diagnosis. When she saw him he appeared strong and healthy. Today he requires an oxygen tank because he gets short of breath with even mild exertion. Such is the nature of pancreatic cancer, one of the deadliest cancers because it is so hard to identify. Most of the time, by the time it is diagnosed, it is too late to treat because it has already spread to other parts of the body. In medical school, we were taught that most patients with pancreatic cancer have less than 6 months to live.

In his case, I think Charlie would be grateful if he could last another 6 months. His doctors told him that they didn't think chemotherapy could help him at this stage, plus he is already weak and short of breath. His wife told me today that he doesn't want to spend his remaining time suffering from the effects of chemotherapy, especially when it is unlikely to help him anyways.

This is so unfair. Charlie is only 49 years old. As his wife said, they know there is a reason for everything, but right now they can't understand why this is happening. I don't think anyone can.

I remembered one of my patients who was diagnosed with liver cancer a few years ago. Probably because he is Chinese, he also consulted with a traditional Chinese medicine doctor who treated him with herbs and acupuncture. His cancer regressed and has not shown any signs of return ever since. His hepatologists and oncologists can't explain it, and have used his remarkable case as a topic of discussion at their conferences. I called him up so I could get the name and phone number of his Chinese medicine doctor. Charlie's wife was grateful to take the information. At this point, what did they have to lose?

I also remembered reading about a small study from a few years ago. A doctor treated 11 patients with inoperable pancreatic cancer with high dose pancreatic enzymes. The average survival time was 17 months, or three times the usual survival time. The longest survival time was 4 years. It was intriguing enough to warrant further study, so now there is an NIH study looking at the use of nutritional therapy to treat pancreatic cancer. I left a message with the principal investigator to see if they were still enrolling patients.

I dug deeper on Google and located a website that claimed to have the exact same formula as the enzymes used in above study, and was selling them for $275 for a bottle of 360 pills. The "ideal regimen" requires 6 bottles a month. I also sent this info to Charlie's wife today and told her that there was no way to know if this enzyme therapy really works, or if the pills being sold were the same ones used in the study. But because doing nothing is equivalent to accepting death, I told her that if it were me, I would try it.

This reminds me of Laetrile, a controversial anti-cancer treatment that we used to discuss in a medical ethics class in college. What can you do when modern medicine has no answer? Is it right to recommend treatments that are unproven, yet expensive, for a terminal condition? Are they just taking advantage of the desperate? Perhaps.

And yet, this is also about hope, a necessary part of medicine and healing. If I hadn't been able to spend 3 hours researching this stuff, I would've had to shrug my shoulders and say, "I'm sorry, but there's nothing more that can be done." I like to give people choices. I want to be able to spend this much time finding those choices for all my patients, not just the sickest. I want time to think, to look up evidence-based answers to clinical problems. Time is what is in short supply in my practice now.

This is another reason why I want to start a solo practice. To have the time to practice better medicine, to know that I've tried my best. Because everybody deserves the best. Especially Charlie.

And now, there is only one other investigational medical treatment I can do for Charlie, and that is to pray.

Countdown: 50 days until target start date

Thursday, November 13, 2003

Forms, Forms, Everywhere are Forms

I hate filling out forms. FMLA forms, DMV physicals, employment physicals, worker's comp, nursing home clearances, insurance forms, disability. I don't mind doing the exams and evaluations. It's filling out the forms I hate.

So it's a major accomplishment for me to finally complete and send in my application forms for:

1) malpractice insurance.

It was a tossup between The Doctors Company, Norcal Mutual and SCPIE. They all had good track records. SCPIE had a slightly lower rating on A.M. Best, an insurance rating company. Norcal seemed pretty good, but I didn't like how the sales rep badmouthed the competition. The Doctors Company is physician owned, so I figure they should have my best interest at heart (more than an insurance company would), so I went with them.

Three years ago, I was named in a malpractice suit because, even though I hadn't seen the patient in 2 years, I was the patient's primary care physician. The woman who had had asthma diagnosed for years ended up having a rare bronchial adenoma which acted like a ball valve and caused shortness of breath. A transfer to another hospital for surgery was delayed, and she ultimately developed pneumonia and died despite having the adenoma removed. I was named, I guess, because a physician reviewer thought I should have diagnosed it earlier, even though all her chest x-rays were always normal, even though this kind of benign tumor is very rare, even though she saw many other doctors during that time. After my thorough review of my notes, I felt that I did nothing wrong. But the defense attorneys hired by Kaiser were pushing hard for a settlement, telling me that if I didn't agree to a settlement that I could end up being liable for a lot more than the settlement amount of $250,000. I even asked a colleague physician (who was also an attorney for Kaiser) if he thought I should settle or not. He said I should settle, so I reluctantly did. I've regretted it ever since, more for the principle than anything else. The attorneys and my colleague did not have MY best interest at heart, it was all about what was best for the organization.

But now whenever a form asks, "Have you ever been named in a malpractice case?", I now have to say "Yes" and explain the whole thing. I've never really had to worry about malpractice before. Kaiser provides its own malpractice insurance. But now that I'll be on my own, it's an area I'm very much concerned with. The more I read about malpractice, the more I realize how broken this system of jackpot justice is.

2) Supplemental info for disability insurance.

They wanted proof that I made the income I said I did. So last year's tax forms and paystubs were copied and sent. I was reminded last night how important disability insurance can be when I dislocated my left pinky finger while playing basketball. I spent an hour and a half in the ER getting x-rays, then reduction (YEEOWCH!), then a splint put on. While I was waiting, I thought about how lucky I was to have a relatively minor injury, and felt reassured that I have good disability insurance for now. If I didn't, would I have to stop playing my weekly basketball? I also wondered what price people would be willing to pay for medical attention if they don't have insurance. It cost me nothing, but a visit like this could easily run someone without insurance over $200, I think. And I feel guilty wondering if $50 is too much to charge for a 15 minute office visit.

That's the thing about working at Kaiser - I don't have a good sense of what physician time is worth. I only know how much I get paid. Once I calculated my pay taking into account ALL the extra time that I put in, not just scheduled clinic time, and it worked out to about $50/hr. But of course, I don't have to pay for overhead. A survey in Medical Economics magazine found the average FP charge for a level 3 visit was $105 for new patients, and $65 for established patients. Hmm, maybe it wouldn't be so bad if I asked for $60 for an office visit.

3) Hospital privileges

I dropped off the forms to Huntington Memorial Hospital, the best known hospital in the area. So much stuff to assemble: CV, DEA, medical license, board certification, 2 passport-sized photographs, list of CME credits. They said it would take about 6 weeks to process, but I'm still missing proof of malpractice coverage, since I just mailed that in yesterday, so it will probably take longer. I had to wait until I got an address for my office before I could send in the applications.

One part of the application I couldn't fill out was the part where they asked who will cover my patients during any absences or vacations. Since I have only been with Kaiser for the past 13 years, I have had very little contact with any non-Kaiser physicians. The only ones I know, in fact, are the ones I play basketball with. So the medical staff personnel gave me a list of family physicians on staff whom I could call to ask if we could arrange some kind of cross coverage, so I could get my application approved.

I would really rather not cover someone else's patients, and I had been planning all along to not have to ask anyone to have to cover my patients. It takes a lot less work to take care of someone you already know. I figured that even if I go out of town, it wouldn't be for very long, and I would still be accessible by cellphone and/or email. In a true emergency, I'd tell the patient to go to the local ER anyways, or call 911. So I left a message with one FP's receptionist, and will await his callback to discuss possible arrangements for coverage. This is a new culture for me, and I don't know what is the norm here. I guess I'll find out.

Next up: forms for participation with Aetna, Blue Cross, Blue Shield, etc. Arrrgghhh! Did I mention how much I hate filling out forms?

Countdown: 53 days until target start date

Monday, November 10, 2003

Swimming Against the Current

I ordered a laptop computer over the weekend. A new Apple PowerBook G4 12 inch 867 mHz for $1299 from I had thought at first that I would get one of the new 15 inch G4 laptops, but there have been reports of "white spots" on the screens, plus the cheapest 15 inch model costs $1999. Does the extra few inches of screen space and small increase in processor speed warrant an extra $700? Especially when I've realized that I will also need to get a second computer to act as a server? I decided it didn't.

I have used the demo of my future EMR program on my wife's laptop, a 400 mHz PowerBook and it seemed fast enough, so I'm not worried about processor speed. I could have gotten a refurbished PowerBook from the Apple Store for $1199, but I figured an extra hundred bucks for a new machine is worth it to me. Although my experience with Apple computers is that they are very well made and last a long time, longer it seems than comparable PC computers. For example, the computer I'm typing this on is a 4 year old Blue and White G3, which I upgraded to a G4 and is still going strong. In fact, I plan to use it as the server for my medical office, while I buy a new G5 for my home office.

One of the email messages on the Practice Improvement listserve today is from a doctor having problems with his PC computer. He can't move received faxes from one computer to another, is having trouble using an OCR (optical character recognition) program, backing up data is a "nightmare". He writes:

does anyone know what the error message "not enough server memory" means? i have hired a computer wizard (formerly of intel) to fix everything, and he is stumped. he even called microsoft, and they don't know what's going on. yes, i have run virus scans (norton and others, all up to date), and the system is clean. i have un-installed roxio, iomega, omnipage and have even re-installed the operating system, all to no avail.

the good news is that business continues to grow, but if i don't get this problem fixed, i can't get paid.

send help!

ps-- is this an object lesson about our dependency on computers?

I think this is an object lesson about our dependency on Microsoft which has used its monopoly power to force the acceptance of its inferior computer products. I have used Macs since they first came out, and while they have their share of problems, too, they are MUCH easier to use and fix than PC's. I am forced to use a PC at Kaiser, so I know how inconvenient they are to use. As a physician who will become dependent on his computer for medical record keeping, financial records, medical billing, posting payments, email and fax communication, medical education/references, and basically my livelihood, I think my choice of computer platforms is one of the most important ones I can make.

Sure, I could choose fancier EMR and billing software if I went with a PC, but is that enough to make up for the hassle factor of keeping up with patches to guard against viruses, worms and bugs that can bring down my system at any time? Why would I want to get a computer system that requires a technician to fix (if they even can), when I can fix any problem my Mac has? I just need something that works, and doesn't get in the way. Macs just work.

This is consistent with the concept of a low overhead practice. It is a myth that Macs are overpriced compared to PC's. Actually Macs are the same price or cheaper when compared to a PC equipped with the same features. And how much overhead (time, money, hair) goes into maintaining a PC network? More than a Mac network.

Okay, enough prosletyzing.

It feels strange to be a double revolutionary. Going solo in a managed care world is hard enough. Going solo with a Mac is really swimming against the current.

Countdown: 56 days until target start date

Thursday, November 06, 2003

OK, first, let me point out how hard it is to write an entry every day. At least, for me it is. I have a newfound respect for those bloggers who are able to write every day.

Next, I'll explain that the folktale in the previous entry was inspired when my wife told me about our daughters' visit to a relative's house last weekend. We had been having a lot of wildfires (we're in Southern California) and the relative commented that there was a lot of dust and ash and she was concerned that it might trigger her daughter's asthma condition. When my wife asked why she didn't close all the windows and doors, the relative said that their fung shei expert told them that they had to keep the windows open to allow for the positive flow of energy. It just reminded me how much influence others have even when it flies in the face of common sense. And not just those in alternative or complementary health. Even the most uninformed person's opinion will command attention by others, as long as they're really sure they're right.

All doctors have come across this scenario: A patient tells you they stopped taking all their medicines because their brother or cousin or co-worker or friend told them that their medicine is dangerous. We may ask rhetorically, "Are they a doctor?" If this were TV, the patient would reply, "No, but they did stay at a Holiday Inn Express last night."

I am counting down my last days here at my job. After today, 11 more working days until I take a "terminal vacation." In the past few days, I've opened a business checking account (Washington Mutual had the lowest monthly fee - $8 - if you go below $2500 balance); yesterday my notice got published in the local newspaper; I submitted my application for a city business license ($350). I and a friend rented a U-haul van and we picked up the used exam table, which is now sitting in my garage.

I've been looking at new and used laptop computers, trying to figure out if I need a fixed computer server. I think I'll get a high speed scanner just because I don't want to stand there and scan individual sheets of medical records into the computer EMR. I definitely want the fax machine hooked up to the computer so it gets downloaded once. I did call ATT and got my telephone numbers already, even though I won't move in until next month. Now, I can get business cards, which people are already asking for.

Still a lot to do. But looking forward to doing it.

Countdown: 60 days until target start date

Monday, November 03, 2003

The Doctor (a folktale updated)

Not so long ago there lived a doctor who went every day to her clinic. There she saw patients with various complaints. She listened to their hearts and lungs with her stethoscope and checked their reflexes with her reflex hammer. She helped many patients feel better. She was happy with her work, and never thought she wanted anything more.

One day the doctor advised a very rich man that he should lose some weight and get more exercise. But the rich man told her that he didn't need to lose weight and exercise because he just bought a bunch of fat burners from the clerk at the health food store. And not only that, he stopped taking his blood pressure and cholesterol medicines because the health food clerk told him that if he took a special blend of garlic, ginseng, vitamin E and co-enzyme Q-10, then he would have an optimal level of health that he had never even dreamed of. The next day the doctor's work seemed harder. Her stethoscope and reflex hammer seemed heavier. She thought to herself, "If only I were a clerk at a health food store, I would not have to work so hard."

Her wish was heard by the spirit who lived in the clinic. That next day, when the doctor returned to her little clinic, she saw instead a beautiful health food store! She saw rows and rows of shelves filled with shiny bottles of blue-green algae, pycnogenel, chromium picolinate and antioxidants. She had dozens of customers lining up to buy their supplements. As she was furiously ringing up their orders, she could overhear a women telling the rich man down one of the aisles, "Don't waste your money on those fat burners! Don't you know how dangerous they are? My psychic healer told me about this noni juice. Look at me, I've lost 15 pounds already! I bet I could get you a 20% discount." As the rich man left the health food store with the woman, the doctor thought, "If only I were a psychic healer! Then I wouldn't have to work so hard."

The clinic spirit heard her. Suddenly the doctor was dressed in a flowery bathrobe and fuzzy slippers, eating a breakfast of pancakes, bacon and eggs. She had cases and cases of noni juice piled high in her kitchen, living room, bedroom and garage. She was quite happy collecting checks and cash from the comfort of her own home for more orders of noni juice until one day, she got a call from the rich man demanding a refund because he had not lost any weight. The rich man said he was switching to Body Solutions because the radio traffic reporter had lost 25 pounds with it. The doctor was outraged. "No matter how much money I make, the radio traffic reporter's power is by far greater. If only I were the radio traffic reporter!"

With a flash of light the clinic spirit turned the doctor into a radio traffic reporter. From her place in the sky she could look out over the entire world. To show her great influence, she described how long it would take to get to work, which freeways to avoid, and why you should copper repipe your plumbing. Day after day she pitched Body Solutions. Then one day her traffic report was pre-empted for a feature story on an author of a bestselling diet. Her voice could no longer reach the rich man. The doctor thought, "Is it possible that this author of a bestselling diet is even stronger than a radio traffic reporter? If only I were an author of a bestselling diet!"

No sooner had she spoken these words than the clinic spirit turned her into an author of a bestselling diet. She could now reach the rich man even with the radio turned off. Before long her wallet was once again filled with green. The speaking opportunities bloomed and her schedule was filled with bookings on all the major talk shows. But the doctor was overcome by her new power. She began to publish book after book. She was on Oprah 17 times. She went to the Oscars. Soon everybody had bought a copy of her book, except for one person. The rich man's great aunt. She told her great nephew that this fad diet stuff was a bunch of hooey. After all, didn't she live to be 92 on her daily diet of sardines and pickles? "You're right, Auntie," said the rich man as he flushed his Body Solutions down the drain. "Besides this stuff tastes like crap."

The doctor was astonished. "Everyone has been swept up by the force of my bestselling books except for the rich man's great aunt. Perhaps the rich man's great aunt is even stronger than an author of a bestselling diet. If only I were the rich man's great aunt!" The clinic spirit heard her wish and turned the doctor into the rich man's great aunt. Proudly she stood up. Then she lost her balance and fell on her hip.

She was rushed to the hospital, and as she lay in the emergency room she heard a strange noise at her feet. She looked down to see what it could be. She saw a woman raise her reflex hammer and strike it against her knee. She felt her painful leg twitch all through her aged body. A chill swept over her as the cold stethoscope pressed against her chest and listened to her heart and lungs. "Don't worry. We'll fix up that hip so it's as good as new," said the surgeon, reassuringly. At that moment she realized that a doctor might not be the strongest of all anymore, but could still be counted on to make a difference when it really mattered.

adapted from The Stonecutter, a folk tale retold by Martha Hamilton and Mitch Weiss (Beauty and the Beast Storytellers) from Stories in My Pocket: Tales Kids Can Tell.

Countdown: 63 days until target start date

Friday, October 31, 2003

Tricks and Treats

Lots of new stuff.

Applied for $20000 loan from 401k 3 days ago. Got it today. Time to open a business checking account.

Submitted DBA for publication in local newspaper. $50 for 4 weeks, once a week. Got ad rates.

One of the parents at our kids' school recently left his graphic design company and started his own business, and said he could design business cards and a logo for me.

Looked at a used exam table from a semi-retired surgeon who is the husband of a friend of my wife. It is older style, but in good shape. He is letting me have it for free. Wheee! Saves me about $900 for a comparable table.

I also ordered my EMR today. SpringCharts for $495 + one year of support for $500. Mainly because the sales rep said the price was going up to $3995 next week since they were coming out with version 5. I get a free upgrade, so I saved myself $3000. It's not as full-featured as some of the more expensive EMR's out there, but this area seems to be changing so quickly that I can't see investing my whole startup funds towards this one tool.

Now I'm looking for other areas to cut back on for startup costs. Maybe I can make do with a used laptop, rather than a new one. It's all about keeping the costs down.

Countdown: 66 days until target start date

Tuesday, October 28, 2003

Passing the buck

One of the things I have disliked about working at Kaiser is that many patients just have no regard for the cost of health care. Because it is a prepaid health plan, most of the time they only pay a $10 or $20 copay, or none at all.

At least once a week, somebody comes in with a sore shoulder or knee and says, "I think I need an MRI." And several times a day, someone asks about Nexium or Celebrex or whatever the latest prescription medication commercial is pushing. A little old lady with no problems walking asked me to order her a motorized scooter, just like her neighbor, because "Medicare will pay for it". Can you imagine what would happen if full body CT's became covered? Yikes!

Part of my role at Kaiser is to be a guardian of our members' health care dollars. I know full well that higher utilization of high costs drugs and tests will only mean higher copays and premiums to the patients. But some patients feel like they are owed the world because they (or their employer) pays for their health care premiums. And no, I don't get paid more for restricting health care spending. At Kaiser, we physicians are paid the same regardless of how many tests I order or how many prescriptions I write.

This recent entry on MedRants refers to an article that discusses how patients will overutilize health care if they don't have to pay for it. Of course. It's only human nature. It is certainly something I've seen firsthand.

Case in point: When Viagra first came out, men would make appointments for physicals, back pain, athlete's foot, and right at the very end, casually mention that there was one other problem they wanted to discuss. And I'd have to evaluate whether they had a "medically necessary" condition justifying Viagra, or if they didn't, in which case they'd have to pay for Viagra on their own.

Many men clearly had erectile dysfunction. But some just wanted to try Viagra because they heard that it made sex "better". One guy asking for Viagra was married, but his wife was living overseas. And he hadn't seen her for the past 5 years. Turns out he had a mistress in the States! What should I do with that???

It just didn't seem right to me that Kaiser member dollars were being spent for a condition which wasn't clearly "medically necessary". And I resented being made the sheriff in charge of who should get treatment and who shouldn't.

A few years later, Kaiser revised the terms of its coverage and now covers treatments for sexual dysfunction as a separate category, paying 50% of the cost, rather than 100%. Now when patients ask for Viagra, I just prescribe it for them. Maybe it's because Viagra's been out for a while, or maybe it's because of the increased cost-sharing, but I don't get too many requests for Viagra anymore.

I realize this is not the current trend in health care coverage. We currently have two ongoing strikes in Southern California, one by the grocery workers, the other by the bus mechanics, both over the issue of health care costs. The employers want to pass more of the cost to the workers; the union wants the employer to pay for all of the workers' health care.

As a physician entering a fee-for-service world, I look forward to having patients bear more of the costs of their health care as a way to maintain checks and balances, to reduce the spiraling cost of health care. Those who want an MRI for that shoulder pain can still get it if they really want to pay for it. And those who really need it will find their money well spent. But I'm aware that there will also be situations that I didn't encounter at Kaiser, like when someone can't get necessary treatment because they can't afford it.

And what am I going to do when patients can't afford to see ME? Hmmm.....still thinking.....

Countdown: 69 days until target start date

Sunday, October 26, 2003

Things to do

This has been a weekend of family activities (gymnastics competition for my daughter, UCLA football game at the Rose Bowl, going out to dinner), and no work. Not that there isn't any work for me to catch up on. For the past decade, as a family physician my Saturdays have usually been taken up seeing patients until noon and then using the remaining time to try and catch up on paperwork, callbacks, labs, etc.

It will be nice to not have to work on the weekends for a change, as I intend in my future solo practice. I don't think I'll mind the occasional calls and hospitalizations as long as they don't occur too often. Maybe I'm just deluding myself. We'll see.

Some of the many things I need to do (this week if possible):
1. Take out loan
2. Open business checking account
3. Submit legal notice of DBA to newspaper
4. Apply for malpractice and business insurance
5. Apply for hospital privileges
6. Apply for participation in Medicare and commercial insurance carriers
7. Submit business license to city hall
8. Get business cards
9. Change address on DEA, medical license, medical societies
10. Order laptop computer and EMR/billing software
11. Write farewell letter to current patients

Here's a new practice checklist which also lists some things that need to be done when opening a new practice (at least in California).

And of course, I've overextended myself again. I promised I'd do an article review for American Family Physician (due last week). I have to review the videotaped simulated interviews done by some 1st year UCLA medical students and critique them.

But I can't complain too much. Not when thousands of people are evacuated from their homes tonight because of the wildfires raging through parts of Southern California. Let's hope the fires get put out soon.

Countdown: 71 days until target start date

Thursday, October 23, 2003

A Day of Surprises

It has been a day of unexpected surprises. The technician came to process my disability insurance application this morning, but did not need to draw any blood. Instead, he only collected urine and ran a dipstick test, and sent the rest off for an HIV test. I didn't even know you could check HIV using urine. Perhaps that's a test I could run in my practice. The technician found out that I was planning to open my own practice, and said he needed a family doctor and would come see me when I opened my practice. I even diagnosed tennis elbow and GERD in him.

I hadn't heard from the landlord who had gone on vacation to China, so I thought I'd give him a call to see if he was back yet. He was not only back, he had been back for a few days. I guess I was under the impression he was going to call me when he got back. He must have thought that I was going to call him, since he did write that he was going to return on 10/20/03 (only I didn't notice that part in his letter until today).

I mentioned to him that I had reviewed the lease agreement with a lawyer (actually a friend who is an attorney and looked it over for free) who recommended some changes. I think the landlord became very defensive upon hearing that. Have you ever had an encounter with a patient where you get this sinking feeling, that for some reason the rapport is just going downhill? That happened to me once right after I walked into the room. "So, Mr. Jones, why are you here today?" "How should I know. You're the doctor." It was kind of like that.

After a few tense minutes during which I was wondering what was going on, I realized he must have misinterpreted what was going on. I think he was worried that I might become a nit-picking, problem-causing tenant who was going to argue over every little thing, and he probably didn't want a tenant like that. It is true that I have been thinking about renting this space for over a year. (That is why there is an acupuncturist there now instead of me, because I took too long to decide.) Since this whole office lease thing has been completely new to me, I kept questioning every cost and fee, to make sure I wasn't getting ripped off. The landlord would usually explain that that was the customary way of doing things, but how could I know for sure?

Anyways, I said to the landlord that I wanted our relationship to get off to a good start, that it has taken a long time for me to make this decision, but with good reason. I am taking a huge risk to leave my position of the past 13 years to go into solo private practice, so I am going to be very cautious and make sure that everything I do is right for me and my family. But I thought that this could be a very successful practice and I hoped that we would have a good working relationship.

Apparently I said the right thing. He said he thought I was the right practice for that office space and that he was very happy to have me as a tenant. After I got home from work, my daughters and I walked (walked!) over to the office, met briefly with the landlord and his wife, and picked up the lease agreement. And now that I have taken them back home and reviewed them, I signed them.

I think the landlord must have known that I was planning to take the space, because when we went over tonight, he gave me a little stack of junk mail that was sent to me at that office address. At first I couldn't figure out how that happened, since I was careful not to list that address for anything official. Then I remembered that I had submitted a DBA (Fictional Business Name request) using that address about 2 weeks ago. At the time, I had felt pretty confident that I would be taking that space, plus I figured if I didn't get that space, I could just file another DBA form. But I was a little embarrassed when the landlord gave me my mail. So for future reference: file a DBA, get junk mail.

I will return the lease agreement to him in the morning, then it'll be off to the races!

Countdown: 74 days until target start date

Wednesday, October 22, 2003

Taking shots

Who would have guessed that you could trigger hemolytic anemia, induce tonic-clonic seizures and rupture someone's appendix just by giving a flu shot?

Of course, I'm kidding.

Yesterday I successfully administered 5 influenza shots, 1 vitamin B-12 injection (hey, it really IS red), and a Prevnar shot (to a 2 year old) without having to call 911. Alas, I was not so successful giving a PPD, as it did not raise a wheal as it should. So the nurse had to give it again, while I apologized to the patient who must have thought I was a resident. It's harder than it looks.

The hardest part is doing everything in one sequence. Uncap needle with prefilled syringe . . . tear open alcohol swab . . . wipe deltoid with alcohol swab. . . . pinch skin . . . insert needle intramuscularly . . . draw out for any blood return . . . inject vaccine . . . pull out needle . . . deposit syringe in sharps box . . . get band-aid . . . open band-aid . . . find injection site . . . apply band-aid . . . breathe sigh of relief! I kept putting the needle and syringe on the counter after I did the injection, but luckily no one got an unintended needle stick. The nurses do this all day. I imagine I will become as proficient as them if I keep doing it over and over.

I'm getting a little worried about my startup cost projections. Others in the Practice Improvement email group mention starting their practices with as little as $7500. Originally, I thought I'd need just $10,000, but lately it's been going up, and now I'm thinking $20,000 is what I should borrow from my 401k. Although I should only take out what I need, I am also worried that I won't take out enough, and have to take a cash advance off my credit card. Even though there are 0% credit cards, they are only for a short time, then a high interest rates kicks in. I figure I'm better off taking out more than I need (at 5% interest), rather than having to take a cash advance at 15-19% interest later.

Then there's always Plan Z: buying a Lotto ticket. I see the jackpot is up to $98 million. It's worth taking a shot, right?

Speaking of shots, I'll be getting stuck tomorrow morning by a technician coming out to draw blood for my AAFP Disability Insurance application. Hopefully his needling skills far surpass mine.

Countdown: 75 days until target start date.

Tuesday, October 21, 2003

Giving it a shot

I'm still waiting for the landlord to return from his trip so I can sign a lease on the office space. He said he needs 30 days to give notice to the current tenant, and 2 weeks to fix up the office. That means I probably won't be able to move in by December 1st. I'll probably have to move back my target start date.

In the meantime, I asked the head nurse at our clinic yesterday if I could practice giving flu shots today. She smiled and gave me one of those bemused looks that one gives a child when he asks, "Can I listen to your heart?" as he places the stethoscope on your head. She must have been thinking, "How cute! The doctor wants to give shots."

It has been a few years since I've given a shot to anyone, but I do cortisone injections a lot, so it certainly couldn't be that difficult. What I'll really need practice in is giving pediatric immunizations to a screaming at the top of his lungs, kicking your teeth out 2 year old toddler who can't be bribed with a lollipop. Maybe I should add chloral hydrate to my list of startup supplies?

Countdown: 76 more days until target start date

Thursday, October 16, 2003

Every Patient Has a Story (Blogs as Narrative Medicine?)

My wife (who is also a physician) emailed me a recent article from the New York Times titled, "Diagnosis Goes Low Tech". Interestingly enough, it was in the Arts and Science section, not the Health section.

Endoscopy. Sigmoidoscopy. Electromyography. M.R.I. These days, the main interaction between doctor and patient is often technological, with doctors relying on complex diagnostic tests that make use of the latest advances in medicine.

This technology has become a religion within the medical community," said Dr. Jerry Vannatta, former dean of the University of Oklahoma College of Medicine. "It is easy to lose sight of the fact that still, in the 21st century, it is believed that 80 to 85 percent of the diagnosis is in the patient's story."

Yet medical educators say that doctors are insufficiently trained to listen to those stories. After all, there is no reimbursement category on insurance forms for it.

It is this lost art of listening to the patient that has been the inspiration behind a burgeoning movement in medical schools throughout the country: narrative medicine.

I think this is part of what I am trying to achieve with my solo practice. A focus on the patient not just a physical body, but as a person with a past made up of memories and secrets; a present filled with family, friends, work, play, pleasure and pain; a future built of hopes and dreams. All culminating in a story that is somebody's life.

Plus, you need to have enough time for the person to tell their story. (I suppose it's possible to write a great short story in 15 minutes, but it's not likely.) My practice will give patients the time to let their stories unfold. This is what we try to teach the 1st year medical students at UCLA, where I am one of the volunteer faculty, as part of their Doctoring Program.

One of the articles we have the medical students read brings home this point. First published in JAMA (Journal of American Medical Association), an attending physician is trying to impress upon a group of medical students how every patient, no matter how ordinary they seem, has a story to tell. He directs them to find the most boring, uninteresting patient is the hospital wards and he will demonstrate his point. The students find a little old lady, originally from Europe. The attending proceeds to interview her and despite quetioning her for a long time finds that she has had a very ordinary life. Just as the attending is about to give up, he notices that her past medical history mentions a broken arm. How did you break your arm? A suitcase fell on it. How did a suitcase fall on it? It happened because the boat was sinking. When did the boat sink? When I was a little girl coming to America. What was the name of the boat? The Titanic.

It turns out she was one of the few remaining survivors from the last voyage of the Titanic. After that, she received a lot more attention and newspaper articles were even written up about her. This is a rather dramatic example, but you get the idea.

But the narrative medicine movement is part of an ongoing trend in exposing medical students to the humanities. It is needed, educators say, to teach aspiring doctors to pay close attention to what their patients are saying and to understand the way their own emotions affect their perceptions, and ultimately their clinical practice.

The basic teaching method is to have medical students read literary texts and then write about themselves and their patients in ordinary language, rather than in the technological lexicon of the traditional patient chart.

Hey! Isn't that what these medical blogs are all about? Can I get CME credits for this?

Countdown: 80 days until target start date

Tuesday, October 14, 2003

Getting off the hamster wheel

Nothing much is happening on the solo practice front, not until I sign the lease agreement.

But I still have my own patients at Kaiser whom I am taking care of. I have begun telling some of my more regular patients that I will be leaving to start my own practice. Everybody has said pretty much the same thing: "We're sorry to see you go", "We know you'll do well". "Can you recommend a good doctor to take your place?"

Today I saw two patients for first time physicals with me, and of course, we used up much more than the 15 minutes allotted for each visit. I felt bad when I told them afterwards that I was going to be leaving, but I felt it only fair that they know that I would not be following up with them for long.

I am supposed to write a "farewell letter" to my patients in the next two weeks. The clinic will then mail it out to all my patients. Some on my panel have never even met me, and will no doubt wonder why they are receiving this letter. However, because of a confluence of circumstances, I won't really be leaving on my final day.

I plan to continue working part-time for a few months since I won't have any regular patients of my own in my solo practice at first. It will take several months for me to get approved for participation with the various insurance carriers. Plus there is currently a hiring freeze at Kaiser so they won't be able to get a replacement doctor for my patients. My boss plans for me to continue to be the primary care doctor for my patients even after my resignation from the medical group. So even though I will be gone, I won't be.

Some days I wonder why I am leaving. I read an article today about how doctors at Kaiser are among the happiest and most satisfied in California, compared to doctors in other managed care organizations or private practice. I really do believe that Kaiser provides very good medical care. It consistently wins awards for quality of care. Plus it offers a good stable and secure lifestyle for most physicians.

But then I have days like today, when I am moving from exam room to exam room, trying to catch up, seeing patients for physicals who also have 3 other problems they want to discuss, then on to the next patient who's here for a cold, and by the way has 4 other things they have questions about, and so on. Then the next patient is sticking his head out the exam room door wondering if I've forgotten about him.

This article from the British Medical Journal describes this situation as "hamster health care." It certainly describes how I've felt about my medical practice for the past few years. This article also mentions the "Kaiser Reward", defining it as "the more efficient you are in seeing patients the more patients you get to see." Some reward.

Through the years, I've developed another interpretation of the "Kaiser Reward". The more patient and compassionate a doctor you are, the more complex and chronically ill patients you'll collect. Once you get a reputation as being a patient listener, then nurses and other patients spread the word and eventually, the patients who like to talk, the patients with 12-inch thick charts will find you. Good for them. Not so good for a doctor who only has 15 minutes per patient.

As the article says, "Systems that depend on everybody running faster are not sustainable." I agree, and that is why I am getting off the hamster wheel.

And not just because I am tired of running. I also want to walk in a new direction, towards providing *excellent* medical care. Maybe some day, I'll even get there.

Countdown: 83 days until target start date

Sunday, October 12, 2003

A Piece of Cake

I looked over the office lease agreement with a friend who is a lawyer, and while there were a few items that could be improved, overall it seemed in order. However, the landlord left for a weeklong trip to China so I have that long to think about it some more.

I attended the first of six Saturday sessions of a medical billing class yesterday at a local community college. It was attended by young to middle aged people, mostly female, looking to start a new and hopefully lucrative career. However, I wonder how many will actually be successful.

We learned the basic terminology (Medicare, HMO, PPO, clean claims, non-participant, EOB's, etc.), and functions of the various billing personnel. Not too exciting so far. Hopefully, it gets better.

The instructor was familiar to me, since I took a medical coding class taught by him several months ago. Except that for the coding class, I didn't tell him that I was a physician. Perhaps he wondered why I was always one of the first students to finish the coding problems he gave us. I figured he must have had other bright students in his classes before, so I wasn't a total anomaly. He told us several times how he would find coding jobs for the best students in his class. I was in constant fear that he would recruit me to go on a coding assignment for some doctor. (And I think I would've done a good job, too!)

From my observations, most doctors think of medical coding like I think of auto repair. It's a big black hole filled with incomprehensible terms and confusing concepts.

But honestly, coding is easy. Sure, there are some subtle bits of knowledge that aren't immediately obvious, but taking the coding class has taught me that it is a facet of my upcoming practice that I can definitely handle. If I can manage a patient with diabetes, hypertension, coronary artery disease and asthma, then coding is a piece of cake. While I plan to do my own coding initially, I may eventually hire a coder, but it would still be in my best interest to understand what they are doing.

Anyways, by the end of the coding class, the instructor came up to me and said, "Where is your practice, doctor?" so I had to spill the beans. So far, in the medical billing class, I am just another student. I had to bite my lip a little when he started rambling about how physicians have to drive jaguars and get their Italian shoes, but surprisingly many of the students objected, saying things like, "Oh, my doctor isn't like that," and "Yeah, my doctor wears jeans and sandals."

Well, I can't blame the instructor too much. After all, he works at USC, where the doctors do drive Jaguars and wear Italian shoes. But they don't know how to code. And that is why this instructor is making the bucks.

Hopefully, by the end of this class, I will feel about medical billing the same way about coding. I don't think I'll ever be able to afford a Jaguar from my solo practice, but something to replace my 1995 Honda would be nice.

Countdown: 85 days until target start date

Saturday, October 11, 2003

Playing By the Rules

I received the lease agreement 2 days ago, and will be reviewing it over the next few days. Since I felt confident that I will rent this office space, I filed an official DBA (Doing Business As AKA Fictitious Business Name) yesterday at the county recorder's office. I will be practicing as (drum roll) . . .

South Pasadena Family Practice Medical Office.

Rather unexciting, but gets the message across that I am in my target community and that they won't have to travel far to reach me.

It cost $10 and they gave me a form that I need to take to a local newspaper in order to publish a DBA notice that has to run once a week for 4 weeks. Our small weekly local newspaper does this service, and I get the feeling it derives a substantial amount of income from them. At any one time, it seems, there are at least 10-15 of these DBA notices published in the classified ad section, more than the actual classified ads.

They also gave me an official DBA form that I can take to a bank to open a business account (using my new business name). Unfortunately, I have nothing to fund this business bank account with yet (except my own money). My startup costs are modest, estimated to be $10,000 to $15,000-ish. I'm not getting any fancy equipment, just the basics. My electronic medical record software will hopefully be inexpensive, as I've mentioned before.

Because we are risk-averse people, my wife and I agreed that I would not use our house as collateral for any business loan. As a result, I have been unable to find any bank willing to make me a startup loan.

OK, I didn't personally go to a bunch of banks and beg, "Give me money, PLEASE!" No, I'm smart. I had someone do it for me. And not just anyone. The person who put together my business plan put me in touch with a loan executive at a major bank. After I described my business concept to him (solo doc, low overhead, high touch, hi tech), he seemed to think it was a winner and said he would call around for me and see who could help with a loan. He did mention that $10,000 was kind of "small change" for the kind of clients he usually dealt with, but he would make an exception in my case.

A few days later, he called me back to say that NOBODY was willing to make that kind of loan at this time. Even people who owed him favors. Ouch. The economy must still be really bad.

I've heard about some loan companies that are willing and able to lend doctors money, but I suspect they do so by charging a high interest rate. Rather than do that, I've decided to invest in myself, and borrow from my 401k plan. I am allowed to borrow up to $50,000 and even after I resign from my current position, I can continue to pay back the loan, rather than count it as a disbursement. I would have to charge myself 5% interest (prime + 1%), but that's a much better deal than taking out a cash advance from a credit card and paying 19% interest. The downside is I would then be making only 5% interest on that part of my 401k investment.

All this business-type stuff has been completely foreign to me. At Kaiser, we physicians are shielded from most of this. I feel like I'm learning a new language. I certainly didn't get this kind of training in medical school or residency. This is a subject matter that we could learn from other practitioners, like chiropractors.

As a child, there were many things that I could be when I grew up. I definitely remember that I absolutely did not want to go into BUSINESS. But as I learned more about the practice of medicine, I realized that Medicine Is A Business (TM). And that good medical care involved knowing how to play by the rules. That is why I'm now willing to go into business for myself.

I want to make some of my own rules.

Countdown: 86 days until target start date.

Wednesday, October 08, 2003

A Really Good EMR?

Yesterday someone posted an announcement on one of the email listservs I subscribe to reporting that AAFP, Medplexus and GE Medical Systems had some kind of agreement for discounts for their EMR (Electronic Medical Record) systems. This is sort of good timing for me since my goal is to go with completely electronic medical records, ie. no paper charts in my new solo practice.

However, this strikes me as falling short of AAFP's original goal of a low-cost, open-source, platform-independent EMR system. I suspect most EMR companies aren't interested in giving their product away, so maybe a discount is the best they can hope for.

A computerized medical record system is the goal of many physicians and medical offices, but has been fragmented in implementation. There are dozens of programs out there, some more polished than others. Most are incompatible with each other. Most cost thousands, some in the tens of thousands of dollars.

Dr. Gordon Moore, the family doctor who started this whole solo-solo doctor thing, went with the Alteer system, which combines electronic medical records with a scheduling and medical billing program. I've seen demos of it, and it looks very sharp. But it costs $20000! By the time I paid off the loan for it, I wonder if it will be obsolete, or if the company will still be in business. I decided that I would rather not spend that much on an EMR system. Since much of the success of this practice will depend on keeping my overhead expenses low, I am planning on going cheap --- er, I mean, frugal.

My EMR choices are limited not only by price, but by computer platform, too. I have used Macs ever since they came out almost 20 years ago. Not only are Macs easier to use, but they are much more stable and secure compared to Windows computers. But there are very few EMR programs for Macs, compared to Windows:

?ComChart, based on FileMaker, a database program.
?MediMac, which is supposed to be coming out with a version that runs on OS X.
?SpringCharts, which is a Java-based program. This last one looks the most promising to me, mainly because it is "Priced far less than published industry norms" ($500). And it works on my Mac! (At least, the demo did.)

I also have the option of running Virtual PC ($250) on my Mac, and getting AmazingCharts, an inexpensive Windows-based EMR which also goes for $500. But then I'd have to deal with all the bugs, viruses and patches to maintain the Windows system. Is it worth the aggravation and wasted time?

So bottom line, unless the discounts for Medplexus and GE's Logician are really substantial, I think I'll be going with SpringCharts or AmazingCharts and save up my money for a really good EMR.

Ironically, we've been hearing for the past 10 years at Kaiser that an EMR is coming. It's always been "a few years" away. Now it looks like I will be getting my EMR first.

Countdown: 89 days until target start date

Tuesday, October 07, 2003

Crest of the Wave

I'm experimenting with different looks for the site. Hopefully nothing looks too weird but things will keep changing.

I and my family met with the landlord 3 days ago and walked through the office space again. As I remembered, it was small and cozy. And the smell! That's because there is currently an acupuncturist there who has jars and jars of various pungent herbs and whatnot sitting on the wall. One of my daughters has asthma, and she could only last 15 minutes before she began getting symptoms and we had to get out of there.

That is one of the reasons why the landlord wants to get another tenant in there. He said he has lost some patients (he is a clinical psychologist) due to the smell. He has a small office that is part of the same suite, so in essence we would be sharing the suite.

In addition, because I am trying to keep my initial costs low, I will be renting out 2 of the 3 offices, and sharing the space with a chiropractor. The landlord tells me that the chiropractor is 65 years old and ready to retire at any time. Since he is on a month to month rental, I can essentially take over the 3rd office any time I want. And to be sure, I will make sure it is written into the contract.

So, we basically agreed in principle that I will rent out this space. The landlord says he prefers a minimum 2 year lease (naturally), but my wife is still a little nervous about the whole venture and would prefer a 1 year lease. Even though we both feel that the practice will be a success, and everyone whom we've talked to in the local community also has told us it will be a success, we both still feel nervous since it is our first self-employed business venture ever. What if nobody comes? What if there is suddenly a huge recession/depression? What if I get disabled? What if I can't stand the hassles of coding and billing and all the other administrative headaches?

I am very reassured by Gordon Moore's recent email message after his visit to the National American Academy of Family Physician's convention, where he said there were many doctors who have made the leap to solo practice, or are planning to do so. He calls it "the crest of the wave". It's kind of exciting to think I might be part of that wave.

Something clearly needs to be done to fix healthcare in America. Perhaps it is us doctors who can right things back again. One little wave at a time.

Countdown: 90 days until target start date

Friday, October 03, 2003

Trading Spaces

I arranged to meet with the landlord of an office building about half a block away from my house tomorrow morning. This is an office that I had first learned of over a year ago when my wife told me she saw it listed in the back of the local medical society journal. I had never noticed this building before even though I must have passed it hundreds of times. Since then I have taken a walk-through twice, so maybe the third time's the charm. It is very small, about 700 square feet. The rent is $1399/month (works out to $2.00/sq. ft. Offices near the hospital are $2.50-3.00/sq. ft.), but I have the option of renting out only 2 of the 3 rooms for $1000/month and the chiropractor who is already there will stay on in his month to month lease. I was told I would have the option to "move into" the 3rd room anytime.

Since my practice model is to go small, with low overhead and no employees, it doesn't bother me to have a small office. The coziness of it all may add to the "small town charm" I'm trying to establish. One room will be my office, the other will be the exam room. There is already a waiting room and a receptionist area that won't get much use. Eventually, I will rent out the 3rd room, and use that for storage and as a place for my daughters to hang out when they come visit. Currently, they come to my office at Kaiser about once or twice a month while I do paperwork. My office walls are their art gallery and my patients comment all the time about their creations.

Other offices I have considered: a comparably sized 2 room office (but it is on the second floor of a building with no elevator - bad for elderly and wheelchair-bound patients); a medical office in the neighboring town which is very nice (but then I can't really market myself as being the ONLY family practitioner in South Pasadena when I'm not even located in South Pasadena); the first floor of an old craftsman-style house (but would need a lot of work to re-make the living room as an exam room). It's a lot like buying a house, but with a much smaller inventory. Fortunately, office rents are nowhere near the stratosphere like housing prices are in this burb.

Besides being the most suitable, the 1st office is on the ground floor, and is next door to an already established OB-Gyn doctor. This could result in some synergy, as newly-delivered mothers would no doubt need the services of a doctor who could do well child checks and treat the sundry colds and flus.

Plus you can't beat walking across the street to go to work.

If I sign a lease, the landlord said he would need 30 days to give notice to the acupuncturist who is currently occupying the space, then 2 weeks to paint and fix up. That would mean December 1st is the soonest I could move in, giving me about 1 month to get ready to hang my shingle by January 5th. Can it be done?

It's quite a leap to go from a physician partner in a secure organization to being on my own. The enormity of it all is slowly seeping into my consciousness, as I think about all the things I still have to do. "Controlled chaos" is my best description. But it's nothing compared to the controlled chaos that modern managed health care has become. I just hope I'm not trading a frying pan for the fire. Uh, hmm . . . . is it just me or is it starting to get hot in here?

Countdown: 94 days until target start date

Thursday, October 02, 2003

On Hold

I had a problem with the "comments" function, but it is fixed now that I am using Haloscan. All previous comments were lost however.

My inexorable trek towards medical autonomy is basically on hold until I can secure an office space, since no one will issue malpractice insurance without knowing where you're going to be practicing.

Since I am specifically targetting a small city (South Pasadena) because of its lack of competition (0 family practitioners), I am limited by its 3.2 square miles of space. I must have looked at every available office space in town in the past year, some more than once. Since I plan to be a solo practitioner with no employees, my space needs are very modest. Gordon Moore, who started this concept of low-overhead practice, works out of a single exam room he rents from another physician with a rent of $500/month.

There are very few physicians in this town (Dr. Drew Pinsky AKA the Loveline Doctor, 1 OB/Gyn, 1 Pediatrician, 1 Ophthalmologist, 1 Plastic Surgeon) and while I haven't asked everybody, everyone I did ask said they had no space available. I think the reason there aren't many physicians is because they are located in the surrounding communities which are only a few miles away. I'm hoping that there will be at least a few patients who don't want to drive those few miles and see me instead. And not just the lazy ones.

Countdown: 95 days until target start date

Monday, September 29, 2003

Don't leave work without it

I mailed my application for disability insurance last Friday. Even though I have about 3 months to go before I lose my disability insurance through my current job, I figure I'd rather not take a chance of going without it for even a little while. Having needed it once before when an Achilles tendon rupture put me out of work for 3 months, I really understand how important this can be. As a solo practitioner, being disabled would mean no patients and no income without disability insurance. I applied for AAFP's disability insurance which pays you if you are not able to continue working as an FP. I guess some disability insurance plans won't pay if you are able to do some other kind of work.

The importance of having good disability insurance was driven home the week before when one of my friends, a Urologist, was shot 3 times by a disgruntled patient in the clinic. Luckily he survived and is now recovering, while his assailant later committed suicide. Apparently, he had been diagnosed with prostate cancer, but my friend said he had absolutely no warning that anything like that would happen with this person. And I believe it. My friend, unlike some busy specialists, is an easy-going, empathetic and patient physician who takes the time to explain things and listen to a patient's concerns. But he only gets 15 minutes per patient, like me, for returning patients. Some studies have found an association between patient satisfaction and the amount of time patients spend with their physicians. I wonder if things might have ended up differently if they could have had more time to talk. This is something that frightens me, as it should frighten us all. If this can happen to as nice a guy as him, then it certainly could happen to any of us.

As my friend said, "I don't know if I can go back and do things the way they've been done."

I know I won't.

Countdown: 98 days until target start date

Saturday, September 27, 2003

I decided to go home "early" last night (meaning 7:30PM) and finish charting today so that I could have some family time. I came in at 7:30 AM and have been plugging away ever since.

Like many physicians, I've found it hard to balance time between work (where I tend to be a perfectionist) and family. I could easily spend all day here catching up. But my daughter has a gymnastics meet from 1-5 PM today at a gym 45 minutes from here. Then I'm going to try to use my season tickets to catch the second half of the UCLA-San Diego State football game at the Rose Bowl (Go Bruins!)

The time in between work, family and personal time is the time I will get to work on getting my solo practice up and running. Fortunately, I am working half time now, so that gives me some free time to work on it. If I was working full-time, I don't think I could manage the daily grind AND starting a business, so I guess I am luckier than most.

I will also try not to spend too much time on this blog. Bye!

Countdown: 100 days until target start date

Friday, September 26, 2003

Bloody turnips

It's 5:38 PM. I just got done seeing my last patient for the day. I now have 22 charts piled on my desk that need progress notes (there were 2 no shows). I saw 7 physicals, 1 new patient, and the rest were returning patients with various problems ranging from something as easy as rechecking a high blood pressure to a laundry list of problems.

I've timed myself in the past. It takes me, on average, 4 minutes to chart and code a visit. I usually spend, on average, about 20 minutes of face to face time with a patient. So today's work will take me 8 hrs and 48 minutes to complete. I was given 6 hrs to do it in. Something doesn't seem right here.

Yesterday I decided that this situation is analogous to trying to perform phlebotomy on a member of the brassica rapa family:

"Here's another bushel o' turnips. I want 10 gallons of blood out of 'em."

"Uh, I've been squeezing and squeezing, but nothing's coming out."

"That's coz you're not squeezing hard enough."

"I think I'm squeezing as hard as I can. My hands are raw."

"C'mon, you can do better than that!"

"No, I mean it. Look, my skin is falling off."

"Squeeze HARDER! WIMP!"

"OWW! Look what you made me do. Hey, I'm bleeding!"

"See, what did I tell ya? You're getting a good gush of blood out of 'em now."

"What are you talking about? That's MY blood!"

"Look, as long as you meet your quota, we don't mind if you want to bleed on your own time."

OK. Time to chart. Although I'm starting to feel a little ........faint.......

Countdown: 101 days until target start date.

Thursday, September 25, 2003

Why is this here?

Practicing medicine in today's environment is hard enough and getting harder. Too much to do (empathetic listening to patient concerns, diagnosing their ailments, answering questions about herbal supplement XYZ, ordering tests, writing prescriptions, making sure preventive care guidelines are being met, charting a complete and defensible progress note, assigning the correct ICD-9 and CPT codes, making referrals, answering phone messages and e-mail, filling out insurance/disability/school forms, following up on test results, etc) and not enough time to do it in (15 minutes per patient).

Uh, right.

This site will chronicle my attempt to replicate what family practitioner Dr. Gordon Moore has pioneered in his "solo-solo practice" (Going Solo: Making the Leap) in the hopes of regaining some control and sanity in my professional (and personal) life. Hopefully, my experiences can help anyone else who might be attempting the same foolhardy stupid insane brave endeavor, and ease their transition while avoiding some of my pitfalls.

A very helpful resource is Dr. Moore's Practice Improvement website where other physicians share their thoughts and experiences on how to improve the practice of medicine.

Some background: I am currently a Family Physician with Kaiser Permanente in Pasadena, CA, and have been there for the past 13 years. Our clinic is very busy but the people there are very dedicated and hard-working, and Kaiser has consistently won awards for its quality of care. But quality medical care has its costs, not just financial, but emotional and psychological, too. Because of the conditions listed above, I submitted my resignation 2 weeks ago.

Kaiser is a closed self-sufficient system, so basically I'm starting out as if from residency. Others who are already in private practice will no doubt have an easier time of this than me.

So far, I've found that I can't apply for participation with private insurers until I have hospital privileges. Which I can't apply for without malpractice insurance. Which I can't get without a business location. I am narrowing my choices in office space, and hope to secure a business location in the next two weeks. And since it can take about 6 months to get approval for participation in health plans, I may be sitting in my shiny new office with no patients for the 1st 3 months of my fledgling practice.

Hmmm. Did I say this endeavor was brave? I think I was right the first time.

Countdown: 102 days until target start date.