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

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

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

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

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.

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

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

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

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

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.

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.
?PowerMed
?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

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

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

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