A Shot in the Arm

Today I gave the 2nd shot of my new practice to a 14 year old boy whom I saw for a check-up last week. I saw from his shot records that he had only had one MMR and advised his mother that he needed a 2nd one. I have not been stocking vaccines until I have a need for them, mainly because . . . have you seen how much vaccines cost???

A 10 dose order of MMR vaccine from Besse Medical costs $416.63. I figured I could use up 10 doses before they expire next summer. If not, I'll be wasting a lot of money. My other choice would have been to order a single dose vial of MMR for $51.49, but that's $10 more per dose. Anyways, I ordered it the same day I saw the boy, and it arrived on ice 2 days later.

Never having needed to give MMR shots before, I learned that the MMR vaccine comes in a powder inside the vial, and needs to be reconstituted with diluent (sterile water) before giving the vaccine. Fortunately, the order came with 10 bottles of diluent, too, so all I had to do was draw it out with a 25 gauge 5/8 inch needle and syringe and squirt it into the vial of MMR vaccine. The MMR vaccine has to be refrigerated between 36-46 degrees Fahrenheit, which is not a problem –– for now.

I got a mini-refrigerator with a separate freezer (even has a door lock!), just so I could keep vaccines. I got min-max thermometers for the separate refrigerator and freezer compartments and have been keeping a log recording the temperatures. That's kind of a pain to keep track of, since I have to make a special trip to the office to record the temperature even when I don't have any patient visits. I've read about low-tech ways to monitor the freezer, put a cup of ice with a penny on top in the freezer and check it daily. If the penny starts to sink down, you may have a problem. But I decided to go high-tech.

My problem is, when the refrigerator is just right, the freezer is too warm (meaning goes above 5 degrees, the maximum temperature for Varivax, the only vaccine that needs to be frozen). And when I turn it down so that the freezer is just right, then the main refrigerator gets too cold for the other vaccines.

I think my solution will be to do "just-in-time" ordering of Varivax, in case I ever need it. One dose costs $71.21, and I'm sure I can convince a parent to come back in 2-3 days for their child's shots. This way, I won't have to worry about a bunch of Varivax going bad. $71 dollars a shot! Still, that's not as expensive as the meningococcal vaccine ($84.77 per dose). Yet another reason college is so expensive.

Then there's the Vaccine Information Sheets (VIS) that you're required by Federal Law to hand out to parents/patients before they get the shot. I did remember to give the mother that. Plus you have to record the lot number and expiration date of the vaccine you gave, just in case it turns out later to be recalled, for some reason, like the Hep A vaccine was a few years ago.

This site has other helpful info on good immunization practices.

As for the actual administration, he was cooperative and didn't flinch when I poked his left deltoid. I'm sure they won't always be this easy and I'm anticipating with dread my first toddler shots. I plan to try using the Shot Blocker or maybe just using topical EMLA cream.

That reminds me. I should eventually get some lollipops and stickers, too! Adults get stickers like this and this. Then again, maybe not.

I've been busy (and sick)

Haven't posted in a while because:
1) I got sick with a virus (cough, cough)
2) Got busy with a PowerPoint presentation to my daugher's 5th grade class on the respiratory system (hooray for snot!)
3) Was busy writing an article for California Family Physician magazine about practice transformation

I'm up to 26 patients seen so far, saw 3 last week. My last 5-6 patients have all had insurance (Blue Cross) for which I can bill later on, hopefully as an in-network provider. Business seems to be picking up a little.

I met with a marketing/PR guy for the 2nd time today, and he gave me a bunch of ideas on how to grow the practice. He thought the solo practice idea was unique and would be attractive to a lot of people. When I told him that I expected to get to a point in my practice where I would be busy enough to not have to do any more marketing, he laughed and said that I was dreaming. In his experience, you have to keep marketing to maintain business. He likened it to a patient saying "I'm done seeing doctors." after getting a one time check-up.

But he did have some interesting ideas on how to get more people to know about me, such as contacting the local PTAs and offering to give talks to them, or getting to know local real estate agents since they would be the ones to know about any new residents in the area. He also suggested direct mail, which I had considered before, and that I could offer to take local doctors out to lunch as a way of generating referrals. While probably true, it seems a little heavy-handed to me. But maybe that's what doctors do when they're trying to build up a practice.

Recently on the Practice Improvement listserv, there have been worries about the viability of Alteer, an EMR company that many of the doctors on the listserv have purchased. It is an impressive system and I considered getting it, too, but quickly decided that it's $25000 price tag was too rich for my blood. Given how unstable the market is for EMR systems, I was worried that I might still be paying off the loan to buy it after the company went out of business. Instead, I went with SpringCharts, not so well known, but much more affordable at $500 plus another $500 for annual support. One of these days, I'll write a little review on it. It's not a perfect EMR, but for me it gets the job done.

I also bought a domain name to make it easier for patients to find my website. $18 for 2 years is a pretty cheap deal.

No Free Lunch

Today I am attending the Pri-Med West Conference in Anaheim, CA.

First, I've got to say how amazing ibuprofen can be. A few hours ago, my ankle was throbbing and each step was exquisitely painful. A couple of Advil and hours later, I can walk almost normally with only mild pain. As a physician who is constantly prescribing medications, it's nice to know that what we tell patients to do actually works. At least, some of the time.

This past week I've seen two more patients, and I have another appointment set up for next week. One difference from previous patients is they all have insurance, Blue Cross, in fact. And that means I can submit my "customary and usual" fees, rather than the "time-based" fees that I have been charging people without insurance. Hopefully, this means increased revenue, not because I can charge the insurance companies more, but because I've been giving a large discount to uninsured patients.

I think I've got it figured out, at least for Blue Cross. At first, when patients used to call for an appointment, I'd get their name and schedule a time for us to meet. End of phone call. Now, I ask who their insurance is with and what their ID number is. I also ask for the toll-free number on the back of their insurance card because that is how I find out their eligibility and exactly what is covered, whether there is a copayment, etc. It makes things a lot easier when I know what to ask for in payment, or whether to even ask.

In the past, I've calculated that for my practice to break even, I need to see about 3 patients a day, assuming an average charge of $78 per patient. In terms of money, it's actually $257/day. I'm a long ways away from that, but I have hopes that business will pick up. This past week has felt different to me, like people in the community are finally starting to think of me for their medical needs.

I arrived at the Conference late today because I wanted to send off an application form to Cigna. I'm starting to get the hang of these forms. They all ask for pretty much the same information, so I now keep my documentation (medical license, DEA, board certification, proof of malpractice insurance, etc) together for easy copying.

By the time I arrived (11:20 am), the morning lectures were ending with a 2 hour lunch session. So I have spent the last hour walking the exhibition area. That's where rows and rows of booths from pharmaceutical companies, recruiters, electronic medical records companies, medical equipment makers are set up, hawking their wares. There are the usual freebies (pens, notepads, totebags, soft pretzels, yogurt, magnets), but not so many as in past years, in my opinion.

It's an amazing sight to see physicians on the exhibition floor carrying bags and bags of mostly useless freebies in both hands as if they were at a flea market. Fortunately, I didn't see any today, but I have in the past. I suppose there are people with no shame in all walks of life.

I've always felt uncomfortable about all the freebies that drug companies hand out, because I know that they are not really free. For that same reason, I stopped accepting drug samples from the drug reps many years ago. I was bothered to think that the free giveaways ultimately meant higher drug prices for consumers. And invariably, the free samples were always for the newest, and consequently most expensive products. They figure, once they get a patient started on a drug (even a free one), they are likely to continue with it, especially if their insurance pays for it. And that drives up the insurance premiums, and then the patients and employers have to pay again.

It was even more evident to me what a waste drug samples were when several years ago, I cleaned out the cabinet where I kept my samples. Because I never remembered to give out any, almost all of them had expired, and were useless. I felt badly at having wasted hundreds of dollars of expensive medications, but I realized then that giving out free samples was not my style, and not compatible with the Kaiser system.

As they say, there's No Free Lunch.

Okay, I'm not that pure. I did take some free pens, 2 notepads and 1 totebag. Plus I did get my lipid profile checked, like I do every year at these things. My LDL is still low at 108, and HDL still high at 60. Hallelujah! I can keep eating In-n-Out for another year...

Good News and Bad News

As the saying goes, I've got good news and bad news.

The good news is I saw 2 new patients in my practice today.

The bad news is I sprained my left ankle tonight at my weekly Wednesday night basketball game. It's swollen to the size of a lemon and currently propped up on a chair as I type this. No more basketball for me until I get disability insurance. I called in sick for tomorrow's afternoon clinic at Kaiser that I was scheduled to work, but I can barely walk right now. It'd be very difficult for me to see 12 patients in 3 1/2 hours like this. Heck, I can't even do that when I have two good ankles.

I was pleasantly surprised to get calls for appointments yesterday. One gentleman saw my ad in the local paper and had saved up various aches and pains to discuss. The second patient was a former Kaiser patient who could no longer afford her insurance, and was referred by one of physicians from the clinic who knew about my practice. I scheduled the first patient at 9AM and the second one at 11AM, thinking that should be plenty of time. Patient #1 arrived at 9AM, and took about 15-20 minutes filling out my forms (Registration, Medical History, Financial Policy, Notice of Privacy Practices, Guidelines for Emailing). It took about an hour, and he left at 10:15AM.

I entered his information in SpringCharts, and proceeded to write the progress note. I've decided I'm not going to try to chart while the patient is in the room. I think it's distracting and gives the patient the impression that I'm not fully focused on what they have to say. When I do finally get a returning patient, I'll bring my laptop into the exam room with me, if it's appropriate. As a medical student, I used to write down EVERYTHING a patient told me, because I didn't know what was relevent and what wasn't. I went from a clipboard to index cards as a resident, keeping one card for each patient. Some time in the first year at Kaiser I gave up the index cards and wrote on little slips of paper attached to the chart. After I started taking part in UCLA's Doctoring Program teaching first year medical students how to interact with patients, I realized that it was all about building rapport with the patient.

I remember a 1st year student interviewing a Standardized Patient (an actor playing the role of a patient). He looked calm and relaxed in his white jacket, sitting back with his leg crossed in a figure 4 position with a clipboard in his lap. As he asked his questions, he kept looking down at his clipboard and occasionally at the patient again. When he was finished with the interview, the other students congratulated him on a job well done. I, on the other hand, said that I thought he looked just like a resident in the emergency room. Which wasn't necessarily a good thing. Why was he even writing on the clipboard? He didn't have to write a progress note or remember anything about the patient after his interview. To me the clipboard or chart is a crutch, a security blanket in case the student gets stuck and can't think of what to say next. But it also gets in the way of developing rapport with the patient. And this class is all about teaching the students how to develop a relationship with a patient, in order to build trust, which in turn results in more information being shared and better care. A lot of doctors could use some of that, too, doncha' think? So now, I gently advise all first year medical students to ditch the clipboard and focus on the patient. They'll have plenty of time to carry their clipboards later.

Which brings me back to now. I try to practice what I preach, so I ditch the chart or clipboard when I first walk into the exam room and greet the patient. I only write if there is some number (eg. BP) or list (eg. medications) that I'm likely to forget. But I've learned that I am able to remember most other details after the patient has left.

By the time I was done with my progress note, the second patient arrived. I spent 50 minutes with her, and because she had no insurance, I was going to round it down to 45 minutes, and told her to pay me $60. Fortunately for me, she caught my mistake. "Don't sell yourself short, doctor!" 45 minutes at $50 per 15 minutes should be $150, with a 20% prompt pay discount that would bring it down to $120. I thanked her for her honesty, and explained that I was rather new to the business aspect of medicine. Which was rather obvious.

Later that afternoon, I worked 4 hours at Kaiser and earned $240 or $60/hr, the going perdiem rate. I realized that I probably made that much seeing those 2 patients in the morning as I did seeing 12 patients at Kaiser. So, if I can get more patients, I think this solo practice thing may just work, financial-wise. It already works satisfaction-wise. And that's good news.

Doing things myself

I'm barely getting started in my new solo practice and I'm already losing a patient. Someone whom I did a physical on about a month ago called me last week to ask if I accepted Blue Cross HMO. He was planning to switch from Blue Cross PPO at $130/month to the HMO plan at $40/month. Since he is a struggling student, he obviously prefers the less costly option. I told him I didn't plan to accept any HMO (meaning capitated) plans, but that I would look into their reimbusement policy. I've learned from talking to one of Blue Shield's reps that an "HMO" plan is not always synonymous with "capitation", and that their HMO actually functions like a fee-for-service plan.

I attended part of our city's "Relay for Life" charity event on Saturday. It was an organized 24 hour walk around the high school track in order to raise money for cancer research. At one time, I had considered being an event sponsor for a significant donation, and maybe setting up a tent to hand out free water since it was expected to be a hot day. However, in retrospect, I'm glad I didn't. It was nice to spend the day instead with my family, continue our 2 week long Monopoly game, and not worry about rushing around. Eventually we arrived at the high school track after it had cooled off and joined friends who were already walking.

I keep hoping that word of mouth from friends and patients about my practice will gradually build, reach a critical mass and start bringing in more patients. I feel a little awkward every time someone asks, "So, how's the new practice going?" My wife (hi honey!) keeps telling me to be positive and say something like: "Business is doing great, thanks for asking!" rather than what I usually say: "Slow. Really slow." She's got a point, I guess. Success breeds success, and the perception of success is as good as the real thing.

I sometimes suspect if I had set myself up as a "concierge practice" that I could have garnered a lot of publicity and more people would be signing up with me just because of the perception that they are getting into something "exclusive". Who knows? I think there are many people who when given the choice will rather choose the more expensive "brand name" over the cheaper alternatives because they perceive that they are getting more value for their money.

Speaking of value for their money, I think I might have saved Kaiser some money. I was working Friday afternoon, and as usual finished late. I noticed a note pinned to the computer screen about a patient calling for their CT results from about a month before. Apparently he had been dealing with a non-resolving otitis externa. The note was from 2 weeks ago, and the CT report hadn't come back yet. Out of curiosity, I checked the computer to see if the report was back yet. It had been dictated just the day before. The radiologist thought there was a parotid mass spreading into the ear canal, suspicious for neoplasm. Uh oh.

After checking the patient's chart, I couldn't find any indication that he had been notified, so I had to assume he hadn't. I managed to get a hold of the ENT specialist on call who agreed that the patient should be seen sooner rather than later. But since it was Friday evening, the appointment service was closed for the weekend. The specialist would try to arrange an ENT appointment on Monday. I left a message for the patient to call me at his earliest convenience about his CT results, and I left my cellphone number. When I was working full-time at Kaiser, I would NEVER give out my cellphone, as that would mean a loss of my privacy. Now, I figure I'm giving out my cellphone number on my business cards, so what difference does it make to give it out to one more person. Besides, I really did want him to reach me. I did eventually reach him an hour later when I tried his number again. ("Jim Jones? No, he's not here." "I'm a doctor calling from Kaiser." "Oh, hold on a second." (a few seconds of silence then the same voice comes on) "This is Jim Jones." Why do people do this?) Fortunately he seemed pretty calm when I told him the results.

I speeded up the process by a few, maybe several, days. Will it make a difference? Probably not. According to this website, 80 percent of all salivary gland tumors are benign, and even if it is malignant, the 5 year survival rate is 85 percent. But I didn't know that at the time. And even if I had known, the right thing to do still would have been to arrange a consultation ASAP. Because you never know when it might actually be cancer. Or giants.

Today I checked out direct mail (or what most people refer to as "junk mail") from the U.S. Postal Service website. While they don't do direct mail themselves, they link to companies that do (and pay for postage, hence the connection). For me to purchase a direct mail list of 11000 names in my local city, it'd cost about $1000 or about 9 cents per name. Or I could rent a mailing list for about $130 but I could only use it once. Supposedly they put decoy names in the list as a way of detecting unauthorized use of the mailing list. Personally, I think this would be fairly easy to circumvent unless they have agents that live in my small town who report directly to the mailing list company any time someone sends them unsolicited mail. Unlikely.

It then occurred to me, seeing as I have a lot of time on my hands, that I could easily walk around the city dropping off flyers and brochures advertising my practice. Heck, I always wondered what it'd be like to be a mailman. Plus what better way to introduce myself to those in the community? But I think there are some who would consider this a rather stupid idea (hi honey!). As stupid as, say, a doctor answering his/her own phone. Or giving his own shots. Or doing his own medical billing. Ha, ha. Yeah, who'd be that dumb?

Oh. Right.

Hmmm. Should I carry some dog repellent?