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?

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.