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.

Advertisements

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.

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

flickr.com

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.

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!

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.

Scary.

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.

Scarier.

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.

Scariest.

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?