Making Time to Write

Who has time to write? I don't.

This article, by way of the Annals of Family Medicine, looks at the plight of the physician-writer and the lack of time available for writing:

People do not, of course, make time. Time exists, for practical purposes, as a linear flow, and people are swept along in it. Like a fast-moving river, time propels us forward, but sometimes we can swim hard to stay at the edges where the flow is a bit slower. So how do busy people find a way to write as they are swept along? I mean, how do people who are practicing clinicians—doctors, nurses, therapists—people with clinical commitments and sometimes life-and-death interruptions—how do they write?

It goes on to describe 3 strategies one can use to find time to write:
1) Deck clearers (aka procrastinators). They can only write when everything else has been done (which means nothing gets written), or when there is a deadline. This has been my modus operandi for years.
2) Wedgers write whenever they find a little free time. Blogging has moved me to this kind of writing - a little bit here, a little bit there and it starts to add up to something substantial.
3) Schedulers force themselves to write by blocking time off specifically for writing. This is the strategy of those who consider writing to be their profession.

I will strive to become a Scheduler, just as soon as I can clear my deck of the all the things I've been meaning to finish.

Who has time to write? I don't. And yet, I do anyways.

Doctor, can you write me an prescription for a robot?

This article (by way of Slashdot) gives a preview of the latest greatest thing for elderly assistance since the electric scooter: robots that you wear like body armor.

Yoshiyuki Sankai is among those who see robots as the future of elderly health care.

A researcher at Japan’s University of Tsukuba, Sankai has developed a robotic suit designed to make it easier for elderly people with weak muscles to move around or for care-givers to lift them.

Although very cool-looking and probably fun to operate, at $30,000-plus a pop, this would only put Medicare into bankruptcy that much faster. Which brings up the question: how long before we see infomercials advertising robots to Medicare patients?

Me and My Shadow

These days my solo practice has actually been getting, well, busy, which has not been the case for the preceding 16 months. Busy for me is seeing as many as 8 patients in a day, although I am averaging 17 patients/week. It may not sound like much but since I usually spend an hour with new patients (sometimes longer), it is a full schedule for me. Plus I have to do all the scheduling, intake, scanning, charting, collecting copays.

As a result of seeing more patients, I have decided that I am busy enough to precept medical students again, as I used to do at Kaiser. At Kaiser, there was never a shortage of patients for medical students to see. In my solo practice however, I would discourage 3rd year students who called asking if they could do a rotation with me because up until lately I didn't think there would be enough cases for them.

Recently a second year medical student from Albany Medical College, Gladys Ng, spent 2 weeks shadowing me in my office as part of a summer family medicine preceptorship. Apart from spending time in her father's Ob/Gyn practice, it was her first experience rotating in a doctor's office with real patients. For those unfamiliar with the concept, shadowing means that the student usually stands quietly in the room observing the patient-physician encounter, i.e. being a shadow. Usually I invite the student to take part in some aspects of the physical examination, such as listening to the heart and lungs. When they get proficient enough, I ask him/her to take the patient's vital signs. If the patient and schedule permits, I may ask the student to interview a patient on their own, getting a chance to "practice" their interviewing skills on a real person. Gladys got a chance to do all those things while she was with me.

At the end of her rotation, I asked her to write a short summary of her experience with me and this solo-solo practice model. She has allowed me to post it here:

I was very excited when Dr. S agreed to let me shadow him, but had mixed feelings when he proceeded to describe his current solo practice. I thought, how could he do all of that by himself (be the receptionist, nurse, doctor, biller all at one time)? This is when I thought that this experience will be interesting, I could either be stuck with the phones and office work, or get a chance to do/see everything that the doctor does. Fortunately, it was the latter.

As Dr. S is still in the growth phase of his practice, the most patients we saw a day was five and this left me ample time to ask questions and have informative discussions on the ever changing or hopefully, evolving practice of medicine. These discussions and accounts of real life experiences really brought home some of the issues that were discussed in some of our classes at school. It was good to hear Dr. S’s reflections on his previous experience at Kaiser.

What really impressed me upon our first patient encounter was the length of time that was spent with each patient. In a typical patient encounter, especially new patients, Dr. S would spend 20-30 minutes speaking with the patient to get a complete understanding of the person. He would start off the whole session with the broad question of “what can I help you with today?” and then gently direct the conversation to draw out pertinent points of information. There were many encounters in which I was amazed by the willingness and the many aspects of the patient’s life discussed and their indirect relevance to the patient’s chief complaint. I learned to let the patient do most of the talking, to employ useful moments of silence, and to listen while maintaining eye contact.

Important to any “one-man show” is the concept of efficiency. Armed with a cell phone on the belt, a sleek Powerbook, and a speedy scanner on his desk Dr. S has paperless set-up, a practice without any patient charts. All necessary paperwork, such as those requiring signatures, are signed and then immediately scanned into his computer while the paper is left for the recycling bin. Also, instead of taking notes on paper while seeing the patient, Dr. S directly types the information into his computer. The benefits to this system were clear to me- save space and time, information is kept in one organized central location, and the chance to be environmentally friendly.

As I have just finished my first year of med school with my head still in the books and the science of medicine, it was a great experience to shadow Dr. S as well as to partake in the practical aspects of clinical medicine. Patience and compassion are two imperative qualities to being a caring physician and it might be hard to convey that to patients in today’s practice of medicine that focuses on the number of patients seen. I am ultimately inspired by Dr. S’s courage and drive to recreate a conducive environment in which his genuine intentions to help and get to know his patients are conveyed in actions as well as words.

I hope that experiences like this can inspire someone to someday become a family doctor, or at least spread the word that there can be a kind of medical practice that isn't driven by productivity and time limits. Also, I strongly encourage other physicians to volunteer to precept a medical student. Not only is it fun, it is educational since my "shadows" always teach me a thing or two. Thanks, Gladys!

My small part to change things

Christopher Brown, M.D. is another family physician who opened a solo practice after being inspired by Dr. Gordon Moore's model. An article in his local Salina, Kansas newspaper last year described what led him to open his practice, Providence Family Health Care, in September 2004 :

Chris Brown went into the medical field to mend patients. He was prepared for that.

It didn't take long, though, for him to realize the profession he had chosen could use some mending of its own.

In medical school and during his residency, Brown, 30, a Kansas City native, saw many patients spending longer waiting than they spent with a doctor. Then, they were rushed into exam rooms and hurriedly pushed out.

"Something was wrong with medicine," he concluded.

The clues were everywhere.

He met children of doctors who were adamant that they didn't want to follow in their parents' footsteps, because their parents were never home.

He saw a documentary where a "dog-tired-looking" medical resident told the filmmaker, "This career is for people who hate their children and never want to have time with their spouses."

Brown found himself apologizing for being late to appointments and cringing when he'd ask patients if there was anything else bothering them, because he knew there was someone else waiting for him.

He wasn't alone. Doctors everywhere are feeling the pressure, he said.

Too many Americans are getting what Brown calls "the fast-food version" of health care.

He easily could have turned his back on the profession. His calling, though, was to practice medicine, and he wasn't going to ignore it just because he didn't like what he saw.

"I started on this career path to be in the healing profession," Brown said. "I believe in this and was very idealistic about what I could do."

And realistic about what he couldn't do.

"It would burn me up inside not to be able to do my small part to change things," he said.

You can read about how he changed things by opening his own solo practice here.

I can't fix the U.S. health care system. I don't know the best way to provide medical care to the uninsured. I don't understand why the we spend more on health care than any other country in the world but still ranked only 37th among 191 countries for overall health care according to the World Health Organization.

But I can blog. And I like to think that in doing so I, too, am doing my own small part to change things by sharing stories like Dr. Christopher Brown's. Good luck, Chris!

The Village Doctor

John Brady, MD, is a family physician who opened his own solo practice in May, 2003 in Newport News, Virginia. He is one of many doctors around the United States who is using the "Gordon Moore" low-overhead practice model.

From a Hampton Roads Daily Press article written by Alison Freehling in Feb 2004 (and no longer accessible online):

Last year, Brady opened a solo practice called "The Village Doctor". His only employee is a nurse who also answers the phones. Instead of a modern building, he rents an old home along Warwick Boulevard.

By slashing his overhead costs, Brady said, he can see fewer patients a day, go out on house calls and still survive financially.

"For me, it has allowed the joy to come back into medicine," he said.
------
Before opening his Newport News practice, Brady spent four years at a large local practice. He said he was lucky to get five or 10 minutes per appointment and got to know just a small number of the practice's 25,000 patients.

In Hilton, Brady has 680 patients and plans for no more than 1,500. He schedules hour long visits with all new patients and blocks out 20 to 30 minutes for others, unless there's a simple complaint such as an ear infection. People get in to see him the same day they call.

The advantage isn't so much catching more problems, he said, but having time to talk about how to stay healthy down the road.

"I don't just deal with the immediate health concern that brought them in," Brady said. "When I'm not in quick mode, I get to counsel them about not smoking, about dieting and exercising."

Brady has made as many as three house calls a day, although it's usually no more than one. He tries to limit trips to people who live in or around Hilton Village.

Maria Brooks, mother of 7 year old Michael and 2 1/2 year old Ben, has taken full advantage of the service. Michael has chronic ear infections and getting to the doctor's office with two young kids isn't easy.

"To be able to call him at 7 a.m. or 4 p.m. and you know he'll be there, that's amazing," Brooks said. "He's looked in their ears and listened to their chests, and you don't have to sit in a roomful of sick people to wait for it."
----
Stories like Brady's are already becoming more common, said Dr. Gordon Moore, a New York-based physician who started a similar practice in 2001 and helps other doctors do the same. More than 100 doctors are part of his online discussion group.

"We help each other as we navigate these uncharted waters," he said. "The number grows each month."

In the Practice Improvement e-mail listserve, John Brady recently shared this update on his 2 year old practice for the benefit of other physicians:

As was stated on my business plan (posted months ago), I ended up about $120,000 in debt at my nadir in 3/04. Since then, the practice has been doing relatively well and I currently sit about $86,000 in the hole. (Much of the indebtedness was my salary which I kept at $100,000/year so I would not go personally bankrupt). My accountant states that this is wonderful growth for a business, but I still hate being in debt. I am currently seeing 12-15 patients a day (4.5 days/week) and strive to see 15-18/day.

Lessons learned:
1) Moonlight to cover salary for the first few months the practice is open.
2) Market everywhere you go (church, children's activities, luncheons, restaurants) and always keep business cards handy.
3) Tell people "if you like it here, tell a friend."
4) Be careful which insurance contracts you sign

Biggest headaches:
1) Insurances-I have come to loathe them. They serve no real purpose except to make money and they do this by creating loop after loop to jump through until we get tired of jumping, and then they blame us.
2) Isolation-I was always in big practices before making the leap and I do not do hospital, so my interaction with other doctors is minimal. This leads to some professional isolation. I fill the void with local medical society meetings, etc, but it's still not the same.
3) Juggling financial responsibilities at home and at work (hopefully will get much better as the loans get paid off and my salary increases).
4) Trying to determine when to cut off to new patients-we are currently seeing 1 new patient a day which I hope will fill the void of those leaving the practice through moves or death (not my fault), but the balancing act between being too busy and not being busy enough is more difficult than I thought it would be.

Biggest benefits:
1) Freedom to practice medicine like I want. No bean counters (except my wife), no administrators.
2) Unfaltering patient satisfaction/loyalty
3) Being a small business owner. I know it sounds goofy, but starting something from scratch, nurturing it, and watching it grow is quite satisfying and a sense of great pride.
4) Scheduling freedom-If I need time off, I take it. Since opening the practice, I have only missed one of my kids' performances/meetings/parties/etc and that was because I was in Richmond lecturing to doctors about the benefits of EMRs. I have also found time to train for and run a marathon, which would have been impossible in the previous office.
5) Being on the cutting edge of the future of medicine-computers, database research, evidence-based information at my fingertips. How cool is that?

Would I do it again? Without question.

John

How cool is that, indeed.

Jumping off the hamster wheel

I am a solo-solo physician, without any employees. I answer my own phones, schedule my own patients, take vital signs and give shots myself, do my own medical billing, order my own supplies, mop my own floor, scan and shred all documents myself (except when I pay my daughter 5 bucks to do it).

No, I am not crazy. Yes, I have way more control over my professional and personal life. No, I don't make anywhere near the money I did at my previous job. Not yet, anyways. Yes, I am happier.

I am emulating Dr. Gordon Moore, who helped pioneer a low-overhead practice model. The basic idea: if you keep your overhead low, you don't need to see as many patients to have a financially sustainable practice. And if you don't have to see as many patients, you can spend more time with them. And if you can spend more time with them, you and your patients will be healthier and happier.

Dr. Moore started a Practice Improvement website to bring together those who are interested in improving their medical practices. As part of this website, there is an e-mail listserve, where others (mostly primary care physicians) trade notes and experiences, or just learn about the possibilities of a practice free of corporate constraints. Some physicians on the listserve are completely solo, like me. Others, including Dr. Moore, have at least one nurse or receptionist/assistant. Some charge a retainer fee. There are many variations of this practice model.

Lately, some have written updates on their practices so far, which I hope to be able to share on this blog. Here is one physician couple's story:

My wife and I are practicing together in a small town of 10,000. Draw area is reportedly about 50,000. We have managed to bill about $144,000 over the first year with about 1200-1300 visits between the two of us. Collections were $84,000 with about $40,000 left in accounts receivable. Collection percentage has remained stable at 79.8% of billed charges. THAT WILL DROP WHEN MEDICAID STARTS PAYING AGAIN.

Startup costs were $60,000 which included $34,000 for EMR, IT, and 5 computer network, Fujitsu high speed scanner, $14,000 for equipment supplies including two exam tables - one motorized for disability access. The remainder of overhead runs $60-70,000 per year for phones, malpractice insurance, etc. I have a spread sheet that I may share when I have time to update it.

Our largest expense was salaries of $120,000 with $60,000 for myself, $30,000 for my wife 1/2 time, and $20,000 for my individual 401k at Fidelity and $10,000 for my wife. Total first year expenses including salaries = $240,000. Operating loss of $150,00-160,000. Fortunately, the local hospital supported us throught the first year. We are targeting the same overhead and salaries for the second year without support.

Breakeven for this next year will likely be 2000 visits and $185,000 net practice revenue or $232,000 gross charges. We averaged 5.41 visits/day over 48 weeks, 5 days per week. We believe 7 patients per day will be enough to sustain our practice and keep the mortgage paid. Obviously not the salaries of 1.5 FTE internists. The key is similar take home pay minus income needed for student loans as these have been forgiven.

In our former employment, at a large multi-specialty group, we were each seeing between 18-24 patients per day with management looking for 28-30 patients per day and annual gross charges of around $400,000. Overhead was high at 55-65%. Salary was ok for 2 years, but production-based compensation was poor. My wife wanted to go part-time and income would have dropped to $130,000-140,000 and resulted in revoked shareholder status and profit sharing, added overhead expense of malpractice and health insurance. Key is we would have been working much harder and longer for slightly more pay ($20,000) than we receive now. But student loans were eating $20,000 per year. Taxes would have been higher and real income lower.

What a blessing to jump off the hamster wheel of the corporate practice of medicine. The problem was there was an inflection point because of 50% medicare and PPO, 50% HMO. When everyone increased productivity from 18/day to 28/day, the only real increase in pay was 5 visits because the other 5 were already prepaid hmo care. Overhead increased 30-40% and actual incomes continue to drop for the physicians there.

We both like the time we now spend with patients. I loathe dealings with insurance companies. Patients pay 30-40% of actual receipts with insurance paying the remainder. Net receipts per visit is about $75-95 including accounts receivable at current collection percentage. Otherwise, $64 per visit and only 60% of gross charges collected to date. (Insurance companies and deadbeats laughing in the background.)

Patients are starting to talk about our clinic. They tell their friends that "The doctor answers the phone!" Others note that we take time to figure out their problems. One patient, after a bout of cellulitis and 4 day hospitalization, suggested that the hospital staff and I restored his trust in humanity by the kindness and concern we showed to him. He had become jaded working as a HVAC contractor and receiving healthcare in the city and suburbs. I have had the time to spend with dying patients and their families. I have returned a patient to health after an attempted suicide by caustic ingestion. A twenty-year-benzo user has stopped after successful treatment of her depression. She almost died of C. diff colitis after routine antibiotic therapy for a dental abscess. Her care was free until public aid approved her disability from my detailed notes. She just turned 65 and lived through the ordeal of being uninsured with multiple serious medical problems at age 64. The list goes on. I am very happy with my practice and medicine today.

Our challenges this year remain improved patient care that can be documented to insurance companies for higher reimbursement. I plan to add laboratory services in addition to my Cholestech cholesterol machine because I can use the revenue, but also because self pay and high deductible patients do not need $300-500 lab bills from a hospital lab. I don't want to bite the hand that fed me, but this borders on extortion. We hope to use Quest, but there may be an interface fee of up to $5000. If so, faxing lab results into e-MDs, our electronic medical record, should work just fine.

Brent and John, I am happy your practices have taught you so much and bring you satisfaction after multiple challenges. I am proud to be a member of this group which reflects and embodies so many of the things I have gone through myself in the last two years, First, when I was contemplating a practice and now, after living it the last year. Our collective knowledge is priceless as we move forward in our own practices and for those who follow the thread of starting their own practices from scratch.

Sincerely and Thank you all !!!

It isn't easy to get off the hamster wheel, but it can be very worthwhile to actually get somewhere for a change. Thanks, K. for letting me post your story and I wish you continued success for you and your wife in your new practice!

Those who wish to check out the Practice Improvement listserve can do so by sending a blank e-mail to
"Practiceimprovement1-subscribe@yahoogroups.com".

To unsubscribe, send a blank e-mail to
"Practiceimprovement1-unsubscribe@yahoogroups.com".

The Good Doctor is Out Not Out

A local family doctor retired last month. While I have never met Dr. Riley, he epitomizes what many think of when a family doctor comes to mind:

"I was 6 years old when he stitched up my chin and he's been my doctor ever since," said Mart Brower, Jr., who is now 54. "He's been there for me all these years."

"He's a very generous man. If you don't got it, you get it anyway, you know what I mean," said Thomas Herod, a patient for 27 years. "He's more like a friend than a doctor. You can talk to him about anything."

Herod's wife, Gloria, agreed. "He's like the old family doctors they used to have years ago," she said. "He's not just business. He's very friendly."

"You did not sit in his waiting room a half an hour waiting to be seen," said Mildred Hawkins, a longtime patient and former employee. "He put you in there and got you out."

Riley said he always made an effort to be available to patients.

"I tried to be not only a doctor and treat everybody well, but to become a friend," he said. "Many people say they can't reach their doctor and he never returns their calls. I've never done that."

--------

Riley said he liked the variety of family medicine. "If I were in a specialty where I had to look at people's feet all day, or mouths all day, I'd go crazy," he said. "Every patient is new and every patient is different."

Riley also kept his days varied by writing. While maintaining his practice, he also published a novel, a book of poetry ("all mushy love poems," he said), a collection of short horror stories, and two collections of funny anecdotes he encountered in his practice.

I bet if Dr. Riley were still practicing, he'd have a blog.

His patients said they will miss his combination of patience, warmth and long experience.

He is "the opposite of how today's doctors are," said Frankii Elliot, who came in for a checkup on Riley's last day as a doctor. "He'd take his time with you. He'd sit there until you were done. It's a huge loss."

Read the rest here.

Fortunately, Dr. Riley is not the last of his kind. A new breed of physicians is slowly appearing that aims to revive the old-fashioned notion that a good relationship between a physician and a patient is essential to good medical care.

Dr. Doug Roberts spent years working for the mega-health care corporations, the ones that force doctors to treat patients like a fork-lift driver treats cartons in a warehouse. As he cared for those who came to him for help, he gradually developed a better idea. Now he has put it into practice, and he expects that other physicians will follow.

Roberts and a couple of other doctors have, as he puts it, "hung up a shingle" in Sacramento. By careful management and cutting overhead dramatically, he and his colleagues are able to dispense good medical care out of small offices. Their guiding principle, Roberts says, is that the doctor takes responsibility for and develops a long-term relationship with his patient.
---
There is one exam room. The doctors use a computer for medical records, which eliminates filing and "saves the need for another room to store charts."

"The technology has allowed me to go back" to the days when doctors focused on patients and not paperwork and bureaucracy. "I take an hour with each new patient, half an hour with everyone else." Roberts estimates that he has reduced overhead by as much as 70 percent.
---
He stresses that a happy doctor is good for the system. "I get a lot of enjoyment," he says. That includes working three long days and taking off the other two, so he can spend more time with his children, who are 3, 5, and 9. "I can't tell you how nice it is to stay at home two days." The doctors cover for one another when the situation calls for it.

"Job satisfaction," Roberts says, "is better for everybody."

The rest of Dr. Roberts' story is here