Setting Goals

Personally, I don't know how these people keep updating their websites every day. I'd be happy updating even once a week. Let's see, my last post was . . . 5 days ago?

YES!!!

That's the secret to success: set your goals low enough and you'll achieve them even if you barely try.

It's 3 PM. I'm waiting for the daughter of a family friend to come in at 3:30 PM to measure her blood pressure and enter it on a form for a summer camp. In my experience, people who have forms to fill in rarely need "just" a blood pressure measurement to be filled in. They often need a complete evaluation and a physician's signature, so that in case the person keels over while hiking/playing soccer/wrestling bears/fill in your own dangerous activity here/juggling kittens, they'll know who to point to when the lawyers come to sue.

Earlier today, I was sitting at home making finishing touches on another ad when the phone rang. I don't usually answer the phone at home because, well, because of this: "For the 50th time, no, I don't want to subscribe to the newspaper! Why? Because I already subscribe!" But for some reason I picked it up today. Good thing. An aquaintance from our kids' school was on the line. They have a construction company, and one of their workers accidentally shot a nail through his thumb. It hurts just thinking about it.

Could I see him today? 45 minutes later, they were in my office. 30 minutes later, they were done. I figured I saved them about 3 hours and $150 if they had gone to the local ER. The only drawback was that I didn't have any tetanus vaccine. Namely because up until now, I haven't had any patients who needed it. So I told the guy I'd give him a call when I had some available and then I quickly ordered it online. Supposedly Besse Medical will ship it out tomorrow. $165 for 15 doses works out to about $11 per tetanus shot. I never had any idea how much they cost before.

My friend's daughter just came and went. The form really did just need a BP and pulse reading filled in. Her mom told her to pay me for my time, but I refused to accept payment. How often do doctors refuse to take money from patients? I don't know, but apparently in China, you can face "serious punishment" if you accept money from patients. I'd make a good Chinese doctor.

Last Friday, I gave the first of my monthly health presentations at the local Senior Center. Topic: Mad Cow Disease. If you define success as having more than 2 people show up AND pay attention AND not riot afterwards because they thought it was supposed to be Free Fruit Cup Day, then it was an unqualified success. Actually, 8-9 seniors showed up and a few told me they thought it was a good talk. Even the little old lady who kept asking, "What about chickens? And milk? Is it okay to drink milk?" After I reassured her for the 3rd time that milk seemed OK, she confided, "Oh, that's good. I don't drink milk anyways."

It occurred to me that perhaps I was missing calls from potential patients who would call my office, but never leave a message on the answering machine. Because I haven't had patients every day, I have not necessarily gone to my office every day, instead doing work at home or running errands, and checking in about once an hour to see if there are any messages. Usually none, but when I checked the Caller ID log, there'd be calls - just no messages. So I signed up for Call Forwarding and now have all calls routed to my cellphone. And since I've done that -- I can't tell the difference. Is that supposed to happen?

But another ad is coming out tomorrow in the local newspaper. I'm taking a "high road" approach, trying to present a positive and dignified image, featuring a photo of a happy local family each time. I've wondered if I should include marketing gimmicks like a coupon for $10 off. But I feel that 1) they don't work to generate new business and 2) they cheapen the image of physicians, putting us on the same level as a fast food chain. Then again, McDonald's made over $500 million last year. But they did give us doctors a lot of business while doing it, so maybe it evens out in the end.

I sent out email inquiries today to 2 other local newspaper about their ad rates. Maybe it's time to expand my advertising range, which so far has been limited to our little city. This weekend is the American Cancer Society's "Relay for Life" fundraising event. Perhaps there is still time to be a sponsor and set up a tent with water bottles, since it's probably going to be over 90 degrees.

I delivered a check for $500 today to the City Recreation Dept. to be a sponsor for the "Concerts in the Park" series this summer. A month ago we received notices that it was in danger of being cancelled due to budget shortfalls in the city government, and thus a call for help to the local business community. Even though we've never personally attended one, my wife and I do feel that this is a worthwhile community activity to promote and continue. And perhaps this year we will attend our first "Concert in the Park".

It does seem like there are an infinite number of charities in need of money these days, and each one represents a marketing opportunity. On the positive side, it's good to be seen as a supporter of the local activities and community at large. To be a good neighbor. On the other hand, I'm running out of money.

For the first time in a long time, I've started acting like the average American consumer: specifically, carrying a balance on my credit card. Fortunately, I'm still in the 0% grace period. Unfortunately, that grace period runs out in June.

I suppose I can then start playing that other American pasttime: the Credit Card Shuffle.

My new goal: to not go out of business before next week. I have reasonable hopes of success.

Busy... Yet Not

1 patient this week: skin tags. But hey, at least I know how to use Verruca-Freeze now and it works fine.

Busy writing a presentation for tomorrow at the local Senior Center on Mad Cow Disease. Not that much in the news these days, but they chose the topic 2 months ago when I first volunteered. Has me rethinking whether we should be eating beef. The more you learn, the less you want to know...

Also haven't posted because I had to downgrade my laptop's operating system from OS X 10.3 to 10.2 in hopes of getting my all-in-one scanner to work. After all the work of backing up and reloading software, it still doesn't work! And HP claims it is Mac-compatible!

Now I'm going to drive over to a family friend's house to take their family photo for next week's newspaper ad. I haven't run one for a month. Maybe that's why not much business?

Quality time

Spring Break is over, has been over, and business in my new practice is sssssss s s l o w.

No patients scheduled for this week. Yet.

I worked half day shifts at Kaiser yesterday and today, and it never fails to remind me of why I chose to leave its relatively sheltered environment. I walked in the room yesterday and greeted the patient, man in his early 60s. He proceeded to unfold his story. He hates coming to the doctor, so the fact that he's here means something is really wrong. He's had "sciatica" for a month, so we go into that. Plus extensive psoriasis that he's never gotten treated before. During the exam, I find that his blood pressure is up, so there's a whole other discussion about how HTN is usually asymptomatic and why that needs to be followed ("Increased risk of heart attacks, strokes, and impotence" - the last one usually grabs their attention). Then he mentions that he's been tripping occasionally whenever he walks...

Another guy is here for a second opinion about the treatment he took for H. pylori, and it segues into a discussion about repeating an HIV test and how he should be immunized for Hep B, since he is gay and in a high risk group. He had tests showing that he was negative for Hep Bs Ab and Ag (twice). And yet no one ever advised him to get immunized for this highly contagious and common infection.

By the end of the half day, I was over an hour behind, and feeling like I had been through a wringer. I feel like I give a lot of myself, going the extra mile to give not just good but excellent service, and I pay for it in the end when I have a pile of charts that I didn't have time to write in because I was constantly playing catch up. OK, it's my own fault. But I wonder, am I an oddball for feeling like I need more time to spend with patients to give them good care? I've timed myself before over a 2 to 3 week period, counting the "face to face" time and the "charting time". I consistently came out to average 16 minutes of "face time" and 4 minutes of "charting time". Which is a problem because at Kaiser, I only get 15 minutes.

What is the norm for an office visit? It depends where you're at.

This study from the British Medical Journal looked at "consultation lengths" in 6 European countries and found that the average duration of an office visit was 10.7 minutes! In Germany and Spain, general practitioners see more than 200 visits a week. That's about 40 visits a day! Oy vey!

By comparison, American patients are living in the lap of medical luxury. This 2001 study looked at the average duration of office visits and concluded that U.S. doctors were actually spending MORE time in 1998 with the average visit lasting 18-22 minutes, compared to 16-20 minutes in 1989. The method of collecting the information however, lends itself to a lot of recall bias. Basically they sent a survey to all physicians asking them how much time per week they spent in various activities, including patient care. Then they asked how many patients, on average, they saw a week. They divided the hours of patient care by the number of patients to come up with the average length of visit.

I like this study better. This commentary from The Lancet sums it up:

They conclude that a doctor who consults more slowly is more likely to provide visits that include important aspects of care, and that longer appointment length can therefore be used as a marker for quality.

As my daughter might say, "Well, duh!" It goes on:

Despite the widespread perception among doctors and others that appointments are more rushed, the length of visits has remained stable or increased modestly over the past decade. This discordance, in part, reflects the fact that there is simply so much more clinicians can do, and are expected to do, during an office visit.

So not enough time in my old practice, and too much time in my new one. Time to try and figure out how to get more patients into my practice. Duh!

Back home

Back from the California Academy of Family Physician's Annual Symposium over the weekend. Met some new people, saw some people from the past. Some of them had heard of the "solo-solo" practice model, others had not but thought it was an interesting idea. Actually, Gordon Moore, father of the "solo-solo" model was there on Thursday night giving a presentation on this very topic. Unfortunately, I couldn't make it, as I was tending to a sick 5th grader at Outdoor Science School at the time. But I'd already heard most of what he talked about already, I think.

I learned some new things at the Symposium. One speaker, Dr. Michelle May, had an interesting concept regarding obesity treatment. Basically, our approach has been all wrong, and diets and exercise and drugs don't work (and she's right, they haven't). Her approach is to retrain people to recognize the physical signs of hunger and to only eat when they are hungry, and to stop when they are no longer hungry. She also teaches them to recognize the other reasons why they may be eating, and to learn to deal with these triggers in more productive ways. She has a website detailing her approach. I'm one of those naturally skinny people she talked about, who eats pretty much whatever I want without gaining weight. But I've noticed that it doesn't take a whole lot of food to fill me up, and I will in fact start to feel ill if I overeat. That is one of the cues that some overweight people have lost the ability to recognize, Dr. May argues.

My own take is that this approach would probably be very helpful to some people, but not everybody. Since overweight and obesity are multifactorial, it makes sense that one treatment would not fit all, and that different people will do better on individually tailored obesity treatments. I wonder if anyone has ever tried to categorize obese patients by type (eg. psychotrauma-related like child abuse/rape, stress-reducing, binge-type, carbohydrate-craving, familial, etc.)?

Another memorable speaker was Dr. Kenneth Moritsugu, assistant surgeon general, who spoke on behalf of organ donation. He related his own touching story about how he lost both his wife (in 1992) and daughter (in 1996) in separate car accidents, but donated their organs thereby giving life to over a dozen people in need of organs. He pointed out a website with more information, and how the Department of Health and Human Services will be making a push to publicize becoming an organ donor with green ribbon pins. He told us to expect them in the mail soon.

On the listserv, there has been some discussions about what our group of "neo-solo" physicians should call themselves, and how difficult it is to describe what we do. "Boutique" or "concierge medicine" has a name for their concept of high-quality, extra-service medical care that comes with an extra retainer fee. As far as I'm concerned, I do most of what concierge medicine physicians do, but without the extra cost (and expense).

Some names that have been suggested for our concept of a low overhead, barrier-free, highly personal medical practice has been called solo-solo (referring to a doctor with no staff/employees), minimalist, cutting-edge, neotraditionalist. But the best suggestion I've heard so far is that of "Personal Medicine". Same day appointments, no waiting, extended length office visits, house calls, email and cellphone access to me at any time of day. Personal medicine. It fits.

However, I don't offer "vigil service" like these personal physicians. But then again, I don't charge $400 an hour either.

Right Place, Right Time

Talk about serendipity! You just have to be in the right place at the right time. I've been at my daughter's Outdoor Science School all week as the volunteer doctor. It is in the local mountains, about a 45 minute drive from home, and out of range for cellphone access. Since I am just starting out and don't have very many patients, and since I don't know any family doctors in the local community well enough to ask them to cross-cover me, I didn't arrange for cross-coverage. I changed my answering machine greeting to reflect my abscence from the office this week, and I've continued to check for messages several times a day. But other than one appointment for a physical for next week, there have been no messages.

Imagine my surprise to have been able to see two patients yesterday. I drove down from the mountain yesterday at around 10:30 am because I had a class to teach at UCLA, and I wanted to stop by my office and check my mail. There was a new phone message which hadn't been there when I called earlier at 7:30 am. It was from one of our family friends who was hoping to get an appointment for her daughter with a sore throat. I immediately called her back and told her how lucky she was that I had come down from the mountain (one of her other daughters is at the Ourdoor Science School, too), and she immediately drove over.

While they were filling out the registration papers, I got another call. This was from the relative of one of the secretaries at my wife's job, who wanted to make an appointment for her boyfriend. At first I thought that I didn't have enough time to see him, because I was already seeing one patient, plus I needed to get down to UCLA by 1:30 pm. Plus I needed to take a shower. Badly. But the alternative was to make him wait.
"Can he come over right now?" I asked. It turned out he lived very close, and he could be over in a few minutes. I told him to come at 11:30 am, to give myself enough time to take care of the patient I had now.

And it all worked out.

I got to try out the OSOM Rapid Strep A test, and I charged them their usual copayment of $10 for an office visit. They have out of network benefits with Cigna, so I will submit a bill to them later. By the time I was done with them, the 2nd patient had arrived. While he was filling out his registration papers, I ran across the street to my house to get a spare stethoscope since I had left mine up in the mountains (how could I have known I was going to be seeing patients?). I got back before he finished filling out the first page. He was happy to be able to get an appointment so quickly, especially because the other doctor he saw 2 days earlier told him today that there was nothing else he could do for him and he'd have to go to the County-USC Hospital. Which is a zoo.

Tomorrow (Friday) is the last day of Outdoor Science School, but I'll be headed to San Francisco for the weekend attending the California Academy of Family Physician's Annual Scientific Assembly. I still plan to check my phone messages from there, even though I probably won't get any calls. But that's not a bad thing when you're out of town. I know it's a luxury I won't be able to have in the future.

In case you're wondering how can I post this when I can't even get cell phone access? Juno.