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.

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.

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

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.

State CME Guidelines

State MD/DO CME Credits
Required
Term
(years)
AMA PRA
Category 1 Credit(s)TM
required
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.

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.

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.