It feels dangerous to write this, but…my practice seems to be working.
I am now running and hiding from lightning bolts, meteors, or stray arrows shot in the air by a Scottish soldier. I am also expecting a raid on my office by the IRS, CDC, and BBC tomorrow morning. I don’t know why I wrote that.
But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving. We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from uncle bouncy. While we’ve started to discuss when we will hire another staff person (probably a nurse), neither me nor my nurse Jamie (may her name be ever blessed) feel overwhelmed at this point. We can handle this volume, which speaks well for the future when we actually have a fully-working system.
The past few weeks have been totally consumed by my need to have an underlying system of organization. After fighting valiantly against the idea for the first two months, I succumbed to the necessity of building my own IT system and have been seeing the many benefits of that decision. Despite being totally obsessed with how data tables connect and whether I’ve left a parenthesis off of a script I’ve written, I now have a place to put data, have a pretty decent task management system, have an integrated address book, and have discussed integration with my phone system vendor, my secure messaging developer, and a lab order/result integration vendor. I’ve also found some strong local tech talent who gets what I am doing and yet doesn’t simply see the market potential for my software.
The reality is, my whole focus is on the practice model, and that model seems to work. As my business and medical care management systems click into place and become more functional, growing the practice should not be a problem. We continue to get several new patients signing up every day, and now the reluctant spouses of establish patients are joining (which is a very good sign – for both my practice and for their marriages).
Let me appease the gods and state clearly that this is by no means a sure thing. There are many, many things that could go wrong. A successful start-up requires not only a good idea and hard work; it also needs requires luck (or at least to avoid bad luck). I could get cancer, my building could burn down, or our city could be overrun by a mob of psychotic llamas. We all know the llama apocalypse is happening; it’s just a question of when, not if. So I accept the fact that I am, to a great extent, in the hands of the fates (and llamas).
That being said, it is encouraging to see the first stage of the practice running reasonably well. The key will be to keep doing what I am doing: working, working, and working. In some ways, the satisfaction of my patients should not surprise me, as the care the got from the health care system sets the bar very low. I am frustrated because I am not yet building care plans for patients or calling to check up on people as much as I would like, but that’s not care that any of my patients are used to getting. They are used to being ignored unless they are sick. They still wonder if they can make an appointment, when I would gladly talk about their problem on the phone. They are simply happy that we still have an average waiting time of about 30 seconds.
Having been under high pressure over the past few months, my recent success makes it very tempting to take a deep breath and slow down a bit. Am I simply setting goals of care higher than they need to be? I think about these things while in the shower. I’m not sure why the pelting of my head with water makes me think better, but it does.
While wetly contemplating my obsession (and whether this was a sign of strength or stupidity), I remembered a physician worked under during my residency at Indiana University: Dr. Larry Einhorn. Dr. Einhorn is credited for the use of Cis-Platinum therapy in testicular cancer, a treatment which made a lethal disease in young men largely curable, even at very advanced stages. He was one of the group who cured Lance Armstrong of his advanced cancer, and was already quite famous when I was there nearly 20 years ago. This group of docs was not only amazing in their clinical and research skills, they were very good teachers and treated us residents with kindness and respect. It was truly an honor and a pleasure to train under them, and I strongly considered oncology as a career because of them.
One of the attendings told me that what made Dr. E so great was that he didn’t stop at the first breakthrough. He didn’t say, “hey, this cures 75% of advanced testicular cancer! I am going to name this the Einhorn treatment protocol and be real famous!” Instead, he focused on refining and improving the treatment to where, while I was there, the cure rate was well over 90%.
That’s not a character flaw, that’s the definition of character. While I am nowhere near in accomplishment to that of Dr. Einhorn, I am tempted to listen to the happy patients, the complements from colleagues, and the band of groupies that gather on the handicap ramp each morning for my autograph. I am tempted to think I’ve accomplished something before the job is done. I am encouraged by the fact that I can handle 300 patients with just a nurse to help. I am encouraged by the fact that I am recovering from nearly having my practice impaled by “meaningful use certified” EMR products and may actually have a system that really improves care.
But I am a long way from where I initially planned to go, and there will always be more I can do. The foundation is laid, but foundations are generally unacceptable (and uncomfortable) places to live. So, I take a deep breath and dive back into all the work I have ahead of me. I hope things continue to improve, but I won’t count on it. People have told me “you’ll do it. I am confident you can make it work.” But their assurances don’t include the footnote that says: “as long as you continue to work most of your waking hours, and avoid doing something really dumb.” That’s no slam dunk.
And don’t forget about the llama apocalypse.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.
I’m new to your posts, so I don’t know all of the details surrounding your practice. In any case, It sounds like you’re doing some great work, and it really seems evident that you are trying to provide the best experience possible for your patients. The fact that they only have a 30 second wait time, and that you’re available by phone to discuss issues, are both details that seem to be lacking with many practices, especially where I live. 45 minute waits are usually the norm, and if you need to make an appointment you can bank on it being at least two months out.
You don’t have to do meaningful use??? Good on you! Hope you aren’t licensed in the state of massachusetts (see other post on this blog).
Rob: I have absolutely loved reading your posts and I am thrilled that you can say the doctor is happy. I had many similar thoughts and complaints about the system as you while in private practice. I have been retired on disability (CIDP) since 2004 and can only observe from the outside now. I can only wish that I was still able to practice and someday join you in what may be a model for the future of private primary care practice. We can only dream that someone will pay attention. Well done!
Really interesting.. Bravo!!
As I read (and re-read) this most wonderful article, I suddenly realized there were two important words embedded.
I mean ‘Modeling’ the practice and building a process oriented system for the Practice – NOT system as in Information Technology.
Unknowingly, perhaps, you created and perfected a process oriented system that is efficient for you and your practice and then built technology to make it work.
Most people get it wrong. They expect Tools and Technologies to do the modeling of internal systems for them, which is completely backwards, and the reason for failure and immense frustration.
Is that a good assessment?
Spot on. Most of the people who tried to sell me software didn’t realize this either.
‘But I am a long way from where I initially planned to go, and there will always be more I can do’. Great advice, all the best.
Rob, what did you do differently in the design of your new IT system than the products that are already out there?
The big thing I did was to totally ignore E/M coding and Meaningful Use. Once that was at a safe distance, I built a system that would put useful clinical information in front of me as quickly as possible. I still wonder why I couldn’t find this stuff on the market, but I looked quite hard and found nothing but trouble. The essence of what I did was to take my business model and practice design and build a system that optimizes it. Otherwise hard to describe why it’s better, but it really, really is.
You *always* have to be on guard on those psychotic llamas. For realz.
Seriously, though, this post proves (again) why you’re such a great doc: humanity, humor, and deep knowledge of how great medicine is practiced – one patient at a time. Now if I just lived closer to your practice, my life would be ideal. (Or am I tempting the fates there?)
This is really great news. Does this revise downward the panel size you were aiming for?
Who’s Uncle Bouncy?
No, if anything it gives me confidence that I can get to the 1000+ I was hoping to reach. I just have to have a solid business and clinical infrastructure to make it work (which is why I resisted growth for a long time). My goal was not simply to give myself a nice job and take care of a few people; my goal was to build a viable alternative to our current system. The only way for that to work is to get back toward the panel size I had in my old practice. I think it’s VERY reasonable to think I can, with proper support staff and a better-honed system, have a practice that delivers on all I was hoping to give.
I’ve been enjoying following your blog and your progress with your innovative approach to your clinic.
I wanted to let you know that we have a secure messaging system that we can give you free use of, and we would be happy to work on some integration for you. We are in early pilot mode for the system. Originally we developed it for internal use by a large healthcare system but we have re-purposed it to be distributed as a free app to consumers.
We are long term technology providers to major healthcare companies like United Healthcare and Mayo Clinic.
I wold love to collaborate with you on this effort.
More info on us:
I would love to look at it. I’ve a bunch of potential ways to go, but am definitely wanting to see what’s out there. Email to info at doctorlamberts dot org.
“Let me appease the gods and state clearly that this is by no means a sure thing.”
Do any physician start-up practices fail?