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.

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.

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.

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.

Great.

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?

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:

http://www.americanhealthsolution.org/assets/Uploads/healthcarereformproposal.pdf

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!