We’re Moving!!!

Photo: lendaproducts.com

Photo: lendaproducts.com


I am happy to announce that the PookieMD blog has moved to http://physicianpracticeseminars.com. The new blog has some cool features that I couldn’t do on this platform. 

 Ya’ll come visit and we will continue the fun!  See you soon!


Book Club: The E Myth Physician

I love to read, especially anything related to business and medicine.  I have finally realized, after 15 years in practice, that is not enough to just be a doctor.  Whether we like it or not, we are all small business owners, and some of us are even entrepreneurs.  Today I will review The E Myth Physician, by Michael Gerber. Gerber is a small business guru, and has written extensively on how to start a business, and common mistakes entrepreneurs make.   His best book, in my opinion, is The E Myth Revisted.  I bought the E Myth Physician hoping for great things, but was disappointed.  The book simplifies when it should be more detailed, and lacks a clear understanding of what exactly physicians do. 

However, I thought the chapter, “On the subject of work” was worthy of discussion.  Gerber casts physicians in to three roles: that of the technician, and that of the manager, and that of the entrepreneur.  Physicians tend to focus on the technician role–that of seeing patients, curing diseases and saving lives.  There is also the role of the manager–scheduling the patients, filing, posting charges etc.  The physician may or may not be involved in the manager role, but none the less, if he isn’t he should at least know what the manager does!  However, according to Gerber, most physicians neglect the last, and most important role, that of entrepreneur.  You may have no interest in being an entrepreneur, but like it or not you are.  If you are an owner or a partner in a medical practice, you are an entrepreneur.  Ignoring this will not make it go away.

Gerber advises us to do “strategic work”  i.e. work on the business, not just in it.  He notes that entrepreneurs will do strategic work in order to help their practice/business thrive.   He advises us to ask and then visualize answers to the following questions:

  • Why am I a doctor?
  • What will my practice look like when it is done?
  • What must my practice look, act and feel like in order to compete successfully?
  • What are the Key Indicators of my practice?

The point of “strategic work” is to have us lift our heads up beyond the minutiae of everyday practice, and make sure our medical practice is in line with our vision of why we are doctors.   Asking these questions will help us design the future of our practice, and plan for that future.  One of my favorite sayings is, “Hope is not a strategy.”  We all need a clear vision of what we want our practice business to look like, why we are doing it, and how we will realize that vision.  To that end we are all entrepreneurs.

Hip Hip HIPAA–Myth Busting 101

Photo: starpulse.commythbusters003_m

As far as I am concerned HIPAA has added another layer of useless paperwork on to the backs of physicians, and I particularly resent the cost it has added to primary care.  Therefore, I was excited to see an article on HIPAA myths.  Below is my summary of HIPAA myth bustin’:

Myth 1: You can’t have a sign in sheet.  Yes, you can.  You must limit the amount of patient information on the list.  E.g. don’t have the chief complaint.

Myth 2: You may not say a patient’s name out loud in front of other people.  Again, say the name, but use the minimal amount of information, rather than, “Mrs. Dysmenorrhea, Dr. Strangelove is ready for your pap test.”

Myth 3: Patients may sue you for non-compliance.  No, but HHS (Health and Human Services) recently fined a home care companyfor a major security breach.  Moral: be especially careful with laptops, pdas etc.

Myth 4: Patients are entitled to a free copy of their medical records.  They are certainly entitled to the records, but not for free.  The cost to the patient may include the cost of labor to copy the records, as well as the cost of supplies and postage.

Myth 5: You may not use a fax to send protected patient information.  Not true, grass hopper!  Faxes must be sent to known locations, from secure machines, with the number pre-programmed to reduce dialing errors.  The cover sheet must contain a request to destroy the  information should it go to an incorrect destination.

So, be safe out there.  And yes, we can finally say our patients’ names again.

The Hospitalist Shift From Hell, and How to Fix It

I came home from my last 12 hour hospitalist shift exhausted.  My eyes were bleary eyed from staring at the EMR , and I was in the state of beatendownness where you have been totally crushed by admissions, cross cover, your coworkers, staff and patients.  Owning a coffee shop was looking better and better, and hey, I love coffee.  However, looking back at the shift from hell is helpful.

Here is a list of what went wrong,and how I will fix it:

  1. I didn’t have a check list in front of me.  I was rushed and frazzled, and didn’t go through my usual mental check list.
  2. I didn’t take a break.  I should have handed the shock box, I mean pager, to one of my co-workers and walked outside for a moment of peace.
  3. I ate too much crap.  Yes, crap. In my frustration I just put my face in to the fridge in the physician lounge and went for it.  Sigh.  I should have brought something from home.
  4. I doubted myself.  I spent a lot of time justifying my thinking to myself.  (I had just finished reading How Doctors Think, and was trying to double check my thinking.)  Doubt slowed me down to the point where I began to question everything.  Solution: hmm, brain transplant?
  5. I wasn’t wearing my scrubs.  I was trying to look more doctor like, so I had on a nice sweater, pressed pants, and the white coat.  (You men wouldn’t understand…)  Next time, forget fashion, I’m wearing scrubs.
  6. I let my colleagues get to me.  We were all crabby from the heavy workload.  Next time I will take a deep breath and remember we are all getting crushed, and put on the lens of perspective.
  7. I was quick to anger.  I got mad when a patient didn’t have a call button close to him, and I found it on top of the sharps box.  He had just had a total knee replacement, for pity’s sake!  I asked the nurse if the staff had a check list they followed when they cleaned the room, so this wouldn’t happen.  She indicated that “they’re pretty good at putting the call light where it should go.  I don’t think they need a check list…”  Ha I say!  How many times am I trying to find the blankety-blank call light for the patient?!  Time for another big breath!  (BTW, check out If Disney Ran Your Hospital.  Good ol’  Walt would see it my way!)
  8. I was exhausted from the get go.  My own mom was in the hospital recently and I spent a lot of time with her, which was good but tiring.  It was eye opening to be on the other side of the bed.  I tried to do too much, and should have gotten help from friends and family, AND NOT FELT GUILTY FOR ASKING!  (Yes, this is a woman thing,doctor thing,  mother thing, brought up Catholic thing.  I’m working on it.)
  9. I wasn’t wearing the no complaining bracelet.  I have a bracelet that I wear to remind me not to complain.  If I do complain, I move it to the other wrist as a reminder to stop carping.  I will wear it today.
  10. I worried too much.  I was worried about patients, my daughter, my dog being in a cold dog house, the dinner in the oven that would be waiting for me when I got home at 9:00 p.m.  And yes, I forgot to set the oven.   By focusing on worry, it was harder to place the focus where it belonged: on the patients.  The daughter and dog were fine, my husband turned on the oven, and the patients were okay.  Today I will leave my home worries at the door of the hospital when I go in.  They will be there waiting for me when I walk out late tonight.

By the way, the ED docs I worked with were great!  They knew we were getting crushed, and were kind and gracious in the face of the united hospitalist of grump coalition they faced.  Today will be better, I’m sure!

And lastly, I’m only human.

Disclaimer: I have no association with the authors mentioned above, and recieve no financial gain in mentioning their books.

Low Tech Health Care Reform: Stop Smoking!

Photo: sonofthesouth.net

I have a very simple way to save the government billions of dollars in health care costs, and make Americans healthier, almost immediately:

Outlaw tobacco.

Likely to happen? Not a chance.  The tobacco lobby is way too powerful, and the tobacco states will rally loudly and strongly against it, not to mention big pharma that will see a decrease in revenues as the use of patches, gums and pills goes down.

Okay, next option: tax the poo out of cigarettes.  Currently the average tax by state on a package of cigarettes is $1.19.  The state with the lowest?  Not surprising, South Carolina, where the tax is just $0.07.  The tobacco states  average is $0.33 per pack, while other states average is $1.30.  Pathetic, but it shows that there is a lot of room to increase the taxes, especially in the tobacco states.  There should be a HUGE federal tax on cigarettes.  Likely to happen?  See above r.e. tobacco lobby.

Next option: teach ’em young.  The feds need to mandate a  ‘smoking is bad’ curriculum YEARLY kindergarten through 12th grade.

Last option: We docs keep plugging at our patients.  I’m not so optimistic on this accord, but I’ll keep trying.  Here was my must recent attempt to convince a patient to stop smoking.  I report a conversation I had with a 70ish year old gentleman, on his way to the OR to have his foot whacked off secondary to peripheral vascular disease.

Me:  (earnestly) Mr. Marlboro, what can I do to help you stop smoking? Would it be helpful to have the nicotine patch while you are in the hospital?

Mr. Marlboro: (just as earnestly)  No, I don’t need the patch.

Me: You know, while you are in the hospital, it’s a great time to quit, because you can’t smoke here.  Besides, cigarettes are so expensive.

Mr. Marlboro: Well, I don’t care about the expense.  I’d just spend the money on something else.  Besides, I’ve smoked all my life, and it’s never hurt me.

At this moment, the transport team arrives to take him to the operating room.

Me: (defeated) Oh.

Good luck out there.  Sounds like I need to brush up on my motivational stop smoking speech, as I’m not envisioning President Obama or Mr. Daschle following my suggestions.

Health Care Reform With Out High Tech: Changing a Culture of Fatness to a Culture of Fitness


photo: flickr.com


President Obama has a stimulus package all ready to roll out.  Reportedly, it will include money ear marked to expand COBRA.  If this is true, there will be precious little left to fund the ‘everybody has to have an EMR’ mandate.

Good, I say.  Let’s work on some low tech solutions that will reap true benefits.  Yes, I admit that the low tech, grunt it out in the trenches approach is not nearly as sexy as an EMR with bells and whistles, but this time, I think low tech will trump high tech.  Here goes the PookieMD save the world through hard work approach:

First, focus on America’s growing middle.  Here are five low tech ways to cut the fat and increase activity.  (Literally and figuratively!)  I will work from the global to the micro.

  1. Mandate the physical education be held every day from kindergarten through 12th grade.  Our plump kids are the diabetics  and cardiac stentees of tomorrow.   Making time for health now will pay off immensely later as we make physical movement a daily part of children’s day.  (By the way, cup stacking is not a sport!  Getting the heart rate up counts!  For a great look on what happens when schools institute a required daily physical education class read Spark, by John Ratey, MD.  Hint: test scores go up, learning improves and discipline problems go down.  Pretty good for having a bunch of kids run around a track!)
  2. Offer tax benefits to companies that have in house exercise programs.  Tax benefits would be proportional to percentage of employees participating.  We need to change the culture of fatness into a culture of fitness.
  3. Get your office workers in shape.  With all due respect, many times the office help are bigger than the patients.  One practice I know had a very successful biggest loser competition.  Why don’t YOU sponsor it, and include yourself? Consider a small prize (gift basket with soaps/lotions?) for the biggest loser.  Of course, absentee rates and sick days will go down as you and your staff get more fit.
  4. Make fitness a part of your office culture.  Have info on health clubs, classes, rec centers available.  Consider a group visit for obese patients, focusing on exercise. Do group walks, enter a 3 k, host a weight watcher type group, do SOMETHING.  Getting your office in the news would be a nice side benefit.
  5. Encourage patients to “chunk”.  (No we don’t want chunky patients!)  The surgeon general recommends 30 minutes of exercise daily.  Encourage the couch  potatoes to start by walking 15 minutes two times a day, or 10 minutes 3 times per day.  There is no law that says it should be all at once, although it’s a good goal.  For the  obese, a gym can be intimidating, so start simple: encourage walking, then jogging, and then maybe a trip to the gym.  It doesn’t get much easier than a walk around the block or up the stairs.  (You do take the stairs at the hospital don’t you?)  Additionally, the television is filled with exercise shows–for those who still can’t tear themselves away from the small screen.

These ideas aren’t new, definitely aren’t sexy, and won’t get your sponsorship from a drug company.  However, they will work and we, as physicians, hold the keys.  We need to start with legislation, and move on to what we as ‘health coaches’ can do.    We can have huge impact on the huge, and not so huge.  Please, please, let me know what WE can do together to move our country to health, starting TODAY in our medical officese and clinics.

Technology will not save health care, personal responsibility will.


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During  President Obama’s speech he stated

“We will restore science to its rightful place, and wield technology’s wonders to raise health care’s quality and lower its cost.”

I completely, totally disagree.  President Obama, health care doesn’t need high technology, health care needs personal responsibility.  America’s health care costs are excessive for several reasons, and most have nothing to do with technology.  America spends 15% of it’s gross domestic product on health care, or from a different perspective,  $5711 per capita.  Our closest big spender?  The wealthy country of Luxembourg,which spends $4611 per capita.  Japan spends $2249, and Italy, where they eat all that pasta, spends $2314 per capita.  Why are we spending so dang much?

Here are the reasons, and they have nothing to do with technology:

  1. We Americans are pigs.  30% of our population is obese.  Note I said obese, not over weight.  We eat in our cars, chow on super sized fat filled “fast food”, and consider opening the refrigerator a sport.
  2. Television watching has morphed into an art form.  The average American watches FOUR hours of T.V. daily! Who has time to watch that much?!  In addition the wii is now considered a way to exercise.  C’mon, gimme a break!  The only way a wii can help you get exercise is when you walk the cardboard box it came in out to the garbage.  (Yes, I have played!)
  3. The Marlboro Man still rides.  Nearly 20% of Americans still smoke.  (Sadly, including our president.)  Those most likely to smoke were those below the poverty level, with the least amount of education, (and the least access to health care).

Sloth is causing Americans to be unhealthy.  High technology will make us more efficient in the way we diagnose and treat illnesses, but it will not prevent them.  Obesity, tobacco and inactivity are the root cause to heart disease, diabetes mellitus, many cancers, and  COPD.  The fanciest technology in the world will not change this.  What will?  America will spend less when we have sweeping cultural changes such that Americans get off the couch, toss away the remote, and spend their money on healthy foods, rather than cigarettes and french fries.

President Obama, I’m glad you’re here, but please, focus on the root of the problem.  Pruning the tree will not change the roots!

Next post: HOW we can create a healthier America with out expensive high technology.

To market, to market! A marketing plan for the next 6 months.



As promised, I would set up a goal for the year, and plan to achieve it.  I had earlier noted that business for my company, ExtraMD was down for the first time in five years.  My company supplies physicians to clinics/hospitals/urgent care in the city where I live.  I am the physician owner, and feel responsible to the other 5 physicians in our group.  So, I developed a marketing plan for the next six months to bolster our shifts.  The general marketing theme was a birthday celebration, as ExtraMD is turning five.   

The goal: have 5o shifts per month for our physicians.   (This is what we usually have, but has suddenly decreased.)

Unless noted, all responsibilities for marketing are mine.

The plan (by month):

January: send an email to our clients, announcing our birthday celebration, and giving a discount of 10% off the first shift.  (Already done by our trusty office manager.)  Send out a press release announcing the birthday celebration.  (My responsibility.)

February: deliver birthday cupcakes to potential clinics with cards/brochures. 

March: build a referral tree via email.  E.g.: if a client refers someone to us that uses us to fill shifts, the referring client will get a discount off their next shift with ExtraMD.

April:  send out postcards reminding clients/potential clients of our services, focusing on how we benefit the practice when one of our doctors fills in.

May: send out email reminder for practices to book now for summer vacations.

June:  send out a newsletter with tips on practice management to our email subscribers.

Most of the marketing will be low cost.  This marketing plan was developed with help from Philippa Kennealy, a physician entrepreneur.  I also consulted Duct Tape Marketing, by John Jantsch.   I’ll keep you informed as to our progress.

And the winner is… Dr. Bobb!

In the contest to describe a goal and a plan to meet that goal for a medical practice, Dr. Bobb is the winner (and the ONLY contestant!)!  Now, I don’t know exactly how well his plan will work, but I’m loving the idea of the vacuum.   He notes that they will take turns cleaning the bathroom.  Hmmm, we’ll see how that works out!  Visit his blog for more fun!

Here is his plan for his practice:

The Goal:
Cut nearly $5000 a year from the practice’s operating expenses.

The Method:
Terminate the practice’s contract with its janitorial service.

The Timeline:
As soon as current janitorial service contract is up, sooner if it is an “at will” contract.

The Plan:
Purchase an iRobot Roomba to vacuum the office building’s carpeted surfaces and a Scooba to clean the tiled floor areas. Cost: about $370.
Office staff will take turns cleaning the office’s bathrooms.

The Personnel:
Office Manager will purchase the cleaning robots. All office staff (including the doctor) will take part in keeping the office clean.

Dr. Bobb is the recipient of  a $15.00 Amazon gift card from PookieMD.  Don’t spend it all at once, and keep us posted, Dr. Bobb!

10 Things Patients Love To Hate About Their Doctors

Patients have a love/hate relationship with their physicians.  They love some things and hate others.  Here is a list of things they hate, and actually take as a sign of incompetence, rather than just poor bed side skills.

  1. Being a slouch.  Patients take the lack of eye contact, hands in pockets and crossed arms as a signal your aren’t listening.  Lack of eye contact finishes it off. ( If your kid did this, would you feel they were listening?)  Lack of eye contact is the NUMBER ONE behavior that patients hate the most.
  2. Standing when the patient is sitting (or laying.) Sit down and look at the patient. 
  3. Standing far from the exam table/bed.  Patients are apt to think that YOU think they smell!  Seriously!
  4. Not being available.  When calls aren’t returned, patients hold it against you.  This also goes for being available while you are in the exam room.  I try to delay answering pages while I’m examining a patient, as I need to BE present for the patient I am examining,
  5. Giving the perception that you are rushing,  Please notice the word perception.  You may be hurried (harried?) but sit down, smile, and use humor if appropriate.
  6. Using technical terms.  Patients are intimidated by the words we throw about.  Speak simply. I don’t know anything about car engines and my eyes glaze over when the mechanic mentions words like “catalytic converter” or “repack the wheel bearings”.  Patients feel similarly about words like “congestive heart failure” and “synovial fluid.”
  7. Not answering questions.  If you don’t know the answer, tell the patient you will get back to them, or ask Dr. Bigg Bux, the orthopod, to explain exactly how the hip will be replaced.
  8. Don’t automatically say no, especially with out a reason.  I am ashamed to admit that I reflexively said no to a family request this past week, thought about the request, and then came back to tell them I could do what they asked.  Why was I so quick to say no?  Arrogance, time pressure, all of the above.  It took more time to change my mind then to do what they asked!
  9. Talking down to patients.  It is difficult to hit the sweet spot.  You want your conversations to be easy to understand but not juvenile.  You never know how patients will take what you say, but being flexible is helpful. 
  10. Mistrusting the patient/type casting the patient.  The book, How Physicians Think, by Jerome Groopman, has an excellent chapter on how physicians make mistakes when they stereotype patients.

Patients will also be less likely to trust you if you are of a different ethnicity, sex or culture.  These are harder to over come, and patients perceptions can be tough to change in these areas.  I still haven’t found a way around the fact that some patients prefer a male physician.  I happen to be female, and that’s one thing that ‘s not likely to change!

Resources: How Doctors Think, and Trust and Distrust in Organizations

Medicine Means You Never Have to Say You’re Sorry

Just as hospitals are encouraging us to apologize for our mistakes, comes a warning from Steven I. Kern, JD.  He cautions that admitting errors may result in loss of malpractice coverage.  He states :

For example, many malpractice insurance policies include a clause that allows the carrier to deny coverage if you do anything that adversely affects its ability to provide a defense.

He relates that saying sorry is basically an admission of wrong doing, and that anyone who hears you say that you are sorry can be used as a witness to testify against you in a malpractice suit.  Mr. Kern also notes that the push by hospitals for physicians to admit to mistakes may actually be based on an effort by the hospital to shift liability away from the hospital and toward the physician.  Yikes!  He also notes that saying sorry can lead to sanctions from peers, family wrath and economic loss.   What he recommends is that first, notify your “health care” attorney, and then together decide if you should notify your insurance carrier.  He then states that the three of you decide if it is appropriate to say “sorry.”  After that, the three of you will craft an appropriate response “to best communicate your regret in a way that is likely to make matters better, not worse.”

Mr. Kerns advice is good, but sad.  How pathetic that we live in a society where admitting we are human and that we have made a mistake is fraught with danger.   He does note that 35 states have variations on ‘apology laws’,  which he describes as “exempting expressions of sympathy and empathy to exempting admissions of fault.”  However, I still would check with your malpractice carrier first before making a move.

As he notes:

Unlike in church, confession doesn’t necessarily lead to absolution in the world of medicine.

I don’t know about you, but last time I checked, I was only human.  Crazy place, this world.

Are You a Bad Apple? 5 Steps out of The Crab Apple Funk

Much has been made of disruptive physicians, giving birth to “code of conduct” booklets that are required reading for physicians, as well as special coaches that help deal with physician behavior.  In my career, I have met only one disruptive physician, a neurosurgeon who was so dismissive and rude to the staff that I felt embarassed for my profession.  However, I think you may recognize some of the other ‘bad apples’ that can make the work day miserable.  You may even recognize yourself.  We all lapse in to ‘funks’, but if you are see yourself here consistently, time to work out a strategy to change from crab apple to golden delicious!

Types of crab apples:

The jerk: this physician delights in being critical, with out offering concrete suggestions on improvement.  Frequently condescending and short  (rude?).  Favorite comment, “Those ED docs are just sieves, man.  Why don’t they take two minutes and actually think?!”  (Heard last night, during my shift.)

The slacker: looks for as many ways as possible not to do the work.  Finds excuses on why tests and procedures can’t possibly be done.  At one institution where I work, if a particular cardiologist is on call, we all wait until the next day (if possible) to request a consult so we will get a different physician.  This particular cardiologist is famous for writing, “anti-arrythmics per hospitalist team.”

The depressive contrarian:  finds as many ways as possible to tell you that something won’t work.  Is so focused on what is wrong, doesn’t see what is right.  Guaranteed to make you feel as grey as a thunder cloud.  Chief sport is complaining. 

So what is to be done?

Here are steps to golden applehood:

  1. Practice optimism.  Before bringing out the sixshooter to gun down any thing remotely positive, try and think in terms of positive outcomes and solutions.
  2. Be civil.  We have lost much in the way we talk to each.  As your mom said, “If you can’t say anything nice, don’t say anything at all.”  Say please and thank you, don’t interrupt, and pretend to be Emily Post, even just briefly.
  3. Be honest, but not brutal.  Stick with the facts, and don’t embellish with emotions.
  4. Listen actively.  Listen much, talk little.
  5. Focus on  doing the right thing, rather than being right.
  6. Don’t be afraid to seek professional counseling.  Why go through life miserable?

Resources: Bad apples and Anger Blog.

Staying Afloat in Tough Economic Waters Part 2

So, continuing on with my tale of my little business…I left off describing how ExtraMD ( my local locums company) was going to weather these stormy economic times.  I have noticed a drastic drop in shift requests.  Over the past two years, we have typically had 10 shifts per month unfilled, almost enough for a full time physician.  However, over the last 3 months, I have seen a distinct drop, such that by December we only had 2 shifts that went unfilled.


Next, an urgent care cancelled a shift, saying they were so far behind in their receivables, they couldn’t afford any more debt.  We haven’t yet received the money owed for work we did there.


In addition, a large clinic system cancelled over 16 shifts for one month, leaving 4 doctors with out work for February.  They emailed me, saying, “Good news for our clinic…we’ve hired a full time physician, so won’t need coverage.”  Bad news for us.  We do have a 30 day cancellation policy, but the clinic squeaked in at 31 days, so didn’t have to pay the full cancellation fee.


So, what will we do?   How will I find work for my  docs, keep my company afloat and sleep at night?

Here’s my plan:

  1. Calm down.
  2. Send out a post card mailing, advertising a birthday discount.  (ExtraMD is turning 5.)  Something cute and eye catching will be on the postcard,  like a birthday cake.
  3. Email our clients, letting them know we have a birthday  celebration discount going on.
  4. Consider taking  birthday cupcakes to our best customers.
  5. Put an ad in the local medical journals.
  6. Talk to the other physicians in our group about leaving business cards and chatting up the business at practices where they are working.  As the physician owner, I have done all the marketing myself, but hey, it’s worth a try.
  7. Create a press release targeting the local market about ExtraMD’s birthday celebration and discount.  Let practices know that we are a  good interim solution during tough times–it’s cheaper to use us than hire another physician, especially if  a practice isn’t certain it can support another full time physician.

I’ll keep you posted as to the results.  How is YOUR practice doing in these tough times?

Visit change.gov and let Mr. Obama know YOUR views!

Hats off to a reader that encouraged me to visit Mr. Obama’s website called change. gov.  The reader encouraged me to leave my comments on e-prescribing.  I encourage all of you to visit the site, and let Mr. Obama know YOUR views on health care reform!

Goodbye Grandpa

My husband is flying to Michigan today to attend the funeral of his grandfather.  He died over the holidays, but specified that his funeral was not to interrupt Christmas.  It’s been a rough several years for my husband, as his dad died of cancer, and now his grandfather died of the same.  My husband was extremely close to both of them, and as he puts it, “it’s the end of an era.”

Grandpa’s death has hit me hard.  We had flown out and spent Easter with him, and he was as vibrant as ever.  We knew he didn’t have long, but we took him out for some meals, reminisced and played some wicked games of cards.  He was so sharp that he sent emails to us until the end. 

Grandpa died the way he lived.  He had a clear sense of how his last days should go.  He didn’t want to be in the hospital, didn’t want any intervention for the kidney cancer, and wanted to play golf until the last.  He died surrounded by his family at home  hospice.  Nothing was done with out his consent, and tomorrow his family will celebrate a life well lived.

Grandpa died like patients SHOULD die, in full control, comfortable, with his wishes fully known and followed.  I would advocate  that we physicians treat our patients like Grandpa’s physicians treated him; they listened thoroughly, were completely honest, and allowed him to set his course til the last.  It takes a special type of physician to let go when it’s time, and fortunately that’s what Grandpa had.   Goodbye Grandpa, and thank you to all of the physicians that saw him through.

And Now A Little About Me: How ExtraMD is Weathering the Financial Crisis

If only I could get paid for worrying!  I was up last night at 1:30 am, worrying about my company, ExtraMD.  I formed ExtraMD five years ago, when I left the large hospitalist group I was working for.  The hospitalist group was (and still is!) made up of intelligent, caring physicians.  I earned a nice salary, got regular bonuses and had excellent benefits.  I left because, with a young daughter, I wanted to have greater control over my time.  Exit the benefits, nice salary and bonuses.  Enter flexibility and a steep learning curve with respect to business.

I consulted an attorney, created my company, got a designer to make up brochures and business cards and declared myself in business.  I would eagerly check the emails of my new business email, waiting for work.  I was studying to recertify my boards, and so was glad to have some extra time.  I was thrilled when I got my first free lance job, working for anther hospitalist group.

I realized that the jobs weren’t just going to pour in, so I decided to market.  One of my friends is a rep for a pacemaker company, and he suggested I try the “lunch with the doc” approach.   I dutifully called several offices, got their lunch orders, and, on the appointed day, would show up with the food.  I was lucky if the physicians at the office would even come talk to me.  The office staff was always glad to see me and consume quite quickly what ever offerings I had, leaving me to clean up the office lunch room.  I did get business that way, but hated doing it.   The final straw came when I was asked to bring lunch for THIRTY.  I complied, and the office staff barely said hello as they chowed down, chatting amongst themselves as I sat alone.  The physicians never showed up.   Offices didn’t care that I wasn’t a big fancy drug company, they just wanted free food.  End THAT strategy. Besides, it was so darn expensive and time consuming.   Not to mention how it made me feel!  I now have great compassion for drug reps.

I had already sent out masses of introductory letters and brochures, and got only one job that way.  I decided to try a different approach, and created a post card mailing with snappy color graphics.  I laboriously created a postcard on Publisher, and printed it on my trusty home printer.  I created a database of local physicians by website mining, then printed out labels and got my baby sitter to stick them on the post cards.  This approach got people’s attention, and I started getting more work in primary care and urgent care, which was what I was after.

ExtraMD grew by word of mouth, post card mailings, and ads in the local medical newsletters.  Soon physicians started approaching me to work for my company.  We have grown so now there are 6 physicians, providing “local locums” service through out the metropolitan area where I live.  In the past 4 years, ExtraMD has always had more work than it could handle, and has actively been recruiting physicians.   We now have a controller, a board of directors and a virtual assistant.  Things have been going on swimmingly, with steady growth in revenues and profits.

Until this past October.  Which is why I am up worrying about “my people”.  More in the next post.

Enter to win a Amazon gift card–list a goal for your practice this year and a plan to achieve it!

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

Power to the Punctual! How Physicians can be on Time!

Patients have a pet peeve: they hate waiting for the doctor.  I hate waiting for the doctor, and hate it when patients wait for me!  It’s very funny, but in my personal life I tend to run late, but at work, I’m usually on time.  Reflecting on what helps me be on time, I came up with some tips:

  1. Don’t check voice mail or email first thing.  Get to the clinic (or hospital, as is my case), and get started.  Checking emails/voice mails will likely take up more time than you have.  Remember, the beauty of email/voice mail is that you can respond when you are able.
  2. Give yourself extra time to get to the office/hospital.  Don’t fall in to the “well, I have three extra minutes so I will check my emails, start my latest article, read up on transplants…”  trap.  Get to work first!
  3. Set your clock or watch ahead by an uneven amount.  (It’s harder to subtract, although my fiendish little brain has become adept at subtracting odd numbers.)  Set different clocks ahead by different amounts.  (Take that, smart brain!)
  4. Estimate accurately how long something will take, then add 15 minutes.  When a nurse calls me and asks when will I see a patient, I estimate how long it will be, and then add the extra 15 minutes.  The patients and families love it because I am on time, and I really look good if I arrive in the room early!
  5. Don’t schedule meetings during peak times.  At one hospital I worked at, they wanted us to meet with the case managers at 9:00 am.  I am hitting my rounding stride around then, and having a meeting in the middle of the morning would really slow me down, (not to mention slowing discharges down!)  My group was able to get a different meeting time set up.
  6. Set a goal for what you want to accomplish ahead of time.  I try to break my day up when I’m rounding into segments.  I will set a goal of seeing 2/3rds of my patients by 1:00 pm for example.  I know I am much slower in the afternoon, so I try to have the bulk of my work done before lunch.
  7. Set up your day so you can use your peaks effectively.  I try to see my ICU patients first, when I am sharpest, and leave phone calls for late in the day, when I can sit down with a cup of tea and really listen to what the families say.
  8. Don’t dwaddle on the Internet.  There is so much to read and learn, but getting sucked into the Internet black hole is a guaranteed time drain.  Be strong!
  9. Cut the optimism.  We all have ideas that we can get “just one more thing” done.  Try doing less, and you will probably be able to do more, because  you are less stressed because you are on time!
  10. Lastly, why are you late?  Is it a rebelliousness toward the system?  Are we physicians late because we can get away with it? Better book some time on the shrink rap couch!

So what are my top reasons for being late:

  1. Exuberant optimism about how much I can get done.
  2. Perfectionism, for example trying to get my computerized note to look “just so.”  (I am desperately trying to break this habit!)
  3. My kid/family/dog.
  4. Reading when I should be in the car driving.
  5. Complaining.  (Seriously, the way we docs carry on!  I am working HARD on breaking this habit, and will post on my ‘no complaining’ bracelet later.)

And you?  What’s keeping you from your patients?  Make 2009 the year when physicians are on time!  Power to the punctual!!!

Resources:  See posts on Lifehack and MedicineNet.

Enter the YOUR plan to improve your practice and win an Amazon Gift Card!

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

Don’t Write Off E-prescribing

I may appear to be somewhat of a troglodyte, but I actually have  committed myself to learning to love technology.  I am the proud owner of a smart phone, have mastered my email, and actually use two different EMRs.  So, you see, this qualified me as an expert on EMRs and e-prescribing (wipe that smirk off your face!)

It was with interest that I read “Effect of Electronic Prescribing With Formulary decision Support On Medication Use and Cost” in the December 8/22 2008 issu3e of Archives Of Internal Medicineby Michael Fischer, MD, MS et al.  The authors describe a study in which physicians using e-prescribing with formulary decision support were compared with physicians using traditional paper prescriptions with respect to prescribing tier 1 medications.  When prescribing electronically, the physicians were more likely to choose the lower cost generic tier 1 medication.  There was a 3.3% increase in tier 1 prescribing, with a decrease in tier 2 and 3 prescriptions.  Fischer et al estimate that this would result in an $845,000 savings per 100,000 patients, based on the assumption that each patient filled one prescription per month.

I love saving money, but what was the cost of saving money?  According to the authors, “government estimates of approximate first year costs were $3000 per prescriber.”  In the study, Blue Cross Blue Shield supplied the software to the physicians, along with a free wireless device, access to a secure Web portal, licensing and wireless carrier.  So, the cost was not borne by the participating physicians.

I think as a first step toward an EMR, e-prescribing makes sense.  I do not think that every insurance company should provide physicians with it’s wireless device.  Can you imagine, five different devices for five different insurance companies?!

So what is to be done?  The federal government must mandate one SINGLE e-prescription system that we all should use, and insurance companies should bear the cost, based on percentage of patients enrolled in each plan.  Why should health insurance plans pay?  Because they are the ones that will enjoy the savings!  I think this would be an effective way to usher in the beginnings of an EMR.  Mr. Obama and Mr. Daschle, are you listening?

As physicians, we must look for ways that we can use e-prescribing efficiently and effectively.  We must commit to learning all the bells and whistles, and using it to our advantage.  So, stop hiding behind your prescription pad, and make way for what is inevitable.  Get out there and lobby for what should be done, rather than whining when we get handed the bill for something that will most benefit the health insurance industry!

Win an Amazon Gift Card: What Are Your Goals for Your Practice in 2009?

As a way to encourage goal setting and planning for medical practices, I am hosting a contest.  I will email a $15 Amazon gift card to the person who sends in the best plan for improving their medical practice in 2009.

Here are the rules:

  1. Under the comments section for this post, list the goal your practice will achieve in the year 2009.
  2. Write out the  step by step plan as to how your practice will reach this goal.
  3. Have a time line accompanying each step.
  4. Assign a person  (don’t use their name, but rather “office manager” or “me”  or “book keeper”) who will be responsible for each action.
  5. All goals/plans must be submitted by January 16, 2009 by 12:00 midnight.
  6. I will pick the best goal/plan/action list, and post it on the blog by January 23rd.
  7. I will email the winning entry a $15 Amazon gift card.

That’s it.  No  bull, just good ideas on how to improve medical practices!  I will post my goals for my company, ExtraMD,  by January 8th.

Here’s to some great ideas!

Link Fest: Updates on group visits, RVUs, Medicare and the ‘Physician Shortage’

I’ve been storing up some links and today seemed to be a good time to have at ’em!  They range from the scary (Health Policy and Market) to the fun (the Efficient MD’s slide show.)

Read The Country Doc Report for another take on the group visit.  Country Doc relates how his practice does a group diabetic visit.  He uses smaller group sizes, and describes the three phases of the visit. 

For  an RVU Review, and exactly WHAT the RUC is, and how it effects you, visit Health Care Renewal blog. Boy, did I learn a lot about how we as physicians get paid (or not, as the case may be!)

To increase your understanding of the complexities of Medicare, Medicare Advantage, and Medicare Gap, see Insure Blog.  You may want to have this posted at  your front desk as patients come in with their “red white and blue” cards.

Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.

I love ways to improve my efficiency, and enjoyed the  fun, short  The Efficient MD’s  slide show.  I love his blog, and wish he would post more often!

For a chilly take on the role of physicians in the future, visit The Health Policy and Market blog.  According to the blog, we have plenty of doctors, and a “federal physician workforce policy” should be in place.  Just what I want, the federal government interfering even more into the business of health care! 

Establish a federal physician workforce policythat achieves the goals of organized care. TDI research has shown that the U.S. does not need more physicians; we have enough to care for America’s needs well into the future.

Let me know YOUR favority business of health care posts and I’ll put ’em up!

State CME Guidelines

State MD/DO CME Credits
Category 1 Credit(s)TM
Required Topics
Alabama MD/DO 12 1 12  
Alaska MD/DO 50 2 50  
Arizona MD 40 2    
DO 40 2 24(AOA 1-A)  
Arkansas MD/DO 20 1 Not specified  
California MD 100 4 100 1 time requirement of 12 hrs. pain mgmt. and end of life care; If >20% of patients are over 65, 20 hrs. in Geriatric medicine required
DO 150 3 60
(AOA 1-A or B
1 time requirement of 12 hrs. pain mgmt. and end of life care; If >20% of patients are over 65, 20 hrs. in Geriatric medicine required
Colorado MD/DO none
Connecticut MD/DO 50 2   1 hr. infectious disease, risk mgmt., sexual assault, domestic violence
Delaware MD/DO 40 2 40  
D. of Columbia MD/DO 50 2 50  
Florida MD 40 2 40 1st time renewal: 1 hr. HIV/AIDS, 2 hrs. medical error prevention; Subsequent renewals: 2 hrs. medical errors prevention; Every 3rd renewal: 2 hrs. medical errors prevention, 2 hrs. domestic violence
DO 40 2 20 (AOA 1-A) 1st renewal: 1 hr. HIV/AIDS, risk mgmt., FL laws & rules, controlled substances; 2 hrs. domestic violence & medical errors prevention; Subsequent renewals: 1 hr. each risk mgmt., FL laws and controlled substances, 2 hrs. each domestic violence and medical error prevention; Every 3rd renewal: 2 hrs. domestic violence. All other hours can be either AOA 1A or AMA PRA Cat. 1. Risk Mgmt, FL laws, controlled substances and medical errors courses must be live, participatory attendance.
Georgia MD/DO 40 2 40  
Hawaii MD 40 2 40  
DO none
Idaho MD/DO 40 2 40  
Illinois MD/DO 150 3 60  
Indiana MD/DO none
Iowa MD/DO 40 2 40 Child/dependent adult abuse (identifying and reporting) required every 5 yrs.
Kansas MD/DO 50 1 20  
Kentucky MD/DO 60 3 30 1 time Domestic Violence; 2 hrs. KY approved HIV/AIDS every 10 yrs.
Louisiana MD/DO 20 1 20  
Maine MD 100 2 40  
DO 100 2 40 (AOA 1-A or B)  
Maryland MD/DO 50 2 50 Partial credit for ABMS
Massachusetts MD/DO 100 2 40 Study board reqs; risk mgmt; (40 AOA 1-A for DOs)
Michigan MD 150 3 75  
DO 150 3 60 (AOA 1-A or B)  
Minnesota MD/DO 75 3 75 ABMS cert/recert accepted
Mississippi MD/DO 40 2 40 For initial certification only: DO credit must be AOA 1-A
Missouri MD/DO 50 2 50 50 hrs. AMA PRA Cat. 1, AOA 1-A or AAFP; or 40 hrs. of AMA PRA Cat. 1 or AOA 1-A if activity includes post-test; or specialty board certification; or ACGME or AOA approved internship / residency
Montana MD/DO none
Nebraska MD/DO 50 2 50  
Nevada MD 40 2 40 2 hrs. ethics; 20 hrs. in specialty; 18 hrs. any AMA Cat. 1. New applicants: 4 credits WMD/bioterrorism
DO 35 1 10 (AOA 1-A)  
New Hampshire MD/DO 150 3 60 Credits reported to NH Med Soc; CME reporting cycle changing to 2 yrs.
New Jersey MD/DO 100 2 40 6 hrs. Cultural competence in addition to 100 for physicians licensed prior to 3/24/05. These credits may be included in 100 if licensed after 3/24/05
New Mexico MD/DO 75 3 75 DO may substitute active membership in AOA
New York MD/DO none
North Carolina MD/DO 150 3 60  
North Dakota MD/DO 60 3 60  
Ohio MD/DO 100 2 40 For DO: AOA 1-A or B
Oklahoma MD 60 3 60  
DO 16 1 16 (AOA 1-A or B) 1 hr. prescribing controlled substances every 2 yrs.
Oregon MD/DO 7 (by 2009)     Pain Mgmt. and end of life care completed by 1/2/09
Pennsylvania MD/DO 100 2 20 12 hrs. Patient safety or risk mgmt (For DO: AOA 1-A)
Rhode Island MD/DO 40 2 40 2 hrs. universal precautions, bioterrorism, end of life, OSHA, ethics or pain mgmt.
South Carolina MD/DO 40 2 40 75% specialty education (30 hrs. every 2 yrs.)
South Dakota MD/DO none
Tennessee MD/DO 40 2 40 1 hr. appropriate prescribing (For DO: AOA 1-A or 2-A)
Texas MD/DO 24 1 12 Min. 1 hr. ethics and/or professional responsibility; (For DO: 12 AOA 1-A)
Utah MD/DO 40 2 20  
Vermont MD none
DO 30 2   Min. 12 hrs. osteopathic medicine
Virginia MD/DO 60 2 30  
Washington MD 200 4    
DO 150 3 60  
West Virginia MD 50 2 50 One time requirement: 2 hrs. end of life care including pain mgmt and 30 hrs. related to specialty
DO 32 2 16 One time requirement: 2 hrs. end of life care including pain mgmt and 30 hrs. related to specialty
Wisconsin MD/DO 30 2 30  
Wyoming MD/DO 60 3 60  


From Medscape.

Walk the Talk: the Patient Encounter

I am fascinated by how we physicians communicate (or not) with each other and with our patients.  As a medical student and resident NO ONE ever thought about how physicians communicated with patients.  We were always so focused on nailing the disease process and treatment that the patient was nearly ignored.  I don’t think I had a single attending that excelled in talking and listening to patients.  I have tried to self educate (isn’t that what most of medicine is?) and found a thoughtful curriculum for residents on line, from the University of Washington.  I will reproduce the salient points here:

  1. Have an opening introduction: “Hi, Mrs. Marlboro, I’m Dr. Pookie.”  (Hand shake, sit down, look at patient.)
  2. Allow the patient to complete their opening statement.
  3. Attempt to get the patients full agenda: “Mrs. Marlboro, what is the most important thing we need to work on today?” At this point, prioritizing the patients concerns is key.
  4. Set the ground rules: “Mrs. Marlboro, it sounds like stopping smoking is what we should focus on today.  Is that right?”
  5. Gather information, with a  mixture of open and closed ended questions.  Summarize and clarify with out interrupting.
  6. Actively listen, using non verbal cues as well as verbal cues.  (“Uh huh, ah…”)
  7. Explore their beliefs about the illness.  (Yes it’s hard to keep your mouth shut when a patient insists that smoking isn’t bad “because, Doc, I know you’ve heard it before, but I don’t inhale.”  Just heard this from a diabetic as he went on his way to the cardiac cath lab…  But try!)
  8. Acknowledge the patients feelings/values.  (“Yes, quitting smoking is really hard, even our President Elect thinks so.”)
  9. Share information in terms that patients understand.  (Save the free radical talk, two gene promotor theory of cancer for some one who cares.)
  10. Encourage questions: “what questions or concerns do you have?”
  11. Reach agreement on the treatment plan, actively encouraging patients to participate in the plan. 
  12.  IMPORTANT: TRY TO GAUGE THE PATIENTS WILLINGNESS  AND ABILITY ENGAGE IN THE TREATMENT PLAN!  The best plan in the world is worthless if the patient can’t/won’t follow it!
  13. Provide resources (hand outs, referrals etc.)
  14. Realize you can NOT cover every item at every visit. 
  15. Close the encounter by summarizing the treatment plan and setting up the follow up plan.

The patient encounter needs to be a balance between “patient centered skills” and “agenda setting skills.”  Interestingly, when a patient is dissatisfied, they underestimate by 8% how much time the physician spent with them, while if they are satisfied, they overestimate the time the physician spent with them by 20%!

Please see link from Society of General Internal Medicine below.   First author is Matthew F. Hollon, M.D., M.P.H., from the University of Washington. 


Allow Natural Death v. Do Not Resuscitate

“Allow Natural Death”

There is a movement afoot to replace DNR with “AND” or Allow Natural Death.  The idea is that patients and families are put off by the verbiage of DNR–that agreeing to a DNR is a death sentence.  Families and patients do not want to sign such an order committing them to what appears to be certain death.  However, Allow Natural Death puts distance between the final moments where the heart and lungs stop, and focuses on events leading up to death.  It is more than a change in semantics, it is a change in the way we talk about death.

AND appears more humane and, forgive me, natural.  Patients and families think that CPR/Code Blue results in saving most of the patients, most of the time, if TV’s ER is to believed.  But the sad fact is, resuscitation is frequently an invasive end of life maneuver that ignores dignity and natural progression.  Moving toward AND will require a shift in thinking whose time has come.  Patients and families want a peaceful, dignified death.  In order for patients to understand that death is a part of  life that can’t be denied, we as physicians will have to do what we aren’t particularly good at.  We will have to talk to patients and families about death.

We need to educate families (and ourselves) that death is part of living, and that sometimes it is best to let God and nature take their course, with out our highly invasive, technological, expensive interventions.  I think the place to start occurs when a patient that is  approaching the end of life.  That is the time  to get a grasp of what a patient wants/doesn’t want.  We shouldn’t wait until a patient is at death’s door to talk about the end of life.   Many patients want to die at home.  (Most, actually want to die at home, and sadly, most die in the hospital.)  The idea then is to address these desires when beforethe patient deteriorates so significantly that death is imminent.  For instance, is it appropriate to treat every infection?  Back in the day, pneumonia used to be called “the old man’s friend.”  Does the patient and family want to treat the pneumonia?  Do they want to go on toward intubation?  Does the 95 year old wheel chair bound patient WANT her fractured hip replaced–or would she be more comfortable at home with a decent pain regimen?  (Yes, just saw this last week when the orthopod called asking for “medical clearance” to replace the patient’s hip.  No one had thought about AND in this case.)   Just as important, does the patient and family want the new mass on chest Xray to be worked up in the 85  year old patient with COPD? 

These are excellent examples of when AND would be a well placed directive.   I think that AND is more than a directive, it is a direction to guide treatment.  Much discussion should go into WHAT treatments families and patients want.  I don’t think we can fore go DNR as it is a clear directive of what to do when a patient has a cardiopulmonary arrest.  However, I think “AND” should be a primary topic of discussion way before we ever get to DNR.

Currently, AND is not a legal replacement for DNR.  I don’t think it should be, but rather would use it as an adjunct to guide diagnosis, management and treatment.  I think it is the responsible way to help patients face the end of  life with dignity.  We need to get good at these discussions, and help our patients in realizing their ultimate decision: the manner in which they wish to die.

Just to be very clear:  this is in NO way a piece advocating that we help patients end their lives.   I am advocating that patients choose how much medical treatment they want as they near the end of their lives, and that we help them explore various options to make this decision.

How Doctors Think Outside of the Medical Box

It was a tough week in Pookieville.  I worked all week at one of my favorite hospitals.  I like working there because the specialists I work with are hypercompetent and always willing to help.  Furthermore, they like to chat. Well, they like to chat about interesting cases.

I was particularly challenged this week because I had to think out of the box.  I will not share the details of the case, as I don’t intend this blog to be about medical cases per se.

When I picked up  my service, I  assumed care of a very complicated patient, with a disease process that was appropriately handled.   Unfortunately, there was an outcome that was unexpected and completely unpredictable .  It was also quite serious.  What I want to share is how hard it was to think out of the box, which was what was required.  Medical statistics and medical science can not predict all outcomes, which is when the “art” of medicine comes in to play.

I walked in to the room to discuss the latest bump in the road, and the various treatment options to remedy the latest bump.  Now, before I went in the room to talk to the patient, I had done my home work.  I had reviewed the latest bump in the road with the surgeons, specialists,  the sub-specialists and several of my co-hospitalists.  There was no clear consensus as to what should be done about this problem, just a general agreement that this problem was indeed, a big problem.  Most of my colleagues were glad they were not me, because it felt as if all options were fraught with danger to the patient.  “Glad I’m not the one that has to write those orders,” was the general feeling.


I explained to the family what the issues were, and that we were now in rock and hard place territory.  I explained that there were no randomized, double blinded placebo controlled studies for where we were at.  I explained the options, risks, benefits and side effects of each option.  I explained that  I had done my home work.

“Do you just fling sh– at the wall and see what sticks?”  One incredulous family member asked.

It must appear that way, when we can’t quote studies, and cite statistics and supply comfort from numbers.  We must appear like idiots when we have to use our experience, and our colleagues’ experience to make a decision when there is no clear cut decision, and when the road is paved with ill feelings and anger at an outcome only God could have predicted. 

But none the less, a choice on treatment had to be made. 

Here is how I made my decision on how to treat the problem:

  1. Identified the problem.
  2. Said “@#%*!”
  3. Asked everyone involved in the case their opinion, including the PharmD, and the head of the department of medicine.
  4. Came up with three options, and picked the one I felt was the safest with the best outcome.
  5. Reviewed options with the patient and family.
  6. Realized that there may be MORE options, once I talked to the family.  (Interestingly, the family was the most creative in looking at solutions.)
  7. Walked out of the room, made more phone calls, and finally came upon the solution that we ended up going with.
  8. Called a renowned specialist at the local University and got the specialist’s opinion, who was in concurrence with the ultimate solution I had crafted.
  9. Went back in the room (a bit demoralized, as I had said there were no other options, but now had come up with one.)
  10. Heard the family’s  intense relief at the more moderate, middle of the road option that we ultimately agreed to implement.
  11. Went for it.

So why I am writing about this?  Because it took me TWO hours to do all of this.   It took two hours for me to think and explore every option, and to finally come up with an option that seemed workable, and the least dangerous.  I took the time because I wanted to do what was best.   It was the family that was most able to think outside of the medical box, and who encouraged me to explore further.

Now, was this the right choice?  Only time will tell, and yes, sometimes as physicians we just have to throw sh– against the wall, and then throw some more, and then consult our colleagues, and then think again to find the answer when there is no right answer.

I just hope that in the future, I have enough time to think out side of the medical box.

How do you think out side of the box?

Medical Practice as a Socially Responsible Business

I have searched for a way to describe my view of medicine as a business.  I finally realized that the practice of medicine should be classified as a socially responsible business.   “Who cares?”, you say.  Well, I say we all should care.  We went into medicine to help people.  However, as I am fond of saying, we can’t help people if we don’t keep the doors open.  We need to have a way to do both.

So how to reconcile the two visions?  We have the altruistic Norman Rockwell picture of the benevolent physician examining a young girl’s doll directly opposing today’s appointment packed, hyper regulated, law suit filled world.  I propose we view our practices as socially responsible businesses.  So what does this mean?

  1. Owners of socially responsible businesses realize that making money is important.  Practices need to stay in business, pay their employees a competitive wage and make a decent living for the physician owners.
  2. Owners of socially responsible businesses realize that as a practice grows, non-financial benefits grow.  You CAN see patients who can’t afford to pay, or can only afford to pay a little if your medical practice/business is financially fit.
  3. Owners of socially responsible businesses realize that non-financial benefits have financial costs.  The socially responsible business may have to absorb higher costs and accept smaller profits.  NOTE: I didn’t say run the business as a charity!  By definition a business is NOT a charity!
  4. The socially responsible businesses/medical practice has at it’s core a mission to provide quality health care AND stay in business.  The two are NOT mutually exclusive, but must intertwine and co-exist.  One must feed the other.
  5. Government intervention and big business are not appropriate business models for socially responsible medical practice/businesses.  Physician owners must start from the ground up and build a profitable, socially responsible business model that DOES NOT involve government intervention.  Additionally, the typical frenzied profit taking by big businesses is not an appropriate model either.
  6. The socially responsible business/medical practice must seek efficiencies where ever possible.  Creativity is a core value of the socially responsible medical practice/business.
  7. The socially responsible business/medical practice avoids “short termism” and “poor governance and regulation, misaligned compensation and incentive systems, lack of transparency, … poor leadership and a dysfunctional business culture.”  (Quote from Al Gore, http://www.careerjournal.com/article/SB122584367114799137.html)  This means that the physician owner is in the medical business for the long haul, and has a clear vision as to where the socially responsible medical business/practice should go.  It means the physician must learn HOW businesses operate, and how to manage the practice in a long term sustainable fashion.
  8. The socially responsible business/medical practice behaves as if people and place matter, because they do.
  9. The socially responsible business/medical practice believes that time is money.  Therefore, it doesn’t waste the time of patients or physicians.
  10. The socially responsible business/medical practice embraces technology, but realizes that government mandates to REQUIRE technology will drive the socially responsible medical practice/business OUT of business.

For more resources and thoughts on the socially resonsible business of medicine, see www.bcorporation.net  View the declaration of independence on “b corporations” at:  http://www.bcorporation.net/index.cfm/fuseaction/content.page/nodeID/9e7f627c-487b-41f1-975b-5adfeceffbb4/  See also Ode Magazine, December 2008, pages 21-25.)  This issue is not yet available on line, but website is www.odemagazine.com.  I have no alliance with the B Corporation.net, or Ode Magazine.

AHIP Rides in to Save Health Care

America’s Health Insurance Plans (AHIP) has released a plan on how to reduce health care costs.  The platform is summarized below:

The new reform proposal would:

Ensure universal coverage by guaranteeing coverage for pre-existing conditions, fixing the health care safety net, giving tax credits to working families and enacting an individual coverage requirement;
Call on the nation to set a goal of reducing the growth in health care costs by 30 percent;
Enhance portability for people changing or in between jobs;
Provide more affordable health care options for small businesses; and
Increase value and improve quality.

An admirable statement indeed. But once again, one must look a little deeper. 

Reducing costs: AHIP points out “Respected studies have shown that patients do not consistently receive high-quality health care and receive care based on best practices only 55 percent of the time.”  Hmm, does  mean that we as physicians are giving ‘low qulaity’ care the other 45% of the time? Who is determining what is ‘high quality’ care?  They advocate using “evidence based standards.”  Aren’t we already doing this?  Furthermore, evidence based standards typically apply to ONE disease state, not the multiple chronic problems primary care physicians deal with.  C’mon give us something fresh!  Stop blaming the doctors for the problem.

AHIP also advocates “exploring” replacing medical liability with dispute resolution. No argument here!  Now who will reign in the powerful legal special interest groups that so effectively court congress?

The reform proposal also advocate controlling fraud.  Now really, how big of a problem is this?

AHIP also advocates pay for performance.  This is a little scary, given the current P4P mess.  I could see this as just another way to with hold payment to providers.  Based on my work as a hospitalist, I find it laughable when the 80 year old post op knee patient is expected to be discharged on day 3.  However, insurance companies don’t care to notice the hypoxia, anemia and confusion attendant with operating on the elderly. Instead, they leave a bright orange sticker on the chart demanding that I justify why the patient is still in the hospital.  Good thing I’m not currently paid for my performance in getting the total knee replacement patient out on time.  The heck with hypoxia!  Clearly I must be doing something wrong and my pay should reflect this!

They also advocate “streamlining” administrative costs.  Gosh, I’d love to streamline my claims, and not have to have extra office staff there to beg insurance companies to pay the bills, or jump through hoops for pre-authorization.  Insurance companies should begin immediately to streamline their administrative costs–they don’t need a government mandate or huge reform to do this–but, I suspect, this may take money from their own pockets.

AHIP states another priority: “Refocusing our health care system on keeping people healthy, intervening early, and providing coordinated care for chronic conditions.”  This is something the health insurance companies should be doing already!  It should not take a “crises” in health care for health care plans to make STAYING healthy a mandate.  They also advocate strongly for “patient centered homes”, a concept that I think is just repackaging of the current model, albeit more top heavy with “midlevel”  and ancillary providers.  

Information technology is embraced (how fashionable!) but no attempt is made as to explain WHO will pay for technology.  Why don’t we admit that the emperor has no clothes?!  There is no money to pay for an EMR and nationalized technology.  Putting it on the backs of primary care practices will drive more physicians out of primary care.  Perhaps insurance companies should pony up for this cost?

They also advocate that everyone should have insurance, regardless of condition.  AHIP also states there should be tax benefits to small businesses so they can offer health insurance, and “large markets should be strengthened.”  They even suggest that the government offer assistance to small businesses. They also advocate broadening SCHIP and medicaid eligibility, as well as offering tax credits to lower income families.    This completely ignores the fact that medicaid reimburses so poorly  that  physicians can’t afford to see medicaid patients!  AHIP also wants  “community health centers” to receive “adequate” support.  Ah yes, another bail out in the making!

American Health Insurance Plans close with a mandate that the feds should provide a “framework” for reform, and that state governments should follow suit.  They also pledge to “cooperate” with the effort.  After reading the entire proprosal, I am left with just one question: what are the health insurance companies going to do?  Are they going to fly to Washington in their private jets to ask the government to pay for the uninsured?

 Visit the complete reform platform at:


Play Nice in the ED: Why Hospitalists and ED Docs Should Be Friends

I do a lot of work as a hospitalist, and have noted a fair amount of antagonism amongst my colleagues towards the ED.  There seems to be a lot of bickering between ED docs and hospitalists as to WHO should take responsibility for patient care. More specifically, if a patient has been admitted to a hospitalist, but remains in the Emergency Department, which physician is now responsible for that patient’s care?

A few rules:

Patient care comes first.

We are all busy, and we are all good, caring physicians.

If a patient is still in the ED, and a crises occurs, the ED MD needs to be responsible.  If I have seen a patient in the ED, then I should be called. However, if a patient is in crises, shouldn’t the nurse notify the ED physician AND the hospitalist?  Of course!  To notify me a patient is getting “worse” when I haven’t had time to assess the patient is nuts.  But it happens all the time.  Common sense must be employed:  DO WHAT IS BEST FOR THE PATIENT!

Now, what about the patients that are not in crises, but about whomthe nurse has questions?  First, I hate it when nurses call me and ask me if Mr. Prinzmetal should be on telemetry (or ask me to designate a level of admission, say observation or ICU) when I haven’t even seen the patient.  The ED physician should have a good enough sense of the patient to designate where (ICU/floor/telemetry) the patient should go. By all means, if I disagree I will change that designation.  So, please don’t call me with THAT question and waste more of my time (and then wonder why I haven’t seen the admissions that have been called to me.)

Now, as to other questions like potassium replacement, sure, call me.  But, please, please, please do NOT call me with major management questions before I have seen the patient.  I hate it when the ED doc calls me to ask if they should start heparin or nitroglycerin drips on cardiac patients.  You have seen the patient, and made the decision that they have an acute coronary syndrome.  You don’t need my blessing to act accordingly.

When the patient gets to the floor, they are my responsibility. Period.  I am watching over most of the patients in the hospital, as we are consulted on most orthopedic patients, and a fair amount of the general surgery patients.  I just ask that ED docs watch over the patients that are physically in the ED.

ED physicians, if you are busy, it means by extension, I am busy. We need to realize that the ED impacts the entire function of the hospital, and directly effects the work flow of hospitalists.

ED docs: here is my pledge to you:

  • I will say thank you every time you save my butt.  I know how many times you have put in lines and run CORs for me when I am crushingly busy.
  • I realize that for every patient I see, you see three.
  • I know that your job is challenging, and sometimes thankless.  I appreciate it everytime you are able to divert the bottom feeders.
  • I will be thankful for the work ups you do.
  • I will bring you candy my next shift.

This post is in response to “Lost in Transition” regarding handoffs at the Moving Meat Blog.  Thank you, Shadowfax and Whitecoat for the dialogue!  See:  http://allbleedingstops.blogspot.com/2008/11/lost-in-transition.html  and http://whitecoatrants.wordpress.com/

Crash Test Dummy: 5 Signs Your Practice is Failing

Buckle up, partner, it’s time for another PookieMD biz refresher course!  This time, it’s on unmistakable signs that your practice business is about to crash and burn!

Knuckle gripping sign number 1:  You have cash flow problems.  You can’t meet payroll because you don’t have enough cash on hand.  YOU MUST BUDGET FOR CASH FLOW!  (Which leads to my even more basic rule for doing business: you must BUDGET!)

Knuckle gripping sign number 2: Expenses are greater than revenues.  Whether it’s decreased productivity, or that @%*# insurance company that pays so late, the basic rules is that revenues must be greater than expenses.  You must figure out what is happening, and how to reverse the trend.

Knuckle gripping sign number 3: You’re borrowing more than Citibank.  If you are borrowing to meet expenses, you are in deep doo.  No, the feds aren’t going to bail physicians out.  Tighten the belt, sniff the smelling salts and make a plan .

Knuckle gripping sign number 4: You hide from the postman.  The overdue notices keep on coming.  You need to structure your own bail out!  Call in the experts, and swallow the medicine.  You wouldn’t encourage a patient to ignore a breast mass, so why are you ignoring your business?

Knuckle gripping sign number 5: No one looks at financial statements.  This is a variation on the ignore the breast mass and it will go away scheme.  To get an adequate idea of how your practice is doing, you need to look at budgets, budget variances, cash flow and accounts receivable monthly, at the minimum.  In tight times, you may need to budget WEEKLY for cash flow.

So, what to do?  Just like you would tell an alcoholic, first you must recognize that you have a problem.  Next you must review your financial statements to find out the depth of the problem.  Then you must develop a plan to get back in the black.  You must budget, analyze your cash flow issues, and tighten the belt.  Lastly, get help.  Would an internist do a cardiac cath in the office?  Of course not!  Why would you try to go the financial world alone?  Get referrals from friends on good accountants and bookkeepers, read all you can, consider educating yourself through seminars, and take it one day at a time.  If you actively follow your plan, your practice can become viable again!

The Common Sense Declaration: How to Fix Health Care

I am on a reading frenzy, and finally got to the October 17, 2008 issue of Medical Economics.  There was an excellent article by Elizabeth A. Pector, MD, on fixing health care.  I will highlight some key points, but encourage all of you to see the entire article (pages 29-33.)  (www.memag.com)

“Establish equal rights for doctors.”  Dr. Pector advocates appropriate reimbursement, taming the paper tiger, and reigning in “etitlementiasisis” by patients.  Bravo!

“Improve access to doctors.”  She again targets physician reimbursement, but my only question is “how”?  Increasing physician reimbursement will be a tough sell in today’s economic times.  Sadly, I don’t see a way off the office visit treadmill that is the bane of primary care existence.

“Stop the blame game.”  Our society has turned into expert finger pointers.  Bad things just happen.  People die.  Sometimes, physicians make mistakes.  We need to have mutual respect between patients and physicians, rather than mutual antagonism.  And hey, tort reform wouldn’t be so bad either!

“Establish workable technology standards.”  Amen.  “We need to establish workable standards for PHR and EHR systems, including mutually compatible communications platforms.  Also, cash strapped doctors need help to fund changes…”  Technology is here to stay, but we need a coherent direction for all of health care, such that physicians and patients can access records through out the spectrum of medical institutions (clinics, offices, hospitals, nursing homes, etc.) 

“Stop punishing doctors and hospitals.”  See my previous rant on the medicare never ever no pay list.  The no pay list will continue to grow as Medicare pokes its fingers into patient management.  The no pay rules range from common sense to absurd, but there seems to be no one reigning in the free wheeling CMS.

“Take responsibility.”  Americans need to pony up and take responsibility for their choices, rather than shifting the responsibility elsewhere.  This will take giant social change, from throwing out the television and X-box to eating meals that don’t come in a “super size.”  Are we up for the challenge?

“Refocus the health insurance industry.”  Pector notes that physicians should be paid for what they do, with out the “gamesmanship” so common today when dealing with health insurance companies.  Additionally, she notes that insurance companies could actually (don’t faint!) assist in helping patients follow through on life style changes and medical compliance.

I think Dr. Pector is my twin sister of a different mother! Keep fighting the good fight, Dr. Pector!

Group Visits: Treadmill Medicine or Meaningful Encounter?

I have been encouraging physicians to explore group visits for a while.  Group visits are especially suited for stable patients with chronic disease–think hypertension, diabetes, COPD. Patients with chronic diseases make up the majority of the primary care office visits, especially for internists.  Group visits can increase patient and physician satisfaction, and encourage healthier patients and lifestyles.

Following is a short primer on what must go into a group visit:

  • Privacy issues must be addressed.  The patient must sign a confidentiality form, allowing their case do be discussed in a group, and also agreeing NOT to discuss other patients’ medical issues outside of the group appointment.
  • The chronic disease addressed must NOT require the patient to disrobe.  (Duh.)
  • A physical exam must be done.  In order to bill appropriately, a nurse should document vital signs for each patient, and the physician should document an appropriate exam for the problem.
  • Patients should be encouraged to have questions formulated for the physician ahead of time.  These questions may be posted on white board and reviewed through out the meeting.
  • Physicians should be prepared to answer questions as they examine each patient.  This is where the efficiency exists–many of the patients will have the same questions, and will be relieved that they are not the only one with questions/problems.
  • Time should be available after the group appointment for individual questions ON THAT SPECIFIC DISEASE PROCESS.
  • Schedule enough time and enough patients.  Eight or nine patients in one hour is a good number.  You may need to have the initial group visits be 2 hours and discuss how the group visit will run.  Realize that Seniors tend to have more flexibility as to scheduling an hour long visit, while working folks may require early morning, lunchtime or late afternoon appointments.
  • Have enough support staff to take vital signs, sign privacy statements and get patients situated.
  • Be prepared for emergencies–if Mr. Pickwick shows up for the group visit with a pulse ox of 70%, be prepared for how you will handle the emergency AND  the group meeting.

As to billing issues: each patient is billed as if seen individually, hence the emphasis above on vital signs, appropriate physical exam, lab tests, level of decision making etc.  Utilize E/M codes 99212-99215 as appropriate.  Documentation is key here.  Consider a check list form, or a template for your EMR, that patients fill in regarding symptoms and questions, and then a check off form for the physical examination.

So what do patients think of group visits?  About 75% of patients that have participated would do so again, and 5% would not. 

I personally have done group visits with diabetics, and enjoyed it tremendously.   We served lunch at the first meeting, and had a nutritionist and pharmacist there as well.  The patients enjoyed it, and learned a lot.  I think group visits will go a long way towards easing the treadmill approach we employ in primary care medicine, and encourage physicians to try it.  Some practices delegate this to the “mid-level” providers, but I think patients get more out of the group visit when it is physician run.  I also believe that most physicians enjoy the interaction and ‘teaching moments.’

Let me know if you do this, and what works or doesn’t work.

For an overview of how Harvard Vanguard Medical Associates is doing group visits, see:  http://www.boston.com/news/local/massachusetts/articles/2008/11/30/the_doctor_will_see_all_of_you_now/?page=2

For more information, forms, and another in-the-trenches view point, see: http://www.aafp.org/fpm/20040900/39grou.html

TightMD Gazette II: 11 More Tips to Tighten the Belt

All right, Dr. Practice Owner, here are more tips to keep you practice’s head above water in these turbulent times:

  • Share staff.  If you have an excess of staff, could they be shared with another office rather than laid off?  You  get to retain a valued staff member, the staff member keeps their job, and everyone wins.
  • Enlist your staff for help.  Everyone is anxious about keeping their jobs.  Set up a brain storming session for ways to save money, and ask your staff for input.  Once they realize they can directly impact how the practice runs, they will be diligent in finding ways to keep the doors open!
  • Pay bills on line.  You can pay bills closer to the due date, and keep the money in your account longer.  (See “sweep account” in previous post.)
  • Get a free energy audit.  Your local power company will do this for free, and can give you information on where the energy is going, and how to improve the leaks.
  • Turn off your computer at night and on weekends.  Ditto the lights.  (Duh, but did I turn off my computer last night?!)
  • Evaluate your payroll company.  Payroll companies must guarantee accuracy in withholding and tax filing.   (Penalties are huge for mess ups!)  However, make sure you are not paying for services you are not using–if there is just three of you, do you really need the Human Relations functions?  Also, examine direct deposit.  See if you can get your payroll service to do it for free.  Direct deposit saves the payroll company money–which should you be paying for it?
  • Make sure you take all the tax deductions you are entitled to.  Keep receipts as if they were gold.  If you haven’t done this during 2008, make it a top priority for 2009.
  • Tax tips continued: ( http://smallbusinessonlinecommunity.bankofamerica.com/blogs/Taxes/2008/03/20/five-tax-filing-mistakes-to-avoid)     

–If you started a qualified retirement plan, you can claim a credit of $500 per year for the first three years to offset the administrative start up costs (e.g., educating your employees about their participation in the plan).
–If you conducted scientific research, you may qualify for a 20% tax credit for these research activities.
–If you hired someone from certain targeted groups, such as a disabled veteran or long-time family assistance recipient, you can claim a credit for a portion of their wages.

  • Choose the best business entity.  Partnerships, LLCs, and Corporations all have various tax benefits.  Talk to your accountant and then business attorney about what is right for your practice.  General rule: “Any business with the potential for claims against it, which includes most businesses with employees as well as those with customers who visit the business premises, should probably opt for an entity type that protects owners’ personal assets.”  (Barbara Weltman, contributing writer for Inc. magazine.)
  • Cross train your employees.  Rather than laying off, see if they can do other functions.  Beware of the training costs, but it may just save you money.
  • Don’t be Scrooge McDuck.  Get creative with perks.  Consider dress down Fridays, if appropriate, or Pizza Fridays.  Ask you staff if they want that Holiday Gala, or if they would prefer some decent lunches, or maybe just a bonus check.

My company, ExtraMD, does the following: we use a virtual assistant, we pay bills on line, we keep payroll in  house, and are looking at giving bonuses this year.  I look at our profit/loss and budget variances monthly.  We have an ace controller, and an amazing tax attorney.  Our accountant is appropriately pessimisic  (that’s what I am paying him for!)  And, yes, I print on both sides of the paper.  I promise to turn off my computer at night.

Good luck!   Keep the doors open, the employees EMPLOYED and your practice business in the black.  Remember, if you aren’t open, you can’t see patients!

The TightMD Gazette: More Ways to Save Money in Your Medical Practice

So now that we are in the spend, spend, spend season, I thought I would round up some more ways to SAVE money in medical practices.  The following tips are from the mundane to the grandiose.

  1. Get your printer cartridges refilled, rather than buying new ones.  And, hey it’s “green”!
  2. Get free forms.  Visit www.entreprenuer.com/formnet.  They have forms for collections, credit cards etc.  Better than making ’em yourself, or paying for them!
  3. Use independent contractors.  ExtraMD (my company) is made up of independent contractor physicians.  We fill in locally around town, and cost less than the big locums  companies.  Practices save because we are independent contractors, and pay our own taxes/malpractice etc.  There may be similar groups in your location.  In addition, consider independent contractors for prn nursing, front desk help etc.  CAVEAT: check with your attorney/accountant to make sure the people you are using fit the stringent IRS definitions of independent contractors.
  4. Shop around for over night mail couriers.  Boy was I shocked at the differences!  It cost about FIVE dollars less to use USPS over night versus another big company!
  5. Make sure you plan for taxes appropriately so you don’t get soaked with penalties.  My bookkeeper calls this “tax anticipation.” 
  6. Get the best credit card rates.  If you run balances, for pity’s sake get the lowest interest rates!
  7. Look at a “sweep” account. If you run large balances for 2-3 weeks at a time, a sweep account allows you to move your money in and out of an interest bearing account easily, and earn interest, rather than having your money sit in a non-interest bearing account.
  8. Ask suppliers if they will give discounts for early payments.  Hey, it doesn’t hurt to ask.
  9. Make sure your billing company is a bull dog.  Don’t let them write off claims too easily.  I will post more on this later.
  10. Get at least three bids on every purchase  (especially the big ones!)  When you DO finally purchase something, see if you can bargain, or quote a competitors price!
  11. Reassess your phone plan and the number of lines you have.
  12. Eliminate paper waste.  Copy on both sides of the page.  Why  add more to the land fill any way?
  13. Use coupons.  Don’t laugh!  Get your medical assistants to find them.  Check out www.searchalldeals.com for lots of coupons on just about any purchase.
  14. Sell equipment you aren’t using on Craigs List.  (www.craiglist.org )
  15. Make sure you are getting the best rates on business/medical/malpractice insurance.

Just try doing one or two, and see where it gets you. I will search out more ideas in the next post.  As a reminder, try to have your staff look at this list and implement a few money saving practices.  Your time should not be spent clipping coupons!  I would love to hear YOUR tips!  Also would love to hear gripes/tips/info on coding in your practice.

For more info check out these on-line articles:



What Will You Be Thankful for NEXT Year?

I work with a business coach, aka the EntrepreneurialMD, who is a physician that helps other physicians who want to think outside the box of medicine.  She sent me a list of questions to ponder.  I have edited them somewhat to tailor them strictly to physicians in medical practice.  Following are items to contemplate as you enjoy that last piece of pie, the sip of wine and the companionship that is Thanksgiving.  If you are really motivated, you might even consider writing down the answers.  (You could do that between commercials during football games.)

– What’s your biggest business/professional objective in 2009?

– What are your biggest opportunities right now?

– Where do you see a gap in your “market” –what’s not being offered?

– What do your “people” (patients/practice partners/employees) complain most about?

– Where are you leaving money on the table?

– What are your top 3 time eaters and energy drainers?

– What is your “Biggest Opportunity Project” for 2009?

– What are the top 5 business/career development strategies you’ll focus on?

– How will you know you’ve had a great year?


And to all of our brethren working on Thanksgiving, I give a whole hearted thanks and God Bless.  We have all walked in your shoes, and are grateful for all you do.  Happy Thanksgiving!

See www.entrepreneurialmd.com for more.

10 Reasons Your Medical Practice is Failing, and How to Fix It

As the ExtraMD, PookieMD has seen lots of practices.  I have also been asked to evaluate failing practices to see where they got off track.  There are some common themes amongst failing practices.  For once, I will NOT carry on about reimbursement, but rather focus on where the physician owners of these failing practices went wrong. Here are my top ten reasons primary care practices fail:

  1. No budget.  With out fail, every time I have asked failing practices about a budget, I get a vague answer, along the lines of, “Well, we look at the numbers.”  NO!  A budget is not something your book keeper or office manager creates, and then places on a dusty shelf!  You need to look at it as a tool, and analyze where your practice’s money is going, where you want your practice to go, and why you are (or are not) getting there.  You must analyze variances and figure out why they are occurring.  When I say you, I mean YOU!  Yes, you must understand this process to guide your practice/business!
  2. Serious lack of planning.  We physicians are masters at trying to anticipate and forecast what happens with patients.  This same skill MUST be applied to cash flow.  You must forecast your cash flow  so you can plan ahead.  Good examples of bad planning: not anticipating paying your staff for holidays/vacations, not planning for the lost revenues while YOU are on vacation, not planning on HOW you will pay your new partner before s/he is generating enough to cover her salary. 
  3. Huge empty offices.  I worked at one office where one exam room was crammed with free give aways from drug reps.  You couldn’t even use the room.  Yup, pens, cute pedometers, plastic clip boards, heart shaped watches were stuffed into the exam room, rendering it unusable.  Yikes!  Who can afford that?
  4. Top heavy staff.  If you are a small office, you really need to examine how much staff you have, and how much your really use and need.
  5. Buying sprees.  Before you invest in what ever new gizmo you think will earn the big dollars, do a thorough market analysis and cash flow projection.  (Worst example I’ve seen: a gazillion dollar laser that a practice bought but never used!)  Don’t just believe what ever a vendor is telling you.
  6. Investing in an EMR and not using it.   I have worked for 4 different practices that bought EMRs and were too busy to a) use them at all b) wrote notes and then typed them in later, c) persistently scanned notes in.  I’m not kidding.  If you are going to get an EMR, commit!  Realize it will take oodles of time to make it useful, but for Pete’s sake, don’t buy it and have it sit there!
  7. Not putting in the hours.  All of the practices I have been asked to review had physicians that felt like they were working quite hard, but were only putting in 6 hours a day.  Many offices would open at 9:00 am, take a 1.5 hour lunch, and then the office would close at 4:30. 
  8. This is not your father’s practice.  Back in the day, the “GP” hung out his shingle, saw 10  patients a day, gave a shot of penicillin in the behind for everything and perscribed milk for ulcers.  If you think the business of medicine is that simple you are in the wrong profession.  Physicians must understand the complexities of today’s medical/legal/business world.
  9. Poor location/top heavy lease.  It’s tantalyzing to have the medical office suite with the fancy furniture and custom wall hangings etc., but get real.  See #1, BUDGET!
  10. No advisors.  We physicians are smart, but not smart enough to know everything.  The practices I have evaluated typically had physician owners that were trying to do everything themselves, with out utilizing advisor such as bookkeepers, accountants and business attorneys.  You must know enough to understand your advisors, but you also need to trust them to guide you.

If you see your practice here, get busy making changes!  Today’s climate is tough, so we need to get tough in how we run our practices businesses.

Survival Tips for Primary Care: How to Save Money

Now that I have vented/ranted/opined on the demise of primary care, let’s move to some survival tips. Following are PookieMD’s two fundamental. most important, and most loathsome rules of survival in primary care medicine.

The money is in the numbers.

Time is money.

Yes, you have to see patients to  make money, and given today’s reimbursement you have to see a fair amount of them.  This is a given, a fact, a law.  If you don’t want to see 20 (or more) patients a day, go in to psychiatry.  If you are in primary care, you probably are looking for a way to make a dollar go a bit further.  Don’t laugh, you might spot something useful here!

  1. Get a set back thermostat.  No, these aren’t just for home use.  If you are paying your utilities, why are you heating the office at night? 
  2. Learn to be efficient.  I have previously blogged on being efficient.  Running yourself ragged to see more patients is a recipe for burn out (if you are not already there!)  Look for ways to become more efficient.
  3. Use your EMR to the fullest.  For heaven’s sake, if you bought the thing, use it!  Learn every bell and whistle it has, every dot command, every work around, every reminder system. .  It will make you more efficient. Reminder: USE the perscribing feature (CMS will be rewarding this, and then penalizing you if you DON’T use it!
  4. If you don’t have an EMR use preprinted check box forms when possible. Write in the extras but the check box forms will save you time, and are usually more legible.
  5. Have your receptionist call and remind patients of their appointments.  An empty slot in your day doesn’t generate revenue.
  6. Look at how you use your space.  Could you rent a spare exam room to a occupational or physical therapist?
  7. Consider extended or weekend hours.  You are paying the rent whether you are open or not.  Consider opening a half day on Saturdays for urgent care appointments.  Don’t let Walmart take away YOUR business!
  8. Consider using medical assistants during their internship.  Lots of local MA schools are looking for practices that will take on a student.  These students are usually in the later part of their training and can extend your man power for free!  Beware, your nurse or MA should supervise them.
  9. Make sure you are billing for in-office procedures.  Train your staff to check off ua’s, strep tests, pregnancy tests etc.  You should then double check when you are filling out the superbill. You are doing ’em, get paid for ’em.
  10. Shop at big ware houses, like Costco.  Get toilet paper, and office supplies at a discount.
  11.  Make sure you charge for vaccination admission and the vaccine itself.
  12.  Use those freebie exam table coverings.  (Yeah, I’m not fond of laying down on an exam table with a paper covered with Viagra logos, but hey, what a poor primary care doc to do?)
  13. Don’t buy new–buy used equipment when possible.  (Checked Ebay lately?)
  14. Consider remote deposit capture.  If you have a big enough volume of checks that come in, you can scan and electronically send the images to your bank to get instant deposits. Cash flow is king!
  15. Consider ancillary services.  See previous post on ancillary services.  See what you can stomach.
  16. Consider group appointments.
  17. Utilize your staff to the fullest.  See previous rants.  Yes, I’m talking to you.

Look, this stuff isn’t fun.  However, if you want to survive, your business (note, I didn’t say PRACTICE), must have revenues greater than expenses.  This is the law of keeping the doors open.  Maybe things will change for the better.  Maybe not.  But if you are doing primary care, it’s up to you how you handle your BUSINESS, and how you keep the doors open so you can see patients.

As The Medical Home Turns: The Final Installment

Final Installment on As the Medical Home Turns:

Yes, students, today is the last installment in PookieMD’s dissertion on the ‘Medical Home’.  At our last session, we were midway through reviewing the “10 Simple Rules for the 21st Century Health Care System,” rules to guide the redesign of the health care system.  These guidelines were put out by the National Committee for Quality Assurance.  Why are we torturing ourselves with this tedium?  Because this may the  measuring stick by which CMS (Center for Medicare and Medicaid Services) will use to reimburse our practices.  And that means, of course, insurance companies will follow suit.  Following are rules 7-10 with my pithy commentary:


“7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice and patient satisfaction.
8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.
9. Continuous decrease in waste. The health system should not waste resources or patient time.
10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.”

Item 7: “The need for transparency.” To me this sounds very similar to ‘rule 4’, free flow of information.  The salient feature is that the health care ‘system’ should make information available to patients about health plans, hospitals…etc.  Who will be responsible for each aspect–are physicians to review a patent’s health plan with them, and review each hospital the patient may go to?  This is an incredibly broad assertion of what needs to happen, but with no clear plan of who exactly needs to provide this information.  Part two, which references the “system’s performance”, appears to be directly related to measuring safety (think the never/ever no pay rules, for example), and also appears that your practice will be measured on evidence based practices and patient satisfaction.  We already discussed evidence based practices, which I consider the basis of modern Western medicine. However, the patient satisfaction issue is murkier.  What exactly IS patient satisfaction?  Would I get higher scores if I didn’t collect copays, gave out lots of oxycontin and ordered any test the patient saw on TV?  Clear criteria need to be established,  e.g. are patients seen with in 15 minutes of their appointment?  Are appointments accessible on a daily basis?  I’m not buying the criteria of “Rate PookieMD on a scale of 1 to 10–where one is the worst physician you ever saw, and 10, PookieMD is better than Marcus Welby, House and Hawkeye Pierce combined.”

Item 8: “Anticipation of needs.”  Yes, indeedy, I certainly try to anticipate my patient’s needs.  More importantly I try to anticipate outcomes.  If I do x, y will happen. But, I also try to have a plan in case z happens.  I can’t anticipate a patient’s every need, but I can use the best of my knowledge and resources to try to move the patient toward health.  Anticipation of needs smacks of wand waving, rather than reality.  Anticipation of outcomes is medical science, and an attainable goal. 

Item 9: “Continuous decrease in waste.”  Sounds good to me.  I hope that includes not wasting MY time filling out endless forms and jumping through hoops to make the ‘Medical Home’ a reality.  It is interesting that the Rules state the health care system should not waste resources or patient time, but makes no mention of physician time.  I’m all for decreasing waste, and hope that much more in depth thought goes into developing the operations and processes of the ‘Medical Home’, so it is not a gigantic bureaucratic wasteland.

Item 10: ” Cooperation among clinicians.”  Please do not patronize me.  Cooperation is a kindergarden skill, and doesn’t belong on this is on the list.  The physicians I know and work with are dedicated and caring, and certainly cooperative.  We don’t always agree on management, which is HEALTHY, and we certainly can be snappy when fatigued, but I think this is rule is over kill.  Shall we form a circle and sing Cum By Yah?

So my final take on the “Medical Home” is that it is a bunch of ‘rules’ that primary care  practices are trying to do already.  (Or as close as they can get with the limited resources they have.)  What it woefully neglects is how systems should be put in place to make health care, health information technology, and a much needed emphasis on PATIENT CENTERED care a reality.

Back to the drawing board.  This time, make sure you invite the physicians in the trenches that actually do the work–the family practice physicians,  the internists and the pediatricians, to guide the guidelines.

Wand Waving Part 2: Common Sense is Uncommon

Let’s jump right  into the second part of PookieMD’s dissertation on the Medical Home.   As you recall, I was reviewing the 10 rules of the medical home, as set forth by the National Committee for Quality Assurance.  The next three concepts are NOT new, and are, you guessed it, common sense.  (Why is common sense so uncommon?)

4.  Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge.
5.  Evidence-based decision making. Patients should receive care based on the best available scientific knowledge.
6.  Safety as a system property. Patients should be safe from injury caused by the care system.

Let’s tack number 4 next: “Shared knowledge and free flow of information…”  I think this is a thinly veiled reference to an EMR.  I am completely for nationwide use of an EMR, but am dismayed at the piecemeal, haphazard free for all that has ensued.  The EMR needs to be accessible to health care professionals across all spectrums of care.  Therefore, the myriad of programs out there are not going to create a system of good access for providers and patients.  It has been proposed that there be a nation wide EMR for all health care providers to use.  I am hesitant in advocating this, as many tout the VA’s system as the model.  I am loathe to advocate anything the VA uses, as I would summarize my experience with all things VA using two words: “profoundly inefficient.”  However, a nation wide, user friendly EMR  would probably be the best option.  BUT,  it has been estimated that it will cost $36,000 per physician to implement an EMR.  Where’s the money coming from?  I don’t see a huge surplus (!) coming any time soon into our Nation’s budget.

5. “Evidence-based decision making.”  No argument here.  I believe this is the very foundation of modern medicine in the West. 

6.  “Safety as a system property.”  It scares me that this is a rule.  Didn’t we take an oath to “do no harm?”  It also scares me that the folks at my favorite institution, the CMS (Center for Medicare and Medicaid Services), have bungled their way in to making rules to keep the patients safe from bed sores, c diff and catheter infections through the “Never/Ever No Pay” rules.  (See post below.) 

So what’s so new and exciting about the Medical Home?  No much so far, just more costs to the physician, a slick new name and a lot of press.  I’ll tackle the next ‘rules’ the next post.

For more info on EMRs, visit Dr. Kevin Pho’s informative post at http://blogs.usatoday.com/oped/2008/10/why-doctors-sti.html.  For more on the technical aspects, see Dr. Josh Schwimmer at http://www.healthline.com/blogs/medical_devices/2008/10/problem-with-emrs-in-united-states.html

Cheers!  Don’t let your hands cramp writing those SOAP notes!

Wave the Wand: The Medical Home Mandate

I am intrigued with the idea of the “medical home”. 

When hearing about the concept, my first thought was, isn’t this what we are trying to do already? 

My second thought was–and just how are we going to pay for all this?

Below is ” Crossing the Quality Chasm: 10 Simple Rules for the 21st Century Health Care System,” from the National Committee for Quality Assurance.  I will go through these ‘rules’, and the lengthy explanation from the PDF PCMH_Overview_Apr1{[1}pdf.  This will take a couple of posts, so don’t glaze over on me.  And yes, there is a homework assignment at the end!

“Crossing the Quality Chasm put forth “10 Simple Rules for the 21st Century Health Care System” to guide the redesign of the health care system. These rules underlie PPC (Physician Practice Connection) and describe a system different from most health care today.
1.  Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits.
2.  Customization based on patient needs and values. The system of care should meet the most common types of needs, but have the capability to respond to individual patient choices and preferences.
3.  The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them.
4.  Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge.
5.  Evidence-based decision making. Patients should receive care based on the best available scientific knowledge.
6.  Safety as a system property. Patients should be safe from injury caused by the care system.
7.  The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice and patient satisfaction.
8.  Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.
9.  Continuous decrease in waste. The health system should not waste resources or patient time.
10.  Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.”


PookieMD’s cross examination/rebuttal on items 1-3:

“Care is based on continuous healing relationships.”  This the very basis of primary care, and always has been.  The remaining docs that are weathering this storm and staying in primary care stay in it for the relationships!  They are certainly NOT in it for the abundance of pay! 

“Patients should receive care whenever they need it…”  Wait a minute!  Who is GOING to provide this care? At what cost?  Who is going to revise the entire insurance/medicare/medicaid system to accommodate this?   You can’t just start mandating that physicians start changing their practices WITH OUT PROVIDING THE TOOLS  TO DO IT!  (Monetary and otherwise.)  Please, please, please do  not set bench marks with out putting deep thought, strong policy and appropriate funding behind it.

“Customization based on patient needs and values.”  As physicians, we try desperately to accommodate patients’ needs and values.     I doubt that ANY physician is trying to force something on a patient that is NOT consistent with the patients’ needs and values.  I think that what is neglected here is the fact that PATIENTS MUST HAVE A PERSONAL RESPONSIBILITY IN MAINTAINING OR REGAINING HEALTH.  Many times a patent’s needs can NOT be met–it just isn’t possible with out a magic wand.  The patient must have as much stake as the treating physician in the wellness process.  Many patients do NOT recognize that their behavior contributes directly to their illness, and desire to just lay back passively and have the physician wave the magic wand.  (For an incredible case in which a patient demanded wand waving, read about a Rheumatologist who was sued and had to pay $400,000 because he didn’t provide an interpreter for a deaf patient.   Visit http://www.pointoflaw.com/archives/2008/10/doctor-held-lia.php.)

“The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them.”  I love it when patients have an opinion.  I also know that I need the TIME to review information and decision making with patients and families.  This is woefully covered in the ‘counseling codes’, and is frustrating for both patient and physician to do in a limited time frame.

All right, enough for today.  Your homework is to read the rules, and see how they apply to YOUR practice.  Then,  think of HOW you will implement them, and what resources you will need.  I’ll go through the rest, and try to dig up some real numbers on the cost.  I’m not dumping the concept, I’m just applying the light of  reality.

What if Starbucks billed like ICD-10?

Ah, yes, ICD-10 is coming!  Yes, the new coding system with 10 times more codes than the previous is slated to go live in 2011.  Much of the world now uses ICD-10 because it has more codes, as apparently, we are running out of codes.  You, my beloved provider, will be shouldering the burden of the cost to implement the system.   A few reasons why this has made my normally smiling face curdle with disgust:


1.  There are TEN times more codes– all codes will be 7 digits, and then, yes, oh yes! You can add a modifier.  Simple, huh? 

“We are just now beginning to learn the increased costs on physician practices associated with moving to the ICD-10 code set – and they are staggering,” said William F. Jessee, MD, FACMPE, Medical Group Management Association president and CEO.

2.   It ain’t cheap.  Implementing the new coding system is estimated to cost $83,290 for a THREE physician office.  (See http://www.aapc.com/news/index.php/2008/10/icd-10-cm-coalition-press-release/).  At an average reimbursement of $50 per patient visit, that’s an extra 555 visits per year, per physician.  If a physician works 5 days/week, 48 weeks per year, this makes an extra 2.3 patient visits PER DAY!  If patients already feel rushed during their visits, think of it now!  And you know what, there’s not a dang thing the physician can do about it!  (Well, I guess concierge medicine might look more attractive…)


3.   You will wait even longer to get paid.  CMS (Center for Medicare and Medicaid Services), which is the government agency behind this change, notes: “…putting in the new system could initially boost by 10% the percentage of claims insurers return to doctors because of coding errors.“   (See http://blogs.wsj.com/health/2008/11/11/look-out-docs-here-comes-icd-10/)


4.   It’s another blow to primary care.  Many primary care offices are solo practitioners, or small groups (three or less.)  These are the groups least able to shoulder the cost of another complex government regulation. 


5.   You won’t have time to implement it.  You will need to learn the new codes, educate your staff, update your super bills and then change over your billing software to accommodate these new codes.   Most importantly, you will need to do some major cash flow planning.  (Yup, adding in an extra 65,000 codes takes time and money!)  This will be tough to do given the time frame the CMS is proposing.  Even the insurers want more time.  (Who’d a thunk it—me agreeing with medical insurance companies!)


6.   Get ready to buy more computers.  If your practice wants to be efficient, you will need computers in each exam room to quickly file the charges.  This is on top of the mandate that medical practies move to an EMR.  (Who’s going to fund THAT?) (See: http://www.ama-assn.org/amednews/2008/09/08/gvsa0908.htm).


7.   Beef up your documentation.  You want to get paid?  Prepare to be exacting!  The reason for a medical chart has changed—it used to be so that we could develop a working diagnosis and plan, based on history and exam to treat a patient.  You poor dinosaur! A chart is a way to get paid! 


8.   It will drive up the cost of health care.  The cost of soft ware, computers, training, IT support and the like will first be passed to physicians, and then eventually to patients.  There is no such thing as a free lunch!


9.    Patient care will suffer.  As physicians, we are ever more focused on computers, documentation, crossing Ts and dotting I’s.  Who will focus on patients when we are focused on coding?


10.   We will lose more primary care physicians.  Small practices, in rural/underserved areas can not afford the implementation involved in transitioning to ICD-10.  Implementing  ICD-10 will be a nail in the coffin of areas that desperately need primary care physicians the most.


I was thinking about opening a coffee shop.  I could code and bill for beverages as follows: a small cappuccino would be a 99212(01), a medium 99213(02), and a large a 99214(03), and jumbo would be a 99215(04).  I could add modifiers to denote skim, 2% or whole milk.  Shots of flavoring would require modifiers as well. So, a medium, skinny cappuccino with a shot of hazelnut would be a 99213(02)-7-13  (taking into account the ‘skinny’ or -7 and the hazelnut -13.)  I would of course charge you, the customer, more for my nifty billing system.   I also could bill based on how LONG it takes to make the beverage.  I don’t know why Starbucks doesn’t do this.  It seems so efficient.

Billing for Phone Calls: Acceptable Practice or Reptilian Behavior?

My trusty health insurance, for which I pay handsomely, (yes, I am self-insured) sent me an email titled, “Calls could cost you.” It states that calling your physician may cost you. I quote:

“Many times people call their doctor to ask a question, resolve a concern, or ask about a referral. Traditionally, doctors haven’t charged to answering these questions. In certain cases, that’s changed.

New rules have been established that allow doctors to charge for telephone consultations in some circumstances. To be a billable call, the patient must not have been seen by the doctor for a week before the call or within 24 hours after the call. If the doctor provides services that could have happened at a regular office visit, then the doctor can submit a claim. The doctor must let the patient know the call isn’t free and that he or she intends to bill.

If the doctor does submit a claim to Humana, we’ll treat it as if the doctor filed a claim for an office visit. So if your benefits have co-payments for an office visit, you’d owe the doctor your co-payment for an office visit. If your Humana plan has a deductible, we’ll apply the allowable claims costs to your deductible. You’ll pay the allowed charges, unless you’ve met your deductible.

These rules don’t apply to most calls people make to their doctor. But Humana wants you to know that under current national rules, doctors can bill both Humana and their patients for some telephone visits.

It’s important to know that calling your doctor could cost you in some circumstances. If you’re aware of the rules, you could save yourself some money.”

Hmmm, this is interesting. What patients should you manage over the phone? What are the legal ramifications? Ethically, what is involved in charging for phone calls?  God forbid, are we behaving like lawyers? I don’t know about you, but I always prefer to see a patient rather than prescribe over the phone. I know some patients absolutely refuse to come in, “I don’t have time,” but I am loathe to diagnose and prescribe over the phone.    (And these are the patients I think are most likely to sue-they seem to be looking for a way to work around the system.)

My take-
If a patient is ill they need to be seen.
If you are going to bill for phone calls, and it is certainly justified in some cases, be impeccable in your documentation.
Establish criteria ahead of time of what sorts of phone calls you will bill for, and what cases ABSOLUTELY must be seen in the office.
Teach your staff how to triage calls.

Following are the codes for phone calls.  (From From the January ACP Internist, copyright © 2008 by the American College of Physicians.)  If anyone is doing this, I would love to hear back as to which insurers are reimbursing, and how you determine which patients are appropriate to be managed by phone–e.g.  coumadin management? 

99441: Telephone E/M service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion
99442: 11-20 minutes of medical discussion
99443: 21-30 minutes of medical discussion

As to liability, here are some guidelines from CRICO/RMF, the medical malpractice company for the Harvard Medical Community.  (http://www.rmf.harvard.edu/patient-safety-strategies/communication-teamwork/telephone-technology/faqs.aspx#Q31)

“Documentation of all phone calls in which medical information is discussed is extremely important. The date and time of the call, patient’s complaints, and advice given should all be recorded. The advice given should include the point at which the patient should seek medical attention. The few minutes taken to record this information will be valuable for ongoing patient care. In the event a patient challenges the quality of medical care they received by phone, or claims he or she made multiple calls and received no or inadequate advice, such documentation will prove worthwhile.”

Good luck with this!  I think that coding for phone calls has a lot of potential for good and bad, and would tread lightly.  And just to make you smile, I got an automated phone call from Humana while I was writing this, encouraging me to visit their web site, where I could get medical advice “tailored for me.”  Shoot, who needs an MD?  Just throw up a web site with generic advice and call it a day!

Another One Bites the Dust: Dr. T. Leaves Primary Care

I received a disturbing email from one of the doctors in my group, Dr T.  My group is made up of internists and family practice physicians that fill in locally through out the large city we live in.  All the physicians are board certified and have been out of residency for five years or more.  Several of them have private practices and work with ExtraMD as a local locums to augment their salaries.

Dr. T. is one of my favorites.  He is in solo practice in a lower income area.  His office is comfortable, his receptionist kind and the atmosphere is homey.    He works with ExtraMD on his days and weekends off.   Dr. T. is leaving private practice.  He has been trying to make it for 5 years now, getting by with a single receptionist and his wife doing the books.  He just can’t make it work anymore. 

But why?  He has tried mightily to serve the working class poor in his area.  He does most procedures himself, runs a tight ship and economizes where he can.  He bought his equipment second hand, takes little time off and spends nothing on frills.  While working, he developed acute cholecystitis and was hospitalized.  His first thought was to let his patients know he wouldn’t be in and his second was to call me because he had a shift scheduled.  Not one word about how he was hurting.  In addition, his wife followed up with a call just to make sure I had gotten the word.  Sheesh, how many of us care that much?

He is leaving because he can’t deal with the constant financial hardship, of fighting with insurance companies, figuring out how to make the cash go further when the payers are late, and how to break even.  He takes medicare and medicaid, because in his neck of the woods, they are some of the best payers.  He is leaving because he can’t keep up with the endless fighting over claims, and can’t afford to hire someone to do it for him.  He is leaving because he can’t afford to hire someone else to beg insurance companies for pre-authorizations.  He can’t afford the mandated EMR, can’t afford the “team” approach required for the patient centered home, and he fears he will go bankrupt trying to follow other of  the latest government mandates. He can’t keep up with ICD-10.  He doesn’t want to be a manager of a ‘physician extenders’ but wants to practice medicine and help people. Dr. T feels as if physicians have “sold out.”

He is leaving, he says because of “the realization that there is no future for the kind of medicine I practice.”

Dr. T, you will be missed.  I will miss your honesty, integrity and caring.  Your patients will miss a force for good, a comforting presence, and a kind and competent physician.  We all mourn the passing of primary care into the hands of those that DON’T care.

Score: Medical Insurance Companies/Government Regulations: 1  Patients/Physicians: 0.

Good bye, Dr. T and Godspeed.

Resuscitating Primary Care: Part II

All right, pencils out, notebooks at the ready!  Quiz to follow!  Here is Part II of Resuscitating Primary Care.  At our last session, we noted the primary care was indeed a “code-blue/COR-0”.  As promised, I will apply my laser sharp focus to “fixing” this problem.

Buckle up!

You are a shrink. This is another unavoidable issue.  You must learn effective ways to help these patients, which make up a large part of medical practices.  In our medical school and residency programs there needs to be a greater emphasis on psychiatry, as mental illness is so pervasive.  As to your own practice, several things will help: learning and using the counseling codes, scheduling enough time for these patients, and having on hand the cards of your favorite psychiatrists, psychologists, and social workers.  Also, you must become well versed in the plethora of antidepressants out there.  Key point: you have limits too, and remember that most mental health professionals have the phrase down, “I’m sorry, but our time is up.  When should we schedule our next visit?”

Insurance companies make life miserable.  We must fight back!  As group, we physicians have laid down and played dead!  From a macro level, we physicians need to lobby for appropriate reimbursement and STOP accepting what ever insurance companies offer.  (See related post: “Entering the Lions Den”.)  At a practice level, your job is to ensure that your coding, billing and collections are top notch.  That means knowing which insurers are paying in a timely fashion, at an appropriate rate. It means dumping the ones that aren’t!  It also means negotiating for the reimbursement your work deserves. It means having a strong stomach, and realizing that this problem is not going to go away unless you make it go away! 

It’s not good mind candy anymore.  Ahh, to find the random pheo and look like a hero!  The reality is we are managers of chronic disease, cheering patients on when they lose weight, lower their A1-C and actually exercise.  Yes, you will still make the occasional brilliant diagnosis, but your focus will be on medical coaching.  You need to learn how to coach, and find joy in it.  Another avenue to explore would be group sessions, which can be energizing and exciting.  Next, you could market your practice as “the practice for the seriously ill” — meaning you WANT complicated medical patients.  This has ramifications for billing/collections, but could be a viable model.  (Note: I haven’t run the numbers, but remember, you will code higher for more complicated patients.  If you really market your practice to get these patients, it may be fairly interesting. Any one out there have a practice like this?)  Lastly, consider leaving slots open for urgent care visits.  There is no reason to give this business away to Urgent Care clinics, and these visits can be fun and interesting.  (Yeah, I know, you will see a lot of URIs, but you will also see the occasional thyroid storm and aplastic anemia!  Been there, done that!)

The environment is hostile.  But you don’t have to be!  If you are on time, sit down, look AND listen to the patient a lot of hostility will vanish.  We have perpetrated some of this, and it is completely fixable by physicians!  Bedside manner, (Marcus Welby, not House!) is where it’s at.  Please, do not hide behind your computer.  Yes, use that high falutin’ super expensive EMR, but set it up so that you can look at the patient and type.  For pity’s sake DO NOT write notes and type them in later! Talking about a huge time waster!!!  Make your exam room and waiting room comfortable, and a friendly receptionist and nurse are a must.  Sourpusses need not apply!

Not everything is fixable.  Yup.  However, our mind set must be that our job is to guide patients toward health, and that there are no quick fixes.  Part of the job is to move patients towards this mind set as well.

Key point of this post:

Make it fun!

We spend too much of our time at work not to have fun. Have a good time with your patients and staff.  When the end of the day comes, I think the one that had the most fun, wins!  Hang in there, send comments on how to make it better, lobby for change, and keep doing the good work!

PS:  I will put up a page with a resource list in the next few days.

Resuscitating Primary Care, Part I

As promised, I will turn my laser like focus to the task of “fixing” primary care.  I will examine both micro and macro ways of doing this, coming up with to do lists that physicians can implement in their practices as well as global suggestions that will take shifts in health care policy.  (Which only we as a group of physicians can enact!)

1.  The pay stinks. Yes it does.  Physicians do not get pay raises because they are more experienced or incredibly good.  The only way to increase the pay is to do one of three things: see more patients, add more services and globally lobby for getting paid for thinking (which is what primary care physicians do best).  At the practice level, you need to examine patient flow, appropriate billing for services rendered (example: are you billing/coding appropriately for immunizations?) and decide on an appropriate number of patients to see.  Calm down, I am NOT telling you to become a patient care mill, rather to be realistic and set a REASONABLE number of patients you could see.  Also realize that the pay is limited, and it will take a major change in reimbursement to get paid appropriately for what you do.  (Sorry, it is what it is.  Get out there and lobby for change!)

2.  You got an MD instead of an MBA.  I am addressing this early in the game because it is probably the most important.  In my neck of the woods, massage therapists, as part of their curriculum, learn marketing and accounting.  They are better equipped to set up a practice then a physician who has spent 4 years in medical school then 3 more in residency! (Academic medicine, are you listening?) Here is the big message of this post:

You must learn the business of medicine.

But how?  There are books on practice management, seminars on practice management, journals on practice management, and a good accountant and bookkeeper are essential.  But YOU must understand the financial underpinnings of your practice, even if you have God’s gift to office managers.  (For more on seminars, visit my website: www.extramd.com.)  Later this week, after I do my nights shifts, I will put up a page with a list of resources I found helpful.  C’mon, as a physician, you are used to soaking up knowledge like a sponge, you can do it!

 3.  Coding is really fun.  Sorry, but this is another one you MUST learn.  I don’t care that it is boring, picky and strong medicine even for the most confirmed of insomniacs.  Once again, avail yourself of every resource you can to learn it.  Think seminars, books, consultants.  No whining, just do it.  (And remember, ICD-10 is coming.  Sheesh.)

 4.  You are a hamster on a wheel.  You will have to weigh revenues vs. practice style here.  Of course, you will need to maximize revenues, billing and collections no matter what you do.  However, if you choose to see fewer patients per day, then you need to reconcile yourself to less revenues, and ultimately less income.  Your practice partners may have some input on this (!), but if you are solo, consider the micro practice model that is getting a fair amount of hype.  Whatever you do, be very clear in your mind what your expectations are.

All right, enough for today.  We will continue PookieMD’s crash course on primary care resuscitation in my next post.  Until then, keep the doors open, and get out and learn a little about the business of medicine!

Black Tuesday For Primary Care: Why Physicians Would Rather Do Anything Else

I have been in practice for 15 years, and most of my colleagues hate primary care.  (Remember, I come from a cohort of internists, the ones that should be the defenders primary care!)  In my rovings as the ExtraMD I still do some primary care, to keep me honest, and to remind me how hard primary care is.  Here are 9 reasons why most of my doc pals don’t do primary care:

1. The pay stinks. Consider this, my fellow refugees from primary care,: the average primary care physician in the U.S. earned $183,332 in 2007. A nurse anesthetist makes about $160,000 per year. (Think about the differences in school and training, as well as life style.)

2. Coding is really fun. Just to perk you all up, starting October 11, 2010, there will be a brand spanking new ICD, the ICD-10! According to Medical Economics October 3, 2008 (page 17) ICD-10 will have about “10 times the number of codes as ICD-9″.

3. You are a hamster on a wheel. The average physician spends just over 50% of their office time with patients, with 25% of their day taken up by answering calls and writing refills and reports.

4. You are a shrink. Here’s what it’s like in the trenches: “Even conscientious physicians …face many obstacles in delivering mental health services to their elderly patients who are depressed and suicidal.” (J Am Geriatr Soc. 2007;55(12):1903-191. And it’s not just the elderly that are depressed, “reliable estimates suggest that symptoms consistent with depression are present in nearly 70% of patients who visit primary care providers.” (The Journal of the American Board of Family Practice18:79-86 (2005). Hmmm, how much time can a physician spend with a depressed patient and get paid for it? Yes, you can code for counseling, but gosh, a colonoscopy sure pays better!

5. Insurance companies make life miserable. A typical primary are office has several staff members devoted to teasing out the tangled web we call health insurance. How much overhead does this add?

6. It’s not good mind candy any more. One of my favorite things about medicine is the diagnostic puzzle. Those days are limited to viewing episodes of “House.” Rather, we are mangers of chronic diseases, trying to find joy in motivating patients to change. (We are not well trained to motivate behavior change, but should be!)

7. You got an MD, rather than an MBA. Primary care medicine requires understanding the intricacies of practice financial management, insurance companies, marketing, HR, and ambassadorial level negotiating skills. Last time I checked, this wasn’t included in the standard medical school curriculum.

8. The environment is hostile. Patients have been fed a steady diet that physicians are uncaring sharks. We spend a fair amount of time dealing with patient anger, and more time yet dealing with re-education. Patients do have real grounds for complaints about waiting times, rushed physicians and lack of continuity of care, but this just adds to why physicians hate primary care.

9. A lot of stuff is unfixable. We’ve come a long way, baby, but we can’t fix everything. As a physician I want to make it all better, and patients certainly want it too! But I can’t, and boy is it frustrating.

So, keeping with my philosophy that if I complain about something, I should have ways to make it better, my next post will be on practice level AND global ways to make primary care better.   (I will have to do a lot of thinking on this, so send me some comments to get me started!!!)

Handoffs or Fumbles: Transferring Care Amongst Physicians

There are many patient hand offs during EVERY physician’s day.  Primary care physicians hand their patients off to ED docs, who in turn hand them off to hospitalists or specialists, who in turn (eventually) hand them back to their out patient physician.  Additionally, there are hospitalist to hospitalist hand offs and specialist to specialist hand offs.  Yikes! 

Here’s my advice on preventing fumbles:

From PCP to ED/Hospitalist: please call the ED or admitting hospitalist if you are direct admitting.  DO NOT HAVE YOUR NURSE CALL BECAUSE YOU ARE TOO BUSY!  Make sure your patient has the following paper work attached to his body:

  • today’s note that clearly states WHY the patient needs an ED eval or admit, and what you did for him in the clinic.
  • legible medication list.
  • legible problem list that includes surgeries and hospitalizations  (Yeah, remember that from med school?  You may have all that in your head, but we are seeing this patient for the first time).
  • contact information on how to get back to you.
  • the concerning EKG that caused you to send Mr. Prinzmetal to the ED in the first place.

From ED MD to hospitalist/specialist:

  • Why the patient needs to be admitted.  Please, please, please don’t say “He just needs to come in.”  Have labs, EKGs, and xrays on hand when you call, and please don’t mind if I ask you a fair amount of questions.  I do NOT expect ED physicians to think of every contingency (that’s my anal retentive job), but I do expect a working diagnosis.
  • What you have done for the patient in the ED, and how he responded.
  • Which specialists you have called, and what their plan is.

From hospitalist to specialist:

  • Why you are calling.  Be VERY clear: “I want you to manage Mr. Prinzmetal’s acute MI.  I think he needs to go to the cath lab.”
  • In what time frame the specialist needs to see the patient.  My favorite specialists will tell me when they will come by, but I try to ask so I can tell the patient.  For pity’s sake, if you need them to see the patient NOW say it!  They aren’t mind readers.
  • What you have done for the patient and how the patient has responded.
  • Have your data handy. I expect the ED to do this for me, and we need to do it for the specialists/consultants.

From specialist to hospitalist/primary care:

  • Communicate the treatment plan.  I love a phone call, but the minimum is a readable note.
  • When you will follow up with the patient.  Expecting a PCP or hospitalist to call you to inquire about follow up plans reduces us to minions and is poor patient care.  Besides, you should be telling this to the patient when you hand them your business card.

From hospitalist to PCP:

  • Call the PCP at discharge(or email the THOROUGH discharge report if you are set up that way).  Most hospitals send dictated summaries, but they frequently arrive after the patient has been seen by the PCP.
  • Make sure the PCP ( and the patient!) has a complete medication list.  Be VERY clear about what medications are new, what has been stopped and what medications remain.
  • Make sure you review pertinent tests and results.
  • Review which specialists saw the patient and what the follow up plans are.
  • Let the PCP know when they need to the newly discharged patient.

There is an interesting post from the Wall Street Journal on surgical resident’s hand offs, but I didn’t find it the most helpful for the PCP-ED-Hospitalist-Specialist circuit.  However, some of the comments are pretty entertaining. Here’s the link if you are interested: http://blogs.wsj.com/health/2008/10/20/how-doctors-can-avoid-perilous-patient-hand-offs/

 FYI: the Washington Redskins had the most fumbles in 2007, reflecting the fumbling going on in the nation’s capitol.

Love to hear your hand off tips! 

The Medicare No Pay, Never Ever List

The Centers for Medicare and Medicaid Services announced 10 hospital acquired conditions for which it will not reimburse.  The no pay rule has been in effect since October 1.  So, with out further ado: (drum roll):

  • “Stage III, IV pressure ulcers
  • Fall or trauma resulting in serious injury
  • Vascular catheter-associated infection
  • Catheter-associated urinary tract infection
  • Foreign object retained after surgery
  • Certain surgical site infections
  • Air embolism
  • Blood incompatibility
  • Certain manifestations of poor blood sugar control
  • Certain deep vein thromboses or pulmonary embolisms.”  (List from AMedNews.com Aug 25, 2008).
  • CMS began to implement the no pay rule October 1, 2008.  Physicians will still be reimbursed for their services, but hospitals will not be reimbursed for their portion of the care.   Now, I don’t know about you, but I agree  some of the events are absolutely “never-ever” events  (retained surgical object, blood incompatibility), but some of the other conditions are out right ridiculous.

    My colleagues and I have come up with some ideas on how to respond to this latest demonstration of government “efficiency.”  We have proposed “buttocks rounds”, where the wound RN examines every patient’s behind and charts presence/absence of pressure ulcers.  We thought it especially important to do this on those 35 year old youngsters we are obligated to admit for chest pain.  We also thought that perhaps we could have a “fanny cam” to take pictures, so our documentation would be impeccable.  We advocated noting that all patients had decubs at admission, but the hospital administration shot this one down.

    Our next suggestion was that every patient, no matter what, should have an admission urine analysis, to document presence/absence of infection.  There could be a little check-in kiosk where the patient signs in, hands in a credit card for the hefty co-pay, and pees in a cup.  The patients could even dip their own urine, and record it on their check in information to speed the process up and decrease labor costs.  Additionally, we thought surveillance ua’s would be helpful in all patients with urinary catheters, probably daily.  Got to nip that e. coli in the bud!  We also considered putting a mandatory quinolone on every order set for patients with catheters, but became concerned when we realized c. diff may soon be added to the no pay list.  It may be worth a try for now, though!  Too bad about the cost of all those extra ua’s.

    As to falls, I have little to offer on prevention of the noscomial hip fracture.  Our hospital uses bed alarms (frequently it requres a doctor’s order, though), and of course we can always get a sitter.  (However, all the hospitals where I work discourage sitters secondary to cost.)  Occasionally we try to get family members to stay with the sun downing patient,  but they rarely do.  Now that Granny is in someone else’s care, they will give some sage advice, like “Don’t use ativan, or haldol, or ambien or seroquel, because Granny gets really nuts with those.  And don’t restrain her either.  Bye.”  They then hurry to the car for their first meal out in months.  Who could blame them? 

    CMS is planning on expanding the no pay list to ambulatory settings, nursing homes and home health agencies in 2009. 

    I am always in favor of intelligent uses of government regulation, but someone missed the boat.  What do you say we make some fanny cam rounds at CMS?

    PookieMD Airlines: How aviation check lists apply to medicine

    I am married to an electrical engineer that loves to fly around in a small airplane.  Because I hang out with him, I’ve been forced to observe the intricacies of not crashing into other planes and landing safely.  I’ve learned a lot.

    Pilots have a check list for everything.  Plane manufacturers include an entire book of checklists for every contingency, from take off, to landing, to what to do if there is an emergency.  ( It is a BOOK, mind you!)  My husband straps the needed check list to his leg and goes through it every time we land or take off or preflight.  He actually LOOKS at the list, touches each instrument and taps on the applicable gauges.  It is not a passive process.  Hence my hubbie and I have logged over 1000 hours safely in the cockpit of our tiny plane.  (Don’t look at me.  I don’t know a dang thing about flying.  I just kiss the ground when we land.)

    Why do we physicians not utilize more check lists as we go through our day?  The medical profession has been (reasonably) stubborn on adapting algorithms and treatment pathways, arguing that each patient is different and no one algorithm can apply to every patient.  But from a patient safety stand point, I will side with the check list every time.  When a patient goes to the OR a check list is utilized, and when a patient is transported in one of the hospitals where I work, there is a “ticket to ride.”  Why don’t we have some simple checklists for ourselves, listing important but (sadly) forgettable to do items for each patient?  Now, some hospitals have an EMR that will generate order sets, but they are usually not as robust as they could be, and frequently only cover one disease state.  These order sets are good, but incomplete, and  lead to “drop offs” on treatment plans.  Hence the need for the check list.

    When one of the hospitals I work at transitioned to order entry, I had to develop a check list that I carried around with me, because going back and forth between multiple screens is onerous.  It included the following:

    • Order labs for next day (first screen)
    • Review current meds (screen #2)
    • order new meds (screen #3)
    • order radiology studies (screen #3)
    • make sure note is entered in the EMR (screen #4)
    • review labs (screen #5)
    • read other doctor’s notes (screens 6 and more, each note a different screen)
    • review radiology studies (screens 7 and 8, depending on if you actually looked at the image.)

    It’s quite easy to drop the details we internists live for.  Seems silly, but given it was a new EMR for me, I had to develop a system to make sure my work flow was preserved and important information and procedures were addressed.  Most of us used check lists as medical students, and then gave up the habit as we grew more comfortable with medicine.   You don’t have to have a check list for everything, but it’s helpful when you are encountering a different situation then usual, like the new EMR I described. 

    I encourage you to add to your history and physical check list the following things:

    • Prophylaxis: e.g. have you written for GI prophylaxis (if warranted) and DVT prophylaxis  (don’t forget that DVT is now one of the  medicare “no pays”)
    • “Treatment plan discussed with patient and family, and they are in agreement.”
    • Note the time spent with patient and coordinating care.  (A must, for billing.  Heck, have this tattooed on your hand if you can’t remember it!)
    • Pressure ulcer present/absent at _____________(location).  (I have a skin category in my physical exam and include the pressure eval here.  Pressure ulcers that develop during a hospital stay are another Medicare no-pay.  More on that in a later post.)

    One of my hospitalist colleagues uses the following check list at discharge, necessitated because the EMR we use makes us go between several screens and logins:

    • write discharge summary
    • write discharge orders
    • send note to PCP
    • set up follow up
    • write scripts

    Useful primary care check lists would be:

    • State of undress for each exam:  (female pap: the full Monty, male: off with the tighty whities for the prostate check, diabetics: off with their shoes and socks!)
    • Check list clipped to chart as to what screenings are done at what age, or in each room.
    • Check list on cabinet door detailing what items go in each cabinet.
    • Check list at discharge for assistant to review: does patient have scripts, referrals, test info, and know when to come back.
    • List of items your front desk staff needs to check at each check in (check address, insurance card, HIPPA).
    • List of items your assistant needs to check as they room the patient (chief complaint, allergies, meds etc.)

    When I wrote this post,  I considered making a “write post” check list, which would include looking for typos.  It seemed like a good idea, but I wuz too bzy so I didn’t have tim to go threw my list witch wud have reminded me to make sur I didn’t have no tipos.   

    We can learn a lot from the world of aviation.    Should we have a check list for Code Blue/COR-0?  Nah, we’re physicians, we know it all.  Besides, the guidelines will change in two years anyway.

    Flaps up!