Where do future family doctors come from?

I came across a recent news article describing how Tulane University is fostering future rural family doctors. There is no question that there are many medically underserved areas in this country. It is also a well documented trend that fewer and fewer medical school graduates are choosing to go into family medicine. It would seem wise to me that instead of focusing on just taking the "best" applicants, medical schools should make a more concerted effort to take the willing, those who want to practice in underserved areas.

In my 2nd year of medical school, I was one of the student representatives of the admissions committee, and we all did our best to find those applicants who appeared to be "doctor" material. Our tools: GPAs, MCAT scores, letters of recommendations, the application form with its one page essay, and for those who made the cut, the live interview. It was always interesting to come across wonderfully articulate essays, and later discover during the interview that the alleged author had at best a weak command of the English language. I learned that lukewarm letters of recommendation ("Joe was a competent student who displayed satisfactory knowledge of the subject material.") could be worse than having none at all. It was then that I realized that anyone who could appear not to be psychotic for at least 15 minutes (twice) could become a physician. This method of selection turned out not to be foolproof, as least at my school.

But it would take some kind of concerted and institutional effort by medical schools to instruct their admissions committees, most of whom are not in primary care, to go after students who showed promise and interest in practicing primary care in underserved areas. A difficult, if not impossible, task. But if our admissions committee had been given specific criteria on what to look for, I'm sure we would have complied. At least, I would have.

From the article:

The school is looking for students like Dr. Margeaux Coleman Walker, who has known she wanted to be a doctor since she was 11 or 12 and helped her grandmother clean the doctor's office in Church Point, a town of 4,700.

But she wants much more than a medical practice. "Hopefully, when I want to retire, I'll be able to say, 'I worked hard and I made a difference in people's lives."

And more:

"If you're looking for more of a 9-to-5 practice where you can sign out and someone's going to cover for you," rural medicine isn't for you, said Dr. James E. Devlin, a graduate of the program.

He's a solo practitioner in Brockway, Pa. (pop. 2,500), checking his hospitalized patients seven days a week. It's hard to find someone to do that if he wants a vacation. But he knew growing up that he wanted to go into practice with his father, who has since retired.

He said he loves being a big fish in a little pond. But more, he loves knowing his patients as friends, as church members, as people. Being part of their community. "I wouldn't trade that for anything," he said.

That's the heart of the matter for Coleman Walker, too. She has done month-long medical school rotations with the current doctor in Church Point, and wants the sort of bond he has with his community.

"He's not only the family doctor - he's a teacher, kind of like a big brother, a dad, because he has to reach out to the young kids and help them, guide them," she said.

OK, I'm not a rural doctor in an underserved area. But I'm trying to bring a similar kind of close patient-physician relationship back to the suburb where I'm at. I think there's a need for this kind of care anywhere. We need to find more doctors and future doctors who are willing to serve people in need. Like in family medicine.

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In the meantime, I've been spending a lot of time trying to catch up on my medical billing. I'm learning if it is worth it to wade through telephone trees and wait on hold for 15 minutes (or more) just to get the health plan to give me 10 more dollars for an injection administration fee that I forgot to bill. Or to find out the reason they denied the $160 charge for a well child exam is because it is a non-covered benefit. For now, I guess it is, because I've got nothing else better to do as I continue to wait for my patient panel to grow. And fortunately, it is growing.

The newest medical tool: an iPod

How's this for convergence? Radiologists at UCLA (Go Bruins!) have figured out an excuse a way to use iPods in their medical practice. Their (free!) product is called OsiriX and helps to manage medical images on the iPods hard drive.

Now if only some bright person could come up with a medical application that primary care doctors could use on an iPod, then I'd have an excuse, uh, I mean, justification to buy one of those little guys. Besides listening to music, that is. C'mon, Epocrates! Port your drug reference over to the iPod, and you are guaranteed an instant market.

Merry Christmas, Happy Holidays, and Happy New Year!

From (flu shot) famine to waste

Like many doctors, I had my order of flu vaccine cancelled because the company I ordered through was selling the Chiron product. Luckily, I had ordered some pediatric doses of flu vaccine just a few days before the bombshell news so I eventually got 10 pediatric doses. Since I didn't have any eligible patients under 3 years of age, I combined 2 doses to make enough for an adult dose and was able to give it to 5 eligible patients. However, I was surprised that even in my small practice, I was having trouble finding patients to give it to. Some of my patients who need it the most still refused to get it, saying they didn't believe in it, or that they had gotten it once and it gave them the flu.

Before I got my small shipment of flu vaccine, I received many frantic calls from patients, both high-risk and not, looking for flu shots, I recall reading about people going across the border to Canada just to get a flu shot.

Now on top of news that the US has secured additional flu vaccine, I'm not surprised to see reports that some flu vaccine may get wasted because either the restrictions were too effective, or many eligible patients are declining to get flu shots.

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I'm still in solo practice, just not blogging. I've been steadily seeing about 40-45 patients/month for the past 3 months, so I've reached some steady state for now. I think I'll need to try direct mail advertising to reach ALL the local households if I want to quickly grow my practice. We'll see how I manage that in the coming holiday weeks.

SpringCharts on a Mac

While researching whether I should upgrade to version 7.0 of SpringCharts, I found this article about another family doctor who also uses SpringCharts with a Mac. (Besides me, that is.) I keep thinking that as smart as doctors are supposed to be, why don't more choose the intuitive, hassle-free Mac platform, rather than the buggy, insecure Windows platform?

"I hear it all the time from other doctors," says Michael Marlow. "They'd like to move to an EMR system, but their partners aren't ready." To convince his own partners that SpringCharts on Macintosh was a sound business solution, Marlow used a number of very logical - and ultimately, persuasive - arguments:

Affordability. "It's far less expensive, in the long run, to own and run anything on Macintosh. Because it lasts longer. The software technology doesn't outpace the hardware technology - or vice versa - within sixteen or eighteen months, like it often does in the Windows environment. And the cost of technical support is minimal."

Ease. "It's easy enough for someone with average skills to install the network, the hardware and software. You don't need an IT support person to come in and do it for you. You may choose to, because you're pressed for time. But if you have the interest; you can do it yourself."

Security. "When you're dealing with confidential patient information, Mac is a far safer choice. It's extremely difficult for someone to get into my network from the outside. But for them to get into my Power Book is almost impossible. And viruses? With Mac OS X, they simply don't exist on the Mac."

While the other two physicians in Marlow's practice have yet to make the leap themselves - "they're still scribbling notes on paper," he smiles - they are impressed with "the oohs and aahs they hear from patients when they see what I can do with my PowerBook."

Come to think of it, I'm still scribbling my notes, too, then retyping everything in later. Maybe I should skip a step and just type everything in at once. I'm proficient enough of a typist where I can type and maintain eye contact at the same time. I'll try it on my next few patients and see if anyone oohs or aahs.

The Ideal Doctor

Found this great NY Times article by way of Medrants.

In my idealistic zeal (okay, what little I have left), my first thought after reading this tale of two interns was that I would rather be like the caring but overworked intern than the efficient but emotionally detached one. In fact, that has been my practice style for the past few years, with the typical results: my self-respect intact but my life an eternal Sisyphean struggle.

As I thought about this more, I realized that these are not the only two choices. Couldn't it be possible to take the best from both practice styles and meld them into one? An efficient, unoverworked, caring and careful doctor who still has time for family, friends, patients, self and sleep? Who not only feels valued and respected, but is also able to generate a reasonable income that is sufficient to pay off school loans, raise a family and live comfortably too? A good doctor who is also a happy doctor? Am I dreaming?

And then I got to thinking, what would be an ideal doctor anyways? It depends on who you ask.

Patients want a doctor who listens, is compassionate, and treats them with respect. Some people have specific criteria or a checklists of things they want to see in an ideal doctor. But many of these things, such as having a courteous staff, or not being rushed because of an overbooked, may be out of a doctor's control. So when people say they want an ideal doctor, they really mean an ideal health care system.

And even though people want a patient and caring doctor, they also expect a doctor to be knowledgeable and clinically competent. Makes sense. Various medical organizations expect an ideal doctor to meet certain endpoints as a surrogate for knowledge and competency.

Many people's ideal doctor is someone like Marcus Welby, M.D. But you know what? Robert Young, the actor who identified closely with the role he played, suffered from depression and had an alcohol problem. If that is what happens to a fictional ideal doctor, imagine how hard it must be to be a real one.

Other television shows have inspired others as to what an ideal doctor should be like. When the British Medical Journal was conducting a survey of the best doctors of all time, real or not, Medpundit wrote:

My vote would be for Dr. McCoy. Despite living in a high-tech world where diagnoses could be made with the pass of a scanner, he never lost sight of the essential requirement for a good doctor: keeping the humanity of his patients at the forefront. He treated enemies and crew members with the same dignity and respect and competence. He was a hands-on doctor, and compassionate. Unlike later Star Trek doctors who spent more time beside their computers than at the sides of their patients, he was always at the bedside, keeping an eye on his critically ill patients. In many an episode he pulled all-nighters to come up with a cure for the latest alien malady to strike the crew. He never hestitated to stand up to his captain if his orders were contrary to his medical ethics. And, I suspect, he was the inspiration of many a child from my generation to go into medicine. (Although you won't find it admitted on any medical school application essays.)

And what about doctors themselves? Most doctors and doctors-to-be recognize the importance of emotional and financial self-preservation.

Patch Adams, MD had this to say about what he values as a physician:

My God, its friendship. Remember, I make my patients my friends. I can't distinguish between them. I don't want a patient that isn't my friend. I want to be intimate with every person that dares be intimate with me. I'm very confused about my boundaries. I literally want to fall in love with every person I'm with. I want that kind of relationship because I love friendship. It's just such a magnificent creation.

And I am curious about people. It doesn't matter where people come from for me. I just want to be with people and enjoy it. The magic of being a physician is that they will let you into their lives. If they perceive you care, they will let you into their lives in ways you cannot dream. People spend their lifetime with a friend trying to get what I can get on the first encounter with a patient. It's pretty breathtaking.

Okay, I'm not going to be best friends with all of my patients, but he's got a point. It's not about being an ideal doctor, isolated in a vacuum. Doctors can only be doctors if there are patients. So it's the relationship that we want to be ideal. All doctors have patients who love them and others who hate them. It's about the right personality match.

It's not about being a perfect doctor, because no one can be perfect. Personally, I think malpractice lawyers (intentionally or unintentionally) continue to foster the myth of a perfect doctor so that they can continue to blame doctors when they prove to be only human.

Patch Adams again:

Also, malpractice is wrong. Malpractice insurance set up an adversarial relationship with your patients. You get afraid if the patient is your adversary. The doctor says, "God, I made house calls, but then my hunch said don't get an X-ray, so I didn't get an X-ray, and they sued me to the wall". We do not carry malpractice insurance. We will not practice in fear and mistrust. In addition, the whole malpractice thing inadvertently reinforces the doctor-as-God concept. If we can't make mistakes, we must be perfect. It also implies that the doctor is responsible for the cure and the patient is the passive recipient of it.

Perfect is the enemy of good. As long as we expect perfection, nothing will ever be good enough. As long as people continue to die or have imperfect outcomes or are unhappy because they feel disrespected, there will be malpractice lawsuits. Which result in higher judgements because of injury inflation. Which means higher malpractice insurance costs. Which means doctors have to see more patients to pay for their premiums, and have to order more tests to protect themselves. Which means higher health care costs for everyone. Which means people expect even more for their hard earned money. Like perfection. Which keeps the cycle going.

For me, I think being an ideal doctor is about being trying to be a decent human being, treating trying to treat others as you would like to be treated, and balancing these with accepting that I can't do everything for everybody and that it's okay to say, "No". All while sharing an experience called life together. Let's see if it works.

Making Contacts

I haven't posted in a while but I'm still here, still in business, still slowly growing, still behind on medical billing, still finding it hard to find time for blogging.

I've gotten a number of calls from doctors who read the article about me and my solo practice in American Medical News, some to ask me questions about how I'm doing things (and how I'm doing, financially). A few have called to say that they've already been there, done that, and offered encouragement to hang in there. It makes me wonder how many other doctors are out there already doing what I'm doing, but who haven't been publicized. Quite a few, I think.

One particular local general internist has gone out of his way to help me. He went solo 7 years ago and now has a booming practice. He has been closed to new patients for the last few years. He read about me in AMN, then called me to see if I wanted to meet for lunch. I visited his office, and he gave me a copy of his original business plan (which was better than mine but similar in many ways), and gave me pointers on how he started his practice.

After residency, he had been working for a group of older internists and he was very busy, and getting busier. The older partners weren't that interested in working as hard, so the younger doctors saw a lot of patients. Since they were thinking of retiring, they offered to sell the practice to him and the younger doctors for more than he was willing to pay. They ended up lowering his pay, so he decided to quit and set up his own solo practice. However, he decided not to sign up with any HMO contracts, which at the time was considered very radical. He was called crazy by his colleagues and written up in newspaper articles and interviewed on national news networks.

(Arizona Republic; 03/21/99)
Now is the winter of doctors' discontent. Across the United States, doctors are complaining that the era of managed health care has robbed them of autonomy, income, time, prestige - even self- respect.

"This is life in hell," says Rex Greene, a Pasadena, Calif., oncologist and president of the Los Angeles County Medical Association - and he says he's an optimist.

A growing minority is rebelling - dropping health-maintenance- organization contracts, seeking clout in professional alliances or unions, filing lawsuits, retiring early, going out on disability or moving out of markets colonized by managed care.

Consider the San Diego gastroenterologist who slapped his physician group with a lawsuit after he was fired for spending too much time or money on patients. Or the cardiothoracic surgeon from the same city who moved to South Dakota, where managed care is nearly non-existent. Or the Pasadena internist whose frustration forced him to cut all ties to HMOs.

"I have been unneutered, restored to my vigorous self," said internist Andre Ettinger. "I can take care of patients rather than having to punt the ball all the time."

Times have changed. Managed care is no longer the main game in town. I have personally chosen not to sign up with any HMO or capitated plans, and this is no longer fodder for national news.

Hopefully, like this doctor, I will succeed without any HMO contracts. The key to his success, he feels, was in introducing himself to other doctors on the hospital staff. In other words, networking. He would have lunch in the doctor's dining room, and chat with the doctors who were there, and later that afternoon get a call from a patient who was referred by one of the doctors he had lunch with. Eventually, he had more than enough patients and he was on the road to a successful practice. Perhaps too successful as he now finds himself staying late, squeezing in extra patients, etc.

He said he is grateful to the many doctors who helped him get started, with no gain for themselves, simply because they wanted to help him out. Now he wants to "repay" their kindness by helping new doctors like myself out, and I'm very grateful for his help.

I hadn't really considered other doctors as a major source of patients. I figured other primary care doctors might see me as a competitor. And I thought specialists only received referrals FROM other doctors, not made referrals TO other doctors. But there appears to be a collegiality among all the doctors I've met so far. Since this doctor's practice is closed to new patients, he said he is actually glad to know of another doctor he can refer new patients to. And apparently, lots of specialists see patients who are looking for a primary care doctor and hope for a recommendation from their trusted doctor.

So this week, he introduced me to a dermatologist. Next week we're meeting an Ob-Gyn and an orthopedic group.

Apart from his contacts, I'm finding out how important networking is. I just mailed a practice brochure and business cards to another Ob-Gyn who contacted me after reading about me in AMN and, feeling a kinship because of our mutual solo status, requested some business cards. And a gastroenterologist I referred a patient to also asked for some business cards. At this rate, I'm going to need to order more business cards. I hope this translates into new patients, but it certainly can't do any worse than my ad in the local church bulletin: $400 annually for a weekly ad = 2 patients (so far).

Going Solo Together

There are probably as many ways to configure a high quality, low overhead practice model as there are physicians. Greg and Heather Sharp are a physician couple who have set up a shared practice. The following describes how they did it:

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Practice Design
On Sept 6th we opened our practice in Woodland Park, CO. Some of you may recognize this as the home of Michelle Eads, who has been a wonderful help and encouragement to us and pointed us to this listserve group initially. We are a husband and wife pair of family doctors who are sharing one full time practice. We are drawing from Gordon Moore's low-overhead, high-quality model of practice, my Father's home office in Houghton Lake, MI and the SimpleCare approach to practice billing. We have one insurance contract and offer a 25% discount for anyone who pays at the time of service by cash, check or credit card. We hope to attract the uninsured, those with high-deductible insurance/HSA, and anyone who doesn't meet their plan's annual deductible and wants accessible, personal, and affordable care. That being said, over two thirds of our first month's patients (28 in all) have had the one insurance we contracted with. In the name of simplicity, and to fully commit to a discounted fee for service model we have opted out of Medicare and Medicaid. This has been a challenging decision and we are not sure yet if this will be a permanent decision, but we would like to give a hassle-free approach a fair try.

Space
We remodeled 750 sq ft in a professional building next to the town post office with a small office, one exam/consultation room (10x14 is a nice size), one procedure room, a restroom, and waiting room. We are paying $12/sq ft/yr plus triple net expenses that comes to just over $1000/month for a two year lease. The landlord split the remodeling costs with us 50/50 but this had to be negotiated. We are quite happy with the amount of space that will allow both of us to be in the office from time to time.

Technology
We are using Amazing Charts for EMR (and eagerly awaiting the next version), but are not using much beyond the patient record and prescription/order writing features. We have had good results with "printing" orders and scripts to the fax machine and have them sent directly to pharmacy, lab, etc. We are using Microsoft outlook to store patient demographics and business contacts which helps with storing fax numbers for use with sending faxes as described above as well as improved mobility with patient contact info in our PDA, and emailing with patients which Amazing Charts messaging does not support. In order to allow us to schedule appointments remotely, we are using the calendar within Outlook which also will interface with a PDA. We looked into PDA/cell technology that would allow real time synchronization with the office Outlook remotely but don't feel the technology is quite there yet.

We bought one new Dell desktop with hyperthreading processor and it has handled everything well so far. We enjoy our dual flat-screen monitors as well, which make running several programs simultaneously so much easier. We wired our office with Cat5e cable for additional computers and bought a network ready Brother printer (HL5170DN) with extra paper tray that has worked extremely well. The additional tray is used for a green security paper for printing prescriptions out of amazing charts when we can't fax them to the pharmacy. Our current network of the computer and printer only required a netgear VPS318 router that is VPN ready (Virtual Private Network for home access).

We just purchased a Visioneer one touch 7300 USB scanner this week and am happy with the one-touch scanning to PDF files which can then be marked with comments/highlights on the computer and stored to a patient file library on the hard-drive allowing us to go paperless. This requires the full adobe acrobat program, not just the free acrobat reader. We have a CD-RW drive which we are using to backup our files weekly.

Phone
We currently have one cell phone, one voice line at the office, and one fax line. We tried to put the fax and phone on the same line with a distinctive ring feature, put this was not practical because we wanted to forward calls. We are forwarding calls after one ring to the cell phone while one of us is with a patient so that the other one at home takes the call. We have voicemail on the cell phone. For office calls that aren't answered (when call forwarding is off) we have an answering machine with a message that includes our cell number for urgent issues. With only one person in the office, we also ordered call waiting so that we can avoid patients getting a busy signal if we are on the office line.

Billing
We are using QuickbooksPro2004 for our practice accounting as well as patient billing. We are also using the Quickbooks card swiper and merchant services for credit card service (VISA, MC, Discover, Amex). No problems so far with credit cards. The swiper was cheap, it auto-enters everything into Quickbooks, it takes up minimal space on our desk and there is a discounted card-swiped rate for transactions. For insurance claims, we are producing HCFA 1500 forms with the EZClaim software and then printing them and mailing them in or giving them to patients for reimbursement from insurances we don't participate with. EZ Claim also has an EZ Link module which exports the HCFA 1500 data to Quickbooks as invoices so that we can track our accounts receivable/insurance payments. At my Dad's recommendation we also purchased FlashCode which has been very helpful in building our fee schedule and exporting CPT and ICD-9 codes to Amazing charts, EZClaim and Quickbooks (for invoices/cash and credit receipts). The FlashCode customer service has been the best I've seen. I am still waiting on the Quickbooks Customer Manager software which should eliminate double entry of data between Quickbooks and Outlook.

Equipment
We were fortunate to get used exam room equipment from our former employer when they sold the practice to the local hospital. We were able to get exam tables, an autoclave, surgical instruments, mayo stands, trash cans and procedure lights from them for a good deal. We also had some exam instruments left over from medical school. Most of our new medical equipment purchases have been for disposable items. These supplies have cost roughly $2650. I have our inventory lists as an Excel file for any of you who might be interested.

Marketing
As has been said on the listserve before, word of mouth seems to be the primary method of marketing that works. We had an article about our practice in the local paper business section that was also very productive. Newspaper ads have been disappointing, but without a listing in the phone book they probably serve a purpose. Most of our patients have come from personal contacts around town, and the local chamber of commerce has been a great help. They are holding a ribbon-cutting ceremony for us in a couple of weeks. We left a full practice 3 hours away to come to a new town, so we knew that we would have to count on slow growth. We have actually been quite happy with how our model has been received and with our panel of 28 patients after one month. The female aspect of our male-female team is undoubtedly an asset in marketing to the community. Our future plans include arranging talks at the senior center, to civic groups and hopefully in the schools to spread the word about what we are doing. Dr. Eads' practice has already made the public here more receptive to a non-traditional format of practice.

With the help of my brother and the websites of others on this listserve, we do have a practice website which describes our practice philosophy in more detail. It's www.idealfamilyhealthcare.com. We hope to make it more interactive for patients in the future.

Financing
We hopefully have the bulk of our startup costs behind us and have currently borrowed $26,000. We don't plan on having a salary for a few more months. We are paying student loans with the proceeds from the sale of our previous home in Alamosa and living with family until the practice is established. We have a cash-flow projection that has us paying off our start-up loan by the end of our first year and a joint salary of $70,000. Only time will tell how close this is to reality. We have planned for the long haul with advisors telling us to count on up to 18 months to break even. I don't think it will take that long because thanks to low-overhead, it's no longer that hard to break even. We are enjoying this new pace of practice and the freedom of setting up a new business immensely.

Thanks again to all of you. I hope this is helpful. We really appreciate the encouragement of you like-minded pioneers out there.

Greg and Heather Sharp MD
Ideal Family Healthcare, PC
PO Box 4918
Woodland Park, CO
719-686-8844

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Congratulations to Greg and Heather for taking the leap! While I don't expect this practice model to replace what's out there now, the fact that more and more physicians are trying this shows that there is a unfulfilled need for this kind of simpler and more personal kind of medicine that is greatly satisfying to physicians and patients alike. This isn't how most of primary care medicine is delivered now, but perhaps it should be.

Really Solo

This article hasn't even officially come out yet, but it's already available on the American Medical News website. It is a Q&A about my "Gordon Moore-type" practice.

Obviously this is not the only way to find satisfaction as a physician. For example, physicians who are tired of working for themselves can go work for a chiropractor. I prefer to be able to look at myself in the morning, however.

Think Different

Three ways to think different:

1. Get a Mac
2. Become a family physician (courtesy of Family Medicine Notes)
3. Go fishing the hard way

How to Get Started in Solo Practice

To continue explaining my practice for those who may also be contemplating going solo, I answer more of my own questions (and hopefully some of yours, too):

What information resources did I use to go solo?
In many ways, I was like a resident looking for a new job when I first thought about going solo. I had been relatively sheltered at Kaiser for 13 years, which is a closed, self-sufficient health care system. We never worried about insurance or billing, because only patients with Kaiser insurance could see us. We didn't worry about administrative issues, unless you were one of the few physicians in an administrative position. No fee schedules because we got paid the same no matter how many patients we saw. We never even had to do any ICD-9 or E&M coding until about 3 years ago. (Kind of makes you wonder why I left, huh? Read my previous entries for answers to that question.)

I bought "On Your Own: Starting a Medical Practice From the Ground Up" from AAFP for $50. ($75 for non-members). It provided a lot of invaluable information for someone like me who was totally ignorant about what it took to set up my own practice. It discusses everything you can think of, from malpractice insurance to credentialing, how to set up an office, how to market your practice, how to set up a computer system, etc. I highly recommend it.

Next I'd recommend Family Practice Management journal. It is published by AAFP and has had several articles on going solo (1) (2) (3) and practice management advice. They also have a section for residents who are new to practice.

Medical Economics magazine (which I used to consider a throwaway journal, but is now one of the few I save and read) has also had a number of helpful articles, including this one profiling 4 physicians who went solo, and this one on startup basics.

Probably the most helpful thing I did (besides listen to my wife) was sit down with a group of financial experts (referred to me by my wife - thanks, honey!) who acted as practice consultants. They asked me questions about every aspect of my future practice: assumptions of insurance mix, demographics, revenue sources; mission statements; how the practice would run; handling of telephone calls; retirement; competition, etc. At first, they were very skeptical that a solo-solo practice model could generate enough income to be feasible. But after plugging in all the numbers, they came up with a business plan that showed that it was doable, with a forecast projected annual income of about $100,000 by the end of year 2. Best of all, it was done for no charge, because I was helping them by being a guinea pig for them to see if they wanted to add practice consulting to their services.

I remember getting a quote from a practice consultant for about $10000, and I thought that was way too much. (I mean, a third of my startup costs??? I don't think so.) I don't know if I remembered wrong or if they lowered their price but they now quote a range of $1260-1980 for a start-up practice consultation. This sounds much more reasonable, and I would have paid that amount for the amount of valuable advice and information I got. Other practice consultants can be found on AAFP's FPAssist page.

I also asked some friends in private practice what it was like, and visited one friend's busy office to get a first-hand look at what it was like in the "real world". But after seeing his busy multiphysician office with nurses and medical assistants running around and a waiting room that was packed, I realized that this didn't really give me an idea of what my future practice would be like. Instead, I would recommend that anyone who really wants to see what a low overhead practice should visit a physician who is practicing that model already, such as the ones on this list (in Excel format).

How did I finance my solo practice?
Although a mortgage refinance would have been an option, my wife and I agreed that I would not tap into any family funds or borrow against our house for this venture. But for many people who already own a house, this is probably the easiest source of cash and given the relatively low interest rates, makes the most sense for startup funds. The downside is that if your practice fails or you are unable to make your refinance payments, then you risk losing your house.

For my startup costs, I borrowed $20000 and then another $10000 from my 401k plan with a 5% interest rate over a 5 year period. This was after having a loan officer at a bank investigate sources of funding for a small business, and what he told me was that nobody was willing to make that *small* of a business loan for a startup practice. I also briefly considered some loan companies that seem to specialize in making loans to physicians, but frankly I don't know if I trust them as they tend to be companies that I've never heard of. You can easily find a bunch by Googling the words "doctors loans". One other financial source would be from your family and friends, but if you default they may not be your family or friends anymore. Best to put these kinds of loans in writing so that there is no misunderstanding.

I kinda sorta looked at Small Business Loans (SBA) sponsored by the Federal US government, but it seemed like a lot of paperwork, and the 401k loan I took out was so easy and low-interest that I thought it was a no-brainer which way I should go.

In retrospect, I should have taken out a larger loan. I had anticipated my startup expenses pretty well, which came out to about $25000. What I forgot to account for was the monthly operating expenses that would continue while I was waiting for patients (and revenue). Unless you know you will be bringing a lot of patients to your new practice with you, I'd say plan for 6 months of operating expenses in addition to the startup costs. Since starting, I've had to take out cash advances on my credit card totaling $10000 to cover operating costs and additional supplies as I wait for revenue to come in. Obviously borrowing against a credit card is not a low interest way to go, but it's possible. I'm hoping I won't need to take out any more loans now that I'm catching up on sending in medical claims.

How successful has my practice been so far?
I think my startup practice is atypical from some of the others who have tried this so far, in that my patient panel has grown slowly, more slowly than I anticipated, but that has been a blessing in disguise. It has given me time to learn about all the things I didn't know about starting a business. I've heard from various sources that you should expect to take 2-3 years to fully grow your practice.

So far, I have seen 100 unique patients and had 139 patient visits after 7 1/2 months of solo practice. And even though I have advertised that I do house calls, only 1 patient (a 91 year old) has ever asked for one. My monthly visits have been as follows:
February: 0
March: 14
April: 5
May: 10
June: 17
July: 10
August: 38
September: 45

How have patients heard about me?
50% Word of mouth (friends, family, neighbors, etc.)
13% Newspaper ads
10% Relatives of current patients (immediate family members)
7% Newspaper article
4% Hospital referral service
4% Former patients at Kaiser
3% Yellow Pages
<2% Other sources (website, internet, charitable sponsorships)

What kind of patients are in my practice?
I have a youngish patient panel so far with the average age being 36. Youngest = 5 months old. Oldest = 91 years old. At Kaiser, I did primarily adult medicine as most children were automatically diverted to the pediatricians, so it has been refreshing for me to see kids again. Gender breakdown: 52% female, 48% male. Ethnicity reflects the local area which is primarily caucasian, but a good mix of Hispanic, Asian, African-American and multi-ethnic backgrounds thrown in.

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I saw my 100th patient a couple of days ago. I had meant to give out a $25 gift certificate to our landmark local pharmacy, but somehow I lost count and didn't realize she was my century patient until after she had left. No matter. I called her on the phone to see if she was feeling better from her URI (she was), and to thank her for being my 100th patient and that I wanted to give her a gift certificate. She declined being photographed for the occasion (too embarrassed), so I told her I would just mail her gift certificate to her.

It has taken me about 7 1/2 months to reach 100 patients. At times, I have felt like an invisible gorilla and wondered why nobody is noticing me. Others trying this low overhead practice model have had faster growth. Mark Newberry opened his practice in Holland, Michigan in July 2003 and reached 900 patients within one year. Kevin Egly in Sandwich, Illinois took only 4 months to see 172 patients. Michelle Eads in Woodland Park, Colorado closed her practice to new patients after less than a year with a patient panel of 450. Nancy Guinn in Albuquerque, New Mexico has about 850 patients after 14 months. John Brady in Newport News, Virginia has close to 1200 patients after 16 months. It just depends where you're at, whether you brought any patients with you from another practice, and how great a need there is for your services. Maybe nobody needs an invisible gorilla doctor?

Happy Anniversary!

It has been one year since I began writing this blog. It has been a slow process to get a solo practice up and running, with fits and starts. A lot like writing this blog. For the one year anniversary of this blog (which has been described by at least one person as a kind of soap opera), I thought I'd write a synopsis, of sorts.

Who am I?
I am a board-certified family physician, born and raised in Southern California, a UCLA alumnus with a double major in biology and English. That may explain why I'm writing a medical blog. I am also a husband (hi, honey!) and father of 3 daughters.

What is the purpose of this site?
To help other physicians who may feel unhappy with their current situation and wonder if there is a better way to practice medicine. A way to have enough time to provide quality medical care, to feel more connected with their patients, their family and their own lives, and not be just another cog in the machine. In other words, to help those who are tired of running find a way off the hamster wheel.

When did I start this?
I began thinking about starting my own practice after reading an article written by Dr. Gordon Moore in Family Practice Management in February 2002. In it, he described how he set up a completely solo practice (no nurse, no staff) and found greater satisfaction doing so. After 13 years working at Kaiser Permanente in Pasadena, CA, I felt like my practice style no longer fit in with Kaiser's system so I resigned my partnership and officially opened my own solo family practice office in February 2004, following the Gordon Moore model. Two years in the making.

Where am I?
South Pasadena, CA. It is a middle to upper-middle class suburb of Los Angeles, definitely NOT an underserved area, but for some curious reason, had no family physician practicing within city limits. This appeared to be a good business opportunity, I reasoned.

In the coming weeks, I plan to write about these topics:
How to get started with a solo practice
How does my practice run (nuts and bolts)
Sources of patients/income
Expenses/supplies
Status of my practice

Patient, Can You Spare a Dime?

I found this recent Washington Post story about doctors asking patients for voluntary donations to help offset rising malpractice insurance costs.

Kenneth M. Greene wasn't sure how his 1,500 patients would react when he asked them for a $10 contribution to help pay his $11,000 malpractice insurance bill.

"The medical malpractice insurance crisis has come full force to Maryland," the 47-year-old Towson internist declared in a letter he sent last December. A "small donation . . . is necessary if we are to continue to keep our doors open."

Nine hundred miles away in North Palm Beach, Fla., family physician Ira G. Warshaw launched a similar plan. Warshaw asked his 3,000 patients to send him a check for $125 ($25 if they were under 25) to help defray his $30,000 insurance bill, which has quadrupled since 2002. If patients didn't send him money, Warshaw warned in a letter earlier this year, he might be forced to stop participating with Medicare and some health plans.

"I felt like I was drowning, really," said Warshaw, a solo practitioner who said he felt "some guilt" about his request but was also grappling with a $100,000 debt from a failed venture in group practice. He felt compelled to act, he said, after his income dipped below the national average for his specialty, roughly $140,000.

I am fortunate to have an annual malpractice premium of about $5500, but then again, I'm in California (where malpractice rates have generally held steady) plus this is my first year of solo practice. Malpractice rates are designed to rise as your practice grows.

I think this is a reasonable request for doctors to make, basically to ask patients to help pay for the cost of doing business, especially if insurance reimbursements aren't enough to cover the costs. There is no free lunch, after all. High malpractice judgements = higher malpractice premiums = higher operating expenses which get paid by whom? Insurance reimbursement rates are relatively fixed by the Medicare fee schedule, so doctors can't charge patient more for services. But the money's got to come from somewhere.

Let the doctor pay for it out of their own income, some say. After all, he/she is still making enough money. The public may see an annual salary of $100,000+ and consider that adequate compensation. On the other hand, a doctor who has spent 7 to 12 years of their life in post-graduate training, with huge debts from school loans, who has spent countless sleepless nights of being on call, and who now has a young family with growing children whom he/she can barely spend time with because of long working hours and patient responsibilities would probably consider this inadequate compensation.

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As for my growing practice, I am fortunate to have more patients calling me in the past 2 weeks. I am nowhere near making a profit yet, but I am getting close to the number of patients I need to see to break even: 3 patients a day. Of course, it would help a lot once I start submitting medical bills regularly for reimbursement, won't it?

You can save a life, too

In one of my other lives, I am a Assistant Clinical Professor at the UCLA School of Medicine in the Department of Family Medicine. This is a fancy way of saying I donate my time to help teach first year medical students. I have been doing this for the past 10 years, and it has always been one of the most enjoyable activities that I do as a physician. Specifically, I help tutor a group of about 8 or 9 1st year medical students in the Doctoring course, which mainly teaches students how to conduct a medical interview by using actors who play the scripted role of a "standardized patient".

Last week, as each small group does every year, we visited the home of a family of a child with a chronic illness. This gives the students an opportunity to see firsthand the effects of a chronic condition on the physical, psychological, financial well-being of a family. In previous years, we've visited families of children with Tourette's, Type 1 diabetes, Down's syndrome, and cerebral palsy.

This year, we visited the home of John Paul, a 3 1/2 year old boy with Diamond Blackfan anemia, also known as DBA.

It is a very rare disorder, with about 350 people in the US having the disorder. His mother eloquently described the family's frustrations, hopes and determination in giving John Paul as normal a life as possible. Which is hard to do because John Paul has to get blood transfusions every 2-3 weeks to replace the red blood cells which his bone marrow fails to make. Because of the multiple transfusions, he has developed liver dysfunction due to iron overload and therefore must undergo daily chelation therapy with a portable infusion device attached to him that runs 12 hours a day. Because he is easily prone to infections, his family rarely takes him out and they've had to limit their own socializing for fear of bringing back a virus. On top of all this, his parents both work, and his mother is a tireless advocate for the cause of DBA and the recruitment of blood donors.

Because there are so few people with DBA, there are no government-sponsored funds for research. Instead the Diamond Blackfan Anemia Foundation was formed to help raise money to finance research for a cure.

John Paul's family is truly a brave and remarkable family. The medical students and my co-tutor and I were impressed and touched by their story. On their behalf and on behalf of the many people in need of blood, I encourage all of you to not only donate blood, but to become a regular blood donor. It is one of the easiest ways to save a life.

I'll be rolling up my sleeve this week for my donation.

From little acorns grow mighty oaks

Thanks to the links from MedRants and MedPundit, I've gotten more visitors in the past 3 days than I've gotten in 3 months. If only it were that easy to get patients into my solo practice.

My last entry talked about being interviewed for a newspaper article about my "Gordon Moore type" of solo practice. Here is the article that came out 4 days ago. The newspaper has a circulation of 35,000. The article was also published in a sister publication which has a circulation of 48,000. Since the article came out I've had 6 calls for appointments generated by the article, 2 calls from Kaiser patients who are unhappy with their care and want me to see them at Kaiser (I had to explain that I cannot do this), and 3 other general inquiries: what are my hours? do I accept HMO? (no); and one letter from a patient documenting how the last 10 doctors she saw couldn't help her but she was hoping that I could.

12 responses out of 83,000 potential readers. And that's not counting their websites. What this tells me is that there isn't as pressing a demand for a old-fashioned country doctor as I thought. Or maybe people just don't read the newspaper very carefully. Or maybe they didn't know how to contact me, since no contact information was included. The ones who found me said they just looked me up in the Yellow Pages.

But that's OK. I was plenty busy today. If I had 20 patients call for appointments, I don't think I could've accomodated them. I can't complain since it didn't cost me anything to be interviewed. I think that there is an abundance of primary care doctors in the suburban area where I live. Plus I think that as much as some people complain about the lack of accessibility to their doctors, it's probably good enough for most people. Of course, I may continue to get calls later on. Some people may have clipped that article and saved it for future reference. And the people I saw today will hopefully tell their friends and family about the doctor who answers his own phone and spent an hour with them. This is about planting seeds for a future harvest.

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Since starting this blog, I've found more and more medical blogs out there. In fact, if I read all the medical blogs from this site, I wouldn't have time to do any work.

The subject of blogs came up in a recent discussion about how to disseminate information about a new diabetes project being sponsored by the California Academy of Family Physicians. Well, consider this the first seed.

As part of the CAFP's effort to bring the Future of Family Medicine Project recommendations to fruit, it has decided to try and tackle the improvement of diabetes management. In our focus group last week, we decided that just about every family doctor knows what good diabetes care entails, we just need some help tracking and following up on our patients.

At Kaiser, they are ahead of most doctors. They actually give a printout every 3-6 months to each primary care doctor listing their diabetic patients and what percentage of them have had their retinal exams or microalbumin done, and what percentage of patients have their HbA1C in range. However, it is still up to the individual doctor to then contact any patients who may not have an optimal lab or may be missing labs completely.

We discussed the possibility of creating and distributing software to family doctors that would offer "one-stop shopping" in diabetes management. It would have a database which can track various parameters and allow you to see which patients are due for various labs or tests. The program would also be able to generate e-mails to patients reminding them when it is time to come in for a diabetes check-up. It would have links to up-to-date patient education material that can be e-mailed or given to patients to assist their self-management. In return for providing this software, the CAFP would get information. The database would be able to upload depersonalized aggregate data into a central database to help provide pooled statistics that can later be used to document (hopefully) superior diabetes care.

So hopefully this seed of an idea grows into something big.

Just as I hope this blog can plant some ideas into the minds of doctors who might want a practice that isn't too bureaucratic or just plain too busy to care for their patients. Now where's my trowel?

The Personal Touch

I was interviewed today by a reporter from one of the local newspapers to discuss my "unique" practice. My practice is following the "Gordon Moore model" emphasizing low overhead, minimal barriers, maximum accessibility via cellphone and e-mail. I described how I have no employees, in order to keep my overhead low, and how in return, I am able to spend more face-to-face time with patients. The reporter seemed impressed, so I'm hoping for a positive news story that might generate more patients.

Lately, I've been finding more news articles about physicians trying to "take back" medical care from the hassles imposed by 3rd party insurers and improve the overall physician-patient experience. Here's are two (1)(2) articles about Dr. Michael Stein in Hampstead, New Hampshire, who is starting a retainer fee practice with many of the same goals I have: more personalized care, flexibility in hours, house calls, unrushed doctor visits. His website is at http://www.realdoc.net/.

Dr. Vladmir Lorentz is highlighted in this article which talks about various businesses doing things the old-fashioned way.

This article talks about how rural medicine has a lot to offer, but seems to be dying out.

As a rural practitioner, Haynes said he loves what he does, especially the close relationship with patients.

''I have never had a burnout in medicine,'' he said. ''Every day I look forward to practicing medicine. I know all the families ... know the type of work the husbands do. I interact with the families as friends and as patients."

I think that this is what attracts many to the specialty of family medicine, getting to know people and their families in a personal, even intimate way that only a few ever get to experience. To be able to share in others' lives. I've always been amazed at some of the things people tell me that they would never tell their spouse or priest/pastor. I think this relationship is something that has been endangered for some time by the modern medical system, by appointment systems that prevent patients from seeing their own doctors, by 3rd party insurers that place restrictions on treatment options.

This opinion piece written by a general practitioner in the UK laments the "end of the patient-doctor relationship".

In an ideal system, the physician not only cares for the patient, but cares about them, too. Also, the patient cares about the physician, is respectful of his/her time, concerned for their lives. A couple of days ago, I got an e-mail from the mother of a boy I saw two months ago. She was reminding me that I hadn't billed her yet! How often does that happen???

What happens when there aren't enough generalists?

First, conscientious generalists get overworked, like this doctor:

Working 12-hour days and five-day weeks in her solo practice, she often double or triple books patients.

While most doctors in the area close their books to new patients when they get overloaded, the Aldinga Surgery GP refuses to. "I try to see people within a few days which is at my own detriment," Dr Mayne said. "We try to fit patients in at some stage, within a couple of days.

"Other people (GPs) just say `I am seeing this number', other GPs have a four week waiting time.

"But I have been here 18 years. I don't really want to knock back an 80-year-old woman who has been seeing me for many years."

Dr Mayne said demands on GPs had increased dramatically in recent years.

"The area has grown immensely and there is just no help," she said. "You can't get locums, you can't get people to do sessions, can't get partners in a practice.

"Waiting times for specialists have made people totally disillusioned by the public hospital system, this all puts more pressure on GPs.

"It has got to crisis point. I am sick of it, I don't want to do it for much longer."

A diary kept for The Advertiser by Dr Mayne showed she was seeing an average of 40 to 50 patients a day.

Secondly, frustrated generalists give up:

Christchurch doctors are walking away from their practices as the shortage of GPs spreads from rural areas to the cities.

Increasing paperwork, the growing threat of litigation and the lure of more lucrative positions in other health-related sectors are taking a toll on existing doctors and making the profession unattractive to debt-laden medical graduates.

A New Zealand Medical Association report shows the number of GPs nationally has dropped almost 10 per cent over two years, and with rural communities already in crisis, health professionals are now saying Canterbury's urban centres, once flush with doctors, are starting to suffer.

The West Coast has the lowest rate of active GPs per capita in the country, with some doctors reporting more than 6000 patients on their books.

In Rakaia, residents have been without a permanent GP for months, and the community has formed a trust to take administrative pressures off the doctor and keep the practice alive. The community is served by a locum and are close to securing a permanent replacement.

The Christchurch School of Medicine's public health and general practice department head, Les Toop, said compliance costs and uncertainty within the profession were putting people off taking on even the most sought-after practices.

"It's happened for some time in rural communities but now it's starting to be seen in the bigger centres. Some doctors aren't even bothering to advertise, they're just shutting up shop."

Thirdly, the remaining generalists are under more pressure because there aren't enough physicians. Overwork. Burnout. Rinse. Repeat.

OK, big deal. These news stories are from Australia and New Zealand. This couldn't happen here in the US, right? It already is.

As a retired schoolteacher with health insurance, Dot Goodwin never thought she would have a problem getting an appointment with her family physician.

She became ill and discovered that her doctor of 30 years had joined another practice.

The doctor who assumed his practice wasn't taking new Medicare patients.

"There I was, bad off, and had to go to the emergency room for treatment," she said.

An emergency room worker told Goodwin about a doctor with a new practice in Decatur. A Lawrence County resident, Goodwin got an appointment with the doctor and continues to see him.

She is one of the lucky few who are able to find a primary care physician in Alabama. Sixty-two of Alabama's 67 counties have doctor shortages so severe that the state has declared them Health Professional Shortage Areas.

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Barganier said some primary care doctors in Alabama treat as many as 8,000 patients.

"There is nothing like being the only physician in a town or being only one of two," Midgley said. "It's hard to take a vacation, it's hard to have family time because you're working all the time."

He called it a self-perpetuating cycle.

"It's hard to attract new doctors because they won't have any backup," Midgley said. "What we have said is that our medical schools need to do more to address the problem. They need to turn out more primary care physicians than they do."

I would argue that churning out more primary care physicians won't happen because let's face it: what medical student would want to walk into this kind of situation? One of the solutions has got to be increasing the reimbursement rate for primary care physicians so that they can make a decent living without working themselves to the bone. If medical students see happy family doctors, they will want to become a happy family doctor, too.

What happens when there aren't enough generalists? Patients and doctors suffer.

Good Press

Dr. Gordon Moore recently got mentioned in a news article that highlighted just one of the benefits of his solo practice model -- same day access. The open access model is certainly not unique to solo practice, and many different practice models utilize it, including some large medical groups such as Kaiser. In fact, the open access or "advanced access" model was first developed at Kaiser by Dr. Mark Murray in Northern California.

Here's another recent news article about a family physician in Kansas City, Missouri who is revamping his practice to better serve his patients: Trying to keep it all in the family:

Need to make an appointment? You can call Soper's office in Kansas City, Mo., in the morning and see him that day.

All your medical records will be computerized. Your prescriptions, printed by computer, will be perfectly legible.

"Patients really like it," Soper says of his approach. "And it makes it a little easier for us to survive."

Survival is on the minds of many family physicians, the better-trained version of the general practitioners of a generation ago.

They can rightly claim that they're already an economical source of quality care. But many say the future of their beleaguered field may depend on more doctors changing their practices, as Soper has done.

He sounds like he is doing much of the same things that I and many other doctors are trying, which is to foment a Revolution. I'm not trying to change the US healthcare system, at least not all of it at the same time. I'm just trying to change my little corner of the world, and maybe it'll work and work so well that others will look up and say, "Hey, that's a great idea. Let me try that."

Still, being a Revolutionary would be a lot easier if I could get some press about my practice, too. Coincidentally, I attended a local chamber of commerce meeting today which was also attended by advertising executives from a large local newspaper. I introduced myself and described my kind of "Gordon Moore" family practice: same day appointments, no waiting, 24 hour a day access via cellphone or e-mail, house calls. They said they would pass the word to someone in the editorial section, and maybe I could get a news story out of it.

The local cable TV advertising executive was there also, and he suggested that targeted TV commercials, especially to a female audience (since many women decide who the family doctor is going to be, so he said), could be very effective. Hmmm. I'm not so sure about that. I can't ever remember seeing a TV commercial for a family doctor before. Besides Marcus Welby, M.D., that is. I would be concerned that I'd come out looking like a cheesy infomercial doctor.

I arranged to meet with the cable TV advertising executive two days from now. Somewhat troubling is that when I gave him my office address, he recognized it immediately and said he had worked with another tenant in the building last year. The other tenant was a Chinese herbalist - whose office I took over. If this is a reflection of how well TV commercials helped his business, then it does not appear to be a very promising method of marketing a physician's practice.

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Best quote from Dr. Marcus Welby a.k.a. Robert Young:

According to an article in McCall's magazine, a doctor said to Young at a convention of family physicians, "You're getting us all into hot water. Our patients tell us we're not as nice to them as Doctor Welby is to his patients." Young didn't mince words. "Maybe you're not," he replied.

The Decline of the Family Doctor?

I came across an article that I had seen a while ago, but never finished (until now), troublingly titled, "The Decline of the Family Doctor". It offers a thoughtful and insightful analysis into why the United States health care system is in the trouble it is in, and how a large part of that is due to changes in how primary care has been valued as a society.

"In the early 1990s, managed care attempted to use primary physicians and nurse practitioners to improve access and quality while, at the same time, keeping costs down. There was talk of the primary physician as the coordinator of all medical care. It didn’t work, and the backlash resulted in a decline in prestige, job satisfaction, and income for primary physicians. Many of the young physicians who flocked to the field felt cheated and misled."

I remember that time in the early 90s when FPs were in demand, and were given the role of "gatekeeper". However, it was not a welcome role, as I and this author observed:

"Furthermore, naming the primary physician as a “gatekeeper” whose approval is required by HMOs before patients can see a specialist suggests more of an obstacle than a caregiver. Personally, I have never encountered rudeness like I saw from HMO patients who came to see me because they were required to do so rather than because they wanted to. This is especially true when they had no interest beyond obtaining a referral slip to see a specialist whom they had already chosen themselves. It is difficult to know how to feel toward such patients and to function properly as a physician for them."

I used to think that a single national healthcare system was the answer. But more and more, like this author, I'm thinking that a single-payer system isn't the answer.

"The first principle is pluralism. Imposed one-size-fits-all and one-fee-fits-all solutions are incompatible with the American tradition and will not work. Choice and diversity must be maintained if American medicine is to remain vibrant, creative, and attractive as a career."

Staying the Course

Last week was a pretty good week for my still fledgling practice: 9 office visits, 5 new patients who all had physicals. This week: 6 office visits, 5 more new patients. Six months into my solo practice, I've had 73 office visits with 60 unique patients, with an even 50-50 split between the sexes, 30 males, 30 females. The average age is 36, and I'm definitely seeing more children and teenagers than in my former practice at Kaiser. This means most of the patients tend to be healthy, which makes for easier and more enjoyable visits, too.

Compared to some of the other doctors who are trying the "low overhead" or "Gordon Moore" model of practice, I feel like an old tortoise racing against Olympic-caliber hares. Scott in Florida just opened a practice right out of residency and saw 45 patients in his first two weeks. Michelle in Colorado closed her practice to new patients after less than a year, capping her patient panel at 450 patients.

Getting approval for insurance participation should help my practice grow. I learned just last week that I have been approved as a participating provider in Blue Cross of California, which has been the most common insurance my patients have had: 36%. That makes two health plans I have joined, Blue Cross and Cigna. I called Blue Shield the other day to ask what the status of my application was and found out that somehow my application had "slipped through the cracks". My credentialing had been approved back in April, but my application was never sent to the appropriate department to finalize participation. Whoops.

Yesterday I received an approval letter from Medicare, which was very fast, compared to the others. Looking back, it took about 6 weeks from the time I mailed the application to the time I got the approval letter. The third party insurers took about 3 months (with some still counting.... )

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Even as my practice seems to slowly pick up steam, I recently got an offer to buy an existing practice in a neighboring city. It is a successful practice with about 1500-2000 active patients, and the doctor is able to make a good income despite having two part-time employees and seeing about 42 patients on the 4 days of the week he works. When I heard these numbers, my first reaction was, "How can he do that?" But in analyzing the numbers a little, it does seem credible. I think I'm still not used to seeing a lot of income because I have not been keeping up with the billing.

When I first considered going into private practice, it had occurred to me that buying an existing practice would be one way to become financially solvent faster. But at the time, no one was advertising a practice for sale, and I wasn't about to go from doctor to doctor asking them if any of them were thinking of retiring. But buying someone else's practice means you get a lot of things that you don't want, too. There would be his employees, who are probably very nice, but a new kind of responsibility to deal with. There would be all the paper charts, since he is not using electronic medical records. His patients might be used to a different style or philosophy of medicine. But I would probably be instantly busy, seeing 10-15 patients/day compared to the 3-9 patients/week that my practice currently enjoys.

It would also mean either:
1) moving my location to another city, which would force me to give up my goal of being my home town's one and only family doctor.
2) Or moving the other practice to my current location (and risk losing patients from that practice)
3) Or keeping both locations and shuttling between them.

I would not be able to keep as tight control over everything, since I'd be forced to delegate appointment scheduling, billing, keeping track of supplies, etc. Some of this would be desirable. It'd be nice to have someone else answer the phone when I'm busy with a patient, rather than a recorded message. And billing can be tedious, when you have a lot of bills to process or if you have to call the health plans to argue over a denied claim.

So today I thanked the other doctor for the generous offer, but I preferred to stay the course and continue building up my own practice. I hope I don't regret it.

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I recently read a newspaper article about another doctor in San Diego who has been practicing completely solo, but he seems to have come up with the idea independently of Gordon Moore. Great minds think alike, eh?

And what can I expect for the future? Hopefully a little of what Kelly is getting. Kelly in North Carolina opened her solo practice about a year ago, and recently provided an update to the members of the Practice Improvement listserv. She wrote:

"My practice is incredible...I knew how hard this would be, but there are so many things that come up which I could't have even imagined let alone plan for.  I finally had to hire someone to help with billing...actually allocating payments and keeping up with the insurance companies, as Alteer handles the actual billing beautifully.

I'm still getting many calls a day for new patients, I have started accepting two a week and am scheduling them into January.  It feels stupid, as I hold my open access system dearly (for my established patients only).  But my waiting list was daunting and I don't want the responsibility of that...so if the people aren't minding I guess I shouldn't.

Though the insurance companies were definately NOT worth the hastle from November until July, they definately ARE now.  The reimbursement has been excellent this month.  Now that I have my pattern established with the ten biggest companies here I'm not having to call much anymore.  What a relief, and I'm getting paid much better than if I charged cash.  I also like the variety of patient's that it allows.

Have to go pick up my kids, who are also very happy with the life this practice allows, and have dinner with my husband (also a doctor at a local clinic) who is getting very jealous of the time I get to spend with my patients."

This gives me hope for a financially viable practice. I already am enjoying the time I spend with my patients - a practically obscene 60-90 minutes with a new patient has been my norm. And it's certainly gratifying to get comments such as this from my patients: "Thank you for being someone who wants to bring the caring quality back into Doctoring!"

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On a final note, I passed my Family Practice Boards (like 90+ percent of the doctors who took it). Yay. Now I have an excuse to send off a press release to the local paper and try and drum up some more business. I may be slow, but I'm not dumb.

Patch vs. Crash vs. ... Switch

I originally sent my Cigna application on 5/13/04. I got a letter back last week informing me that I had been approved as a participating provider. About 3 months, which is what others had told me. I am no longer in the limbo world of out of network providers. I am now a Participating Physician!

Or not...

I looked on Cigna's website and I am not listed in the online Physician Directory yet. So more waiting. Hopefully, I'll be hearing from Blue Cross, Blue Shield and Aetna in the next few weeks as to whether I'm accepted into their plans as a participating provider.

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Stop me if you've heard this one before. Complex system and infrastructure integral to providing healthcare has numerous flaws and obstacles to providing excellent care. Patches and fixes are like applying bandaids to plug leaks in Hoover Dam. You can keep tinkering with the system even as more and more problems arise. Or keep up with the status quo and crash and burn. Or you can try a radical change in the way things work.

The Gordon Moore Model? No, this time I'm talking about computers.

Eventually, if you wait long enough, everything converges. I ran into an article on Slashdot.com which discusses two of my favorite topics: medicine and computers. Fed up hospitals defy patching rules.

Problem #1: WIndows-based PCs are vulnerable to new viruses and worms. This is bad for hospitals that use PCs, ie. ALL hospitals.
Solution #1: Apply system patches and updates to plug vulnerabilities.

Problem #2: System patches often render software programs inoperable, including medical devices and instruments.
Solution #2: Software vendor tests their program with system patches to make sure they are compatible first.

Problem #3: Testing takes several months.
Solution #3a: Software vendor finally produces a product compatible with patched operating system. Repeat Problem #1.

or

Solution #3b: Hospitals apply patches anyways, and roll the dice, hoping their medical software and devices will still work. This leads to...
Problem #4: Vendor voids warranty because they didn't promise it would work on a patched system.

"When Microsoft recommends we apply a critical patch, the vendors have come back and said 'We won't support you,'" says Dave McClain, information systems security manager at Community Health Network in Indianapolis.

So the hospital has gone ahead and applied critical Microsoft patches to vulnerable patient-care systems when vendors wouldn't, McClain says. The hospital views the failure to apply patches as a possible violation of the federal Health Insurance Portability and Accountability Act (HIPAA ). "We have HIPAA regulatory issues, and you can't hold us back from compliance," he says.

Sometimes, the software vendor itself is the source of the virus infection:

There have been several instances in which viruses originated from medical instruments straight from the vendors, says Bill Bailey, enterprise architect at ProHealth Care, a Milwaukee healthcare provider. Medical equipment arrived with computer viruses on it or service technicians introduced the viruses while maintaining the equipment, he says.

(Getting on my soapbox)

As medical systems become more and more dependent on computers and electronic medical records, the information confained within them is only as safe as the operating system they run on. Increasingly, the Windows-based operating system is being exposed for its poor design and lack of security. As a physician, I feel that we should not trust our vital data and patient care to a buggy system, especially when there are safer alternatives. Either a Mac or Linux-based computer is a more secure solution.

This is not going to be a viable solution for everyone. There are not as many medical EMR/software/practice management options for Macs as for PCs. But for a solo physician, this is certainly something that is affordable and feasible. I'm living proof that it can be done.

Computer: Powerbook G4 12 inch 867 mHz
Scanner: HP Officejet 6110 All-in-one
Printer: HP Laserjet 1150
EMR: SpringCharts
Billing: Medrium
Financial: Quickbooks
Web browser: Safari (no pop-ups!)
Other software: Microsoft Office, Mail
Backup: daily automatic backup to offsite storage site, once a month complete backup of entire hard drive to external Firewire drive.
No known viruses for Mac OS X as of this time.

For ideas on how to switch to a Mac, go here.

(Getting off soapbox now)

Long Distance Medicine

It's nice to see that even though I am on vacation in Banff, Canada, I am still getting requests for appointments. 4 this week so far (one by email). Because of the distance, however, it's been a little trickier in calling people back and scheduling appointments.

First of all, I changed my answering machine message to note that I will be out of the office for the entire week, and that I would be returning on Monday, August 2nd. If they needed to be seen before then, I gave them the names and phone numbers of two local FPs who agreed to let me post their info. Since I've only seen about 50 patients, I told them it was unlikely they would get a call from one of my established patients. And I threw in the bit about, "If you think you have a medical emergency, call 911." Lastly I gave my cellphone number for anyone who really wants to get a hold of me, otherwise they could just leave a voice message.

Cellphone reception hasn't been bad, considering we're high in the Rockies. But for some reason, my cellphone often switched over to voicemail before I had a chance to answer it. The only calls I got were from a local magazine asking to verify the size of an ad I was placing, and a patient who was returning my call.

Internet access has been more difficult. At first, we were led to believe that there was free internet access in our hotel room, but that wasn't the case. They charge $15 (Canadian) for 1 hour of laptop hookup to the internet, which is cheaper than $20 for using one of their computers. After being spoiled with wireless access throughout our house, my wife and I find it a little inconvenient to trek downstairs just to access our email. It's still a heckuva lot cheaper than using our dialup service. The closest phone access is in Spokane, WA. While I was able to dialup and connect from our hotel room, the 45 minutes I connected ended up costing $57 in hotel long distance access fees. Ouch!

And for some reason, I'm not able to send outgoing email even though I can receive it. I'm sure it has something to do with the fact that I'm trying to access my ISPs email servers which I'm not connected on my ISPs network. So to send outgoing email, I have to use a web-based email server, like Yahoo or Hotmail.

My dream is to someday get an iSight web camera and be able to see and hear people from long distance, like a videophone, and be able to have a long distance doctor's visit that I can still charge for. That would be real long distance medicine.

Billing for Dollars

I've been spending a lot of time billing and trying to catch up on submitting bills for visits from 1, 2, even 3 months ago. I use Medrium, which I've found to be very helpful. I will write a little review of it later.

A couple of days ago I got my first two checks from patients who have insurance. Their insurers didn't cover the entire charge for their visit, so I sent them a bill. I've been setting my fees higher than Medicare's, using the rationale that Medicare's fees are the "baseline". I remember reading somewhere that you should set your fees higher because each insurer has their own individual "allowed amount" for each E&M code, and if you undercharge them, you could be losing out on some money.

For instance, a level 3 visit for a new patient (code: 99203) would be paid $104.46 by Medicare. Blue Cross's allowed amount is 101.02. My stated amount is $155. Unfortunately, if the patient's deductible hasn't been met yet, then the patient gets charged $155.

Another example, a preventive health visit for someone aged 18-39 (code: 99385). Medicare doesn't pay for preventive health visits so nothing to compare with there. I found some other fee schedules on the internet and chose a fee of $165. Blue Cross's "allowed amount": $165. That suggests to me that this is not their highest allowed amount, and I probably could have charged for more money. In this patient's case, however, his insurance only pays for 60% of the visit. So it's kind of a game to figure out how much money to charge to maximize reimbursement from the insurers without gouging the patients.

Yesterday I received a letter for denial of payment for a sports physical for a teenaged boy because their coverage does not include preventive health visits. I resubmitted it as a level 2 new patient visit ($105) because otherwise his family would be responsible for the entire charge of the sports physical ($160). I'd rather have the insurer pay for part of the visit, even if I get a lower total amount. I think the patient's parents would appreciate that, too.

I'm getting ready to take a week off, as my family will be going out of town. In the past, I've never been busy enough to even worry about patients calling while I was away. This time, I plan to change my answering machine message to let callers know that I am gone for the week, but they can still reach me by cellphone. Plus, I made arrangements with a couple of local FPs who agreed to let me give out their names and phone numbers if there are any patients who need to see someone before I get back.

I Got Paid Today!

A momentous occasion has arrived! I got a check from Blue Cross for $149.61 today.

This represents my first successful 3rd party reimbursement. Yippee! Of course, it's not what I charged for my services, but I didn't really expect full payment. That would be just ludicrous in this day and age. This amount breaks down to a $99 payment for a $165 charge for a physical on a healthy 30-something male; and a $50.51 payment for a $155 charge for a level 3 visit for a new patient (maximum allowed amount = $101.02. Where do they come up with these amounts???).

It only took 15-17 days from the time I first submitted the claim until the date they cut the check. Not bad.

This means that I can start submitting all my other pending claims with the reasonable expectation that not all of them will be automatically rejected. This also bodes well for my future income projections since my initial estimates were for an average payment of $78 per visit. According to my Quickbooks program, I have about $3500 in accounts receivable, ie, this is how much money is owed to me. This is with an average of about 3 patients/week over the past 5 months. When and if I ever build up my patient visits to what I hope (10-12 patients a day), then I see myself finally able to make a living from my solo practice.

For now, I look forward to just being able to break even. For that, my estimates call for at least 3 patients/day. I have a long way to go.

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FP Boards came and went uneventfully. They gave us 7 hours to answer all the questions. I used 4. I wasn't even the first one to finish. Some stuff was easy, some was hard. Either you knew it, or you didn't. All I can remember now is Lewy Body dementia and Henoch-Schonlein purpura. Or more specifically, I remember wishing I knew more about them.
__________

Over the weekend, while having dim sum in Chinatown with my family and some friends, I got a call from a friend who was sitting in the emergency room with her husband, who was not my patient. He had accidentally severed part of a finger off with a power saw and they were waiting for a callback from a plastic surgeon. She was hoping I knew someone who might be able to respond faster. Unfortunately, I didn't. I still don't know very many specialists in the local area, since I haven't ever had to deal with them or refer to them before. But I'm going to have to.

My first instinct was to call UCLA, since that is where I have a teaching appointment, plus it is one of the premier medical institutions around. The ER nurse connected me to the page operator who said she would page someone. While I was waiting, my wife paged a plastic surgeon she knew. He gave me the name of someone at USC, which is a lot closer than UCLA, but unfortunately no one answered at that number. So USC's page operator said she would page a hand surgeon from their facility. All this took place as we walked through the streets of Chinatown, with my cellphone clinging to its one bar of battery power left. I knew I should have charged it up before, but before that day, nobody ever called me on a Sunday!

In the callback race, the USC hand fellow called me back first (while taking the metro train back home). I explained the sketchy details I knew, and he explained that usually you had up to six hours to reattach a severed digit, depending on how bad the cut was. After some initial reluctance, I ended up convincing him to call my friend on her cellphone so she could talk directly with him. I figured they wouldn't want to just up and leave from one ER to go to USC's ER, but it might make them feel like they had a chance to have everything possible done.

UCLA's surgeon didn't call until after I had gotten home, but he explained that he had been in the middle of surgery and had asked a nurse to try calling me back earlier (but I hadn't gotten any calls from them). I thanked him for calling, and said it had been taken care of already.

We found out later that night, that my friend's husband ended up going to a Kaiser facility, and underwent skin graft surgery, but apparently they were unable to reattach the digit because of the severity of the cut.

While I was very much on the periphery in this case, it reminds me that in the not too distant future, I will probably be in the thick of things, taking care of hospitalized patients and calling the shots. I need to admit and attend at least 6-8 patients and be proctored by a current hospital staff physician in order for me to receive full hospital privileges. So far, I haven't had any, mainly because the local hospital ER doesn't know about me yet. But I plan to drop by and introduce myself and tell them I'm available for inpatients, but not until after summer's over. It may be the last quiet summer I have for a while.

As for now, my cellphone needs recharging...

The Third Path

It is the eve of my Family Practice Boards Recertification exam. Once every 7 years, I and many of my fellow FPs take the test, and if we pass, we can proudly claim that we are "Board Certified" in our specialty. It will be my 2nd recert, and even though I haven't studied very much, I'm not worried. I answered some practice questions and got around 70% correct. Plus the pass rate for the ABFP boards averaged between 92-96% between 1986 and 1996. Although there was that one year in 1993 when only 85% passed. Whoops.

There are courses every year to help you review for the Boards, and I took one 7 years ago for my first recertification. But my opinion now is that for most FPs, they are probably unnecessary, given the high pass rate we already enjoy. It appears to be a lucrative enterprise, though.

In the past week, I've had to deal with a new kind of problem: what to do when established patients call with a new complaint?

One woman got rearended in a car accident, and developed whiplash-like neck pain. A patient's mother had a form that needed to be filled out so he can go on a summer educational cruise. Another patient had been having vertigo for a few days. Another patient's mother emailed me asking if her son should get orthotics for knee pain that began ever since he started training for cross country 2 weeks ago.

All of these problems could be handled, more or less, without an office visit. My dilemma is that, without an office visit, I won't get paid for my services or time. My choices are:

1) Encourage everyone to make an appointment to be seen by me in the office for a "proper" evaluation, and risk alienating each patient who may conclude that I am only making them come in to make money off them.

2) Help them out by phone or email, then charge them a separate fee to be billed later. One flaw with this option is that I have not established any kind of policy on charging for these services. Until I establish a more formal policy and inform patients beforehand that they will get charged, I think I will avoid doing this. I did read, however, that there is now a CPT code available for online consultations. Read about it here.

Even if I were to establish a policy of charging for telephone or email consultations, it might be seen as "nickel and diming" patients. I recognize that other professionals, such as attorneys, bill for their time, such as for telephone advice. As a physician trying to get a new practice off the ground, it might not be in my best interest. Maybe later, after I am more established. Which brings me to option number...

3) Help them for free, which is what I've been doing. It's building goodwill, and hopefully I'll get compensated for it later on with a new patient brought in by a good word from these patients I've helped for free.

This is in contrast to the transition of a local doctor's practice from a traditional office to a "concierge medicine" practice. I don't know who it is, but I've heard about it from a couple of patients or their relatives. I keep thinking that if people only knew about me and my practice model, they would realize that they don't have to pay that extra retainer fee to get good service and personal attention.

Unfortunately, this brand of medicine does not yet have a catchy buzzword name to describe itself. In my search for a suitable descriptor, I came up with "The Third Path". It sounds kind of mystical, like a spiritual movement, and I suppose to a certain extent it could be that.

The First Path of modern medical practice is what physicians do now. Reimbursements are fixed by third party insurers. Expenses keep going up. Those who follow the First Path try to make ends meet by seeing more patients to generate more income. This generates more work, more claims, more charts. So more ancillary help needs to be hired, which raises expenses more. Which means even more patients need to be seen. It's a hamster wheel.

Those who take the Second Path are boosting their income by charging patients more, an extra retainer fee to insure good service and to pay for all the services that don't get reimbursed. This is the "Concierge" or "Boutique Medicine" that seems to be getting more and more popular. More income means they don't have to see as many patients to cover their expenses, so they can spend more time with patients. Which means doctors can relax and enjoy practicing medicine again. Everybody wins. Except those unfortunates who can't afford the extra fees. This is medicine for the wealthy and well to do, and creates a second-class patient. Plus, Medicare will probably go after anyone who charges extra for what it considers covered benefits.

The Third Path is the way I've chosen, led by our prophet Gordon Moore. Instead of raising fees, we seek to control expenses by doing as much as we can ourselves, by streamlining operations with EMR's and email and cellphones and the Internet. And by thinking small, as in small offices, short waiting times, minimizing barriers and hassles as much as possible. The Third Path is not the Usual Way Things Are Done. Hopefully, it's better!