Style vs. substance

Things are happening slowly, it seems. Or maybe I'm just getting anxious. You think?

I've finalized the logo design for my new practice, but I have to hold off on sending it to the printers because I haven't gotten official approval for use of the fictitious name by the California Medical Board yet. I spoke to someone at the Medical Board and they said it should be approved by next week. I'd really rather not pay for business cards and stationary that turns out to be unusable. On the other hand, I'd be shocked if they denied my application, since there is no one else using "South Pasadena Family Practice Medical Office" in the whole state.

I did end up getting an EKG machine, but not the one I originally planned to buy. The owner of the the business recommended another machine instead made by Nihon Kohden, a company I had never heard of. But I did have a chance to look it up on the internet while I was there, to satisfy my need to know that this was a reputable company, and it was, being big in Asia. It cost more than the first machine I looked at, but it also had more features, like an alphanumeric keyboard and an LCD screen to preview the heart rhythm. In the end, I decided that $2250 was a fair price for it, so I bought it. It wasn't the cheapest price on the internet, but I figure that I don't always need to get the lowest price. I just want a fair price. I know these guys need to make a living, too. Hopefully, my patients will be as understanding when I give them my bill.

I've started filling up my virtual shopping cart at two online medical supply sites, Henry Schein and Besse Medical Supply. I got a list of exam room supplies from Kaiser to help me get started. I'll have to sit down and compare their prices, but so far they seem comparable.

Even though I will have a very small practice, I want to distinguish my practice from the usual medical office in small but meaningful ways. One of the best ways I can think of is getting rid of those flimsy patient gowns. I hate those things, having had to wear them myself. And the disposable ones are even worse. Surely there's got to be a better, more dignified way for someone to be examined by a doctor. I found some websites selling thicker bathrobe or kimono-type gowns, and those seemed to be the best choice to me. But each one costs from $14-30. I think I'd need at least 25-30 so that I have enough to get by doing laundry only once a week. Luckily, my mother-in-law is an expert seamstress, and my wife offered her mother's services to make some stylish "premium" patient robes/gowns. I told her that if these are popular enough, it could be the start of a new business for her mother.

I put in a call to a handyman to find out if it would be possible (and affordable) to widen the doorway to the small kitchen area so that I can get my mini-refrigerator in there. Hopefully, it won't be too expensive or involved. It's just an inch too wide! It would free up some much needed space in my very small exam room if I could move it out.

Fortunately, the exam table fits just fine. I got it from a retired surgeon who let me have it for free, and it had been sitting in my garage. I and a friend wheeled it over at 10:30 PM 3 nights ago on a small dolly across the main street to my office half a block from my house. We moved it then because traffic would've been too heavy earlier in the day. Now I need to get one of those scales with the height measurement bar, a baby scale and a cabinet to hold supplies, and the exam room is pretty much done with the big items.

Since I'm trying to have an "old-fashioned" style practice, I thought it would be more fitting to have one of those baby scales where you have to slide the weight over to get the reading. Plus those kinds of scales are cheaper than the digital ones. But after thinking about it, if I were a new parent, I think I'd be more impressed with a doctor who has a digital electronic scale, even though both would record about the same weight. I want people to think of me as a doctor with old-fashioned values, like honesty, patience, empathy, while at the same time having the intelligence and know-how to use the latest technology and science. These are some of the marketing things I have to consider as I move closer and closer to opening my own practice.

Style vs. substance? I plan to have both.

Countdown: 16 days until new target start date

High tech

I finally received my refrigerator-freezer today. The delivery guy was most unhelpful, when he realized the large box and wooden pallet it was strapped to would not be able to fit through the rear doorway of my office. He just put it down, asked for my signature on the work order, and left. I didn't put up much of a fight, since I figured I could get a mini-refrigerator inside by myself.

This is when I encountered Surprise #1 of My Solo Career (the first of many to come, I am guessing). Before I had ordered this refrigerator, I had carefully measured the space where it would go in the little kitchen area, next to the other mini-refrigerator already there, and made sure it would fit. Unfortunately, I forgot to measure the doorway INTO the little kitchen area. It was too narrow for the refrigerator to fit. So I just hauled it into my cluttered up exam room for now. While annoying, it only forces me to be a little more cramped for space than before. Nothing disastrous.

I have anticipated that I will need to be flexible as I set up my solo practice, in ways that I have not imagined. Hopefully, this is the worst surprise that happens to me.

I am in my supply-acquiring phase right now. I am driving out to Camarillo, an hour away, to take a look at a Welch-Allyn Schiller AT-2 ECG machine. Manufacturer's suggested price: $4411.30. This place quoted me a price of $1549 for a new machine. That's why I'm driving out to see it with my own eyes. If it is indeed new, I'll buy it.

I've read that doing your own ECG's is not a big moneymaker, with reimbursements about $25-30. At that rate, I'd have to do ECG's on 62 patients before I start to make any money off it. But that's still a lot better than having to see 147 patients (if I bought it at full price). The main reason I want an ECG machine is because I think patients would expect a doctor to have one. Plus, it might come in handy if someone is having chest pain and I see ST depression.

I guess every piece of equipment I get has to have a reasonable ROI, or Return of Investment. I found this gadget called the CardioCheck PA Analyzer, which can do a complete lipid profile from a fingerstick drop of blood. Plus it's CLIA-waived, so I can do it in my office without having to pass an inspection. From crunching the numbers, if it costs $800, and Medicare reimbursement minus supply costs will pay $11 per test, then I would need to test 72 patients before I broke even. If I don't buy the thermal printer, and just write down the numbers myself, then I would only need to test 41 patients to break even. Hmm, this might be a way to generate some income, and provide convenience to patients at the same time. Plus, I hate to draw blood.

I wonder what other gadgets are out there that I could use? I realize that using these machines does not necessarily equate with better care. But I also realize that there are a lot of people out there who do. Part of being successful in private practice is in meeting the patients' expectations, within reason, of course.

So for those patient who are into high-tech, I'll be covered. And for those who want high-touch, I've got them covered, too.

Countdown: 21 days until new target start date

Coming around again

Today was a productive day. Mailed my application to Aetna after making xerox copies of my medical license, DEA, certificate of malpractice insurance, AAFP board certification, CV, W9 form, lock of my firstborn's hair, etc. Next will be Blue Cross, then Blue Shield. Medicare? Hmmm... Still thinking about it.

I recorded a "Welcome to my practice" message for my office voice mail, instead of the generic greeting. Maybe somebody will leave a real message now rather than the annoying recorded messages I've been getting trying to sell me "Get instant credit!" products. How the heck did they get my number? Now that I think about it, how will anyone know to call me since I haven't advertised yet? I've handed out about 10 business cards so far to some friends who came to our Christmas party, but other than that, I have not publicized my phone number. That should change in the next few weeks.

Yesterday I spoke to a sales rep for the local Yellow Pages about putting in a line ad. Another sales rep from the day before gave me a hard sell about how I "needed" to buy a big display ad if I hoped to get any new patients. But I've read from many doctors that Yellow Page ads just don't generate a lot of new patients. Word of mouth is the best form of advertisement, and it's free, too. But I did cave in a little and ordered a BOLD line ad for $9.00/month instead of the plain $6.50/month single line ad. I'll survey my patients and see how they heard of me, and that way determine the most cost effective means of marketing. Since the Yellow Pages is only published once or twice a year, any new docs should find out when the publishing deadline is so that they don't miss out. I was told that I would make it by the Jan. 31st deadline.

I took off the painter's tape from our paint job last week, vacuumed the carpet and assembled my office furniture today, too. That is, all that I had: a desk, return, lateral file drawer and a hutch that sits on top of it. It took all morning, but it made me feel like my practice is finally getting started.

It hasn't felt much like that so far this week since I have been working every day at Kaiser, though it has been only for a half day. I'm still seeing many of my old patients, the only difference is that I'm seeing them out of someone else's office, since I had to move out of my old one so that someone else could move in. It's ironic in a way. When I first started at Kaiser, I moved from office to office because there was not enough offices for all the doctors. The newest ones had to work out of whoever's office was free for the day. I'm leaving Kaiser the way I started 13 years ago.

What goes around, comes around.

Countdown: 26 days until *new* target start date

A new beginning

Happy New Year! Holidays and viruses (*cough cough*) have distracted me from updating this blog for the past 2 weeks. Okay, and inertia, too. Tomorrow was supposed to be my target start date, set about 3 months ago, but it has been clear to me for the past month that I would not be able to meet that deadline.

I originally chose January 5th because it will be my official resignation date from Kaiser. I finally managed to clean out my office on New Year's Day, and get all my abnormal labs and phone messages taken care of. A nice feeling, to have all my work caught up, with nothing hanging over me. But the funny thing is that my first day as a solo family doctor will be spent . . . working at Kaiser! I have signed up to work as a per diem or fill-in doctor for the next several months whenever there is a need for one. Since I don't have any patient in my own practice yet, it will be a way for me to earn some income as I get my new practice off the ground. In essence, I will be doing what I have been doing for the past 13 years still, but I will be getting paid less for it, since the perdiem rate is less than the rate I was paid as a partner physician.

My own practice? Well, I had new tile installed in the exam room where there was carpeting before. My sister and brother-in-law helped me paint my tiny 8 x 8 ft office two days ago. I picked up my office furniture from Plummer's today, and will be assembling it throughout the week. They are delivering my vaccine mini-refrigerator/freezer next week.

I have to decide on a logo this week so that I can get my business cards and stationary made. When I asked for their opinions, my various relatives preferred a different logo than the one my wife and I liked best, so we're going to have to think about it. Part of the problem is that they chose the one that "looked the best" while my wife and I chose one that matched "the image we wanted the practice to project."

I have my applications for Aetna and Blue Cross but still have not finished filling them out. Since I've heard that it takes up to 3-6 months to be accepted as a provider, I plan to test how much of an interest there is from cash-paying patients for an open-access doctor in this area. I heard on the radio today that California has as many as 200 "boutique medicine" practices, where patients get 24 hour access, longer appointment times, easy to make appointments in exchange for extra fees. That sounds like a high number to me, but I believe that it will get more and more popular among physicians.

But what if you could get boutique medicine service without the boutique medicine price? That's what I'm going to be trying to offer. I've heard that there are at least 2 local physicians in the Pasadena area who do not accept any insurance, but do cash-only business, and supposedly they have very successful practices. While tantalizing, I'm sure they built up their practices over a long period of time. I plan to allow myself two years to build up my practice, with a goal of 1000 patients in my panel and $100,000/year income. We'll see how close I get.

People have been asking me when I will open my practice. I used to say, "Sometime in January." Now I say, "As soon as I can." All I need to open my practice is:
1) to get my furniture assembled (this week)
2) stock my exam room with medical supplies, vaccines, medications, etc. (2-4 weeks)
3) get inspected by the city fire department so they can issue me a business license (?)
4) get approval for my fictitious name permit from the California Medical Board (supposedly 8-10 weeks from the day I mailed it in in October)
5) get business cards and stationary printed (2 weeks)
6) place ads in local newspaper

So my new target start date will be Feb. 2nd, just because I like to set definite targets. I have about a month of vacation time saved up which will be paid in a lump sum upon my resignation, so I will not be struggling financially yet. I have some time to relax a little before my solo practice begins. Hopefully, I'll use the time wisely.

Countdown until *new* target start date: 29 days

Less filling, tastes great

Yesterday I ordered some office furniture from Plummers, which is slightly more upscale than Ikea. Since my office is really small (an 8 x 8 foot room), I had to make sure everything fit and optimized my space. It isn't the cheapest stuff, but also not the most expensive. It still came out to about $1500 though.

A recent article in American Medical News talked about getting seed money to startup new practices, and the consultants in the article gave figures of up to $150,000 in startup costs for a solo family physician. Yikes! I'm more like this guy. It depends what kind of practice you want. I'd rather have one that's less filling (than tastes expensive).

Countdown: 19 days until target start date

Old fashioned values, 21st Century gear

Things are progressing as I slowly move towards opening my solo practice.

I started moving in a week ago, much to my pleasant surprise. I thought the acupuncturist might end up staying past his 30 day notice, but he did not. The sink fit, but the carpet got soaked from the installation. No matter, as that is going to be replaced.

The cable installers came today, and installation was a breeze. I assigned myself an email address to be used exclusively with the practice. I had originally thought that HIPAA required that any email communication had to be via a secure encrypted server, which meant going with a free service, like the ones offered by the California Academy of Family Physicians or by Medem. Or you could pay $50/month for secure email through RelayHealth.

The problem with CAFP's site is that it is not fully compatible with Macs (my platform of choice), so I and my Mac-using patients would be left out of some functions. Since I am in California, I hope that CAFP can fix the website to allow full functionality for Mac users. In fact, I'm going so far as to volunteer to be on an advisory committee on technology issues for CAFP to make sure that it eventually comes to pass.

Medem is advertiser-supported, meaning your free website has to display ads, unless you choose the non-sponsored version which costs $30/month. The email service is called an "online consultation" and permits physicians to charge a fee if they want to or not. My reading on the subject so far has been that very few patients are interested in paying for email communication (or phone calls) with their doctor.

RelayHealth looks like a great site and I have used their eScript prescription refill service at Kaiser. It works well. But they do charge quite a bit, basically $600/yr. If I ever consider hosting my own website, maybe I'll consider them again.

My interpretation of HIPAA is that while secure email is best, unsecured email is permitted as long as you disclose to the patient that this form of communication is not totally confidential, and that as long as they understand this and agree to this avenue of communication, then a physician is not going to be penalized for using regular email. We'll see how well things work.

How will I get patients in my new practice? I hear this question a lot.

Word of mouth, of course. I am getting more and more requests from people/friends as to when my practice will start, and what kind of insurance I will take. We had a Christmas party last weekend, and one friend said she already has 5 families lined up for me whenever I'm ready. I even handed out some homemade business cards my daughter made on the computer, just so people could get the word out.

One of my daughter's friend's father is a graphic designer who just recently left a big graphics design firm to start his own business (just like me!), and he offered to help me design something for free (although we eventually agreed we would barter his services for a complete check-up). He showed me his designs today for identity logos which blew me away with how professional they looked. To paraphrase an old movie line, "I could be somebody!" with business cards that looked like they belonged to a Fortune 500 company, rather than a one doctor operation in a small suburb. The hard part will be trying to decide among the 6 great designs he came up with and choose which one will represent me.

Email. Business cards. Logos.

It is all part of an image I will be trying to present to my target population. That of a caring, community-oriented, small-town family doctor who is also extremely accessible and technologically savvy. Old fashioned values, 21st Century gear.

Countdown: 21 days until target start date

What's in a name?

I got the keys to my new office today. I guess I should say, our new office. I am sharing a 4 room suite with a psychologist (my landlord) and a chiropractor, who each have one room. I have 2 rooms. Two *small* rooms: a 9'7" x 9'5" exam room and a 8 x 8 foot windowless room, which will serve as my office.

The pedestal sink I bought was incompatible with the plumbing fixtures, so the landlord and I made a quick trip to Home Depot to buy a cabinet style sink which looks just fine. There are holes in many of the walls where a bunch of cabinets used to hold large quantities of pungent and bitter-smelling Chinese herbs. The landlord said that he and the chiropractor both lost patients because of the smell, so he is glad that I am moving in.

The landlord also kept telling me how busy the previous tenant, an acupuncturist, was. But he chose not to renew his year-long lease, instead going on a month to month lease. That was what enabled me to take his space, because the landlord wanted a tenant with a long-term commitment. I'll try not to make that mistake when my lease renewal is due. This is assuming my practice is a success.

What to do next? I have to get furniture for my tiny office, and chairs. Bookshelves. I don't know how I'm going to be able to fit everything in my office, since I would prefer not to leave anything out in the common area, at least nothing of significant worth. I know my wife wants to have some say in the color of paint, and wall decorations.

A major project will be ripping up the carpet in the exam room to lay linoleum tile. This is to allow for easier cleanup (and a more sanitary environment) just in case someone has an "accident". After all, besides being my own nurse, receptionist, biller, and office manager, I also will be my own custodian.

I also have to figure out how to fit a refrigerator/freezer in to store my vaccines.

And business cards. And newspaper ads. And business stationary.

The phone installer is coming between 8AM-5PM tomorrow. Talk about a "narrow window". Good thing I have the whole day off. And the cable installer is coming next week to hook me up for cable modem internet access (which I've found to be faster than DSL for home use; plus I hate the local phone company that provides DSL service).

A lot of things to juggle. As a family physician, I am used to that.

The landlord asked me how I wanted my name printed on the signs outside. "No middle initial?" he asked after I told him. No, I preferred a simpler identity. First name, last name. M.D. But then I wondered what to put after that. "Which sounds better? Family Practice or Family Physician?" I asked him and his wife.

I had recently read about the American Academy of Family Physicians voting to rename the specialty "family medicine" instead of "family practice" ; and "family physicians" instead of "family practictioners".

"While it may be semantics to some, perception is everything," Lindholm said. "I specialize in family medicine. If our own colleagues in medicine don't understand that we're specialists, I don't think our patients can (understand), either."

It is something all family physicians have to put up with, I think. Our patients don't know what kind of doctors we are. Many assume I am an internist, or a pediatrician (when I see a child), or a general practitioner. This mirrors the findings of focus groups questioned by the Future of Family Medicine Project, which found that a third of patients who saw a family physician didn't know their doctor was a family physician.

The landlord and his wife both thought "Family Practice" sounded more familiar to them, so I told them to put that after my name on the sign. But now that I think about it, I would rather be known as a family physician than a family practitioner. Time to think different, just like my solo practice model.

So tomorrow morning, i will call the landlord and tell him to put "Family Physician" after my name. Because that's what I am. And proud to be.

Countdown: 28 days until target start date