PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Imagine, you are the pilot of a 747, getting ready to land the plane at LAX (pilot speak for Los Angeles International Airport), your ear phones are strapped on, you are talking to the tower, verifying your landing instructions, going through the check list, lowering the landing gear, adjusting the fuel mixture, and just as you throttle back–

“Excuse me, captain, but the passenger in 12B really needs to go to the bathroom even though the no smoking sign is on.  Is that okay?” 

Pilots have the sterile cockpit–a situation in which, if the plane is below 10,000 feet, only conversation directly relevant to flying is allowed.  The rule was developed because take offs and landings are the most likely time a crash will occur, and take offs and landings occur below 10,000 feet. Simple enough, and it saves lives.

Physicians need a sterile cock pit.  I speak as a hospitalist, but I imagine many specialties would benefit as well.  What are mission critical times during my day? For admissions, I would say writing (or typing!) the H&P is the most critical time, followed by order entry (or order writing.)  For discharges I would say medical reconciliation is the most critical time.  For rounding, I would again say order making followed by the “plan” part of the SOAP note.

Wouldn’t it be nice if we could have a “cone of silence” or sterile cockpit in which we could think and perform these critical functions? Wouldn’t it be nice to have all pages delayed for a set amount of time (say, 20 minutes) until we are through with our critical tasks? (Does such a pager exist?) I’d still be willing to get Code Blue pages, but can’t the other stuff wait?  (Mr. Smith’s constipation for example.)  Nurses at my institution have a “no talk zone” around the pyxis to help decrease medical errors, so why are physicians any different than pilots and nurses?

They aren’t.  It’s a cultural issue.  Page early and often needs to be replaced with “page urgently when appropriate,” and an understanding that physicians need to be able to think uninterrupted to make good decisions and give good patient care.

I was at church this past Sunday, after a particularly harrowing week at the hospital, spent trying not to get frustrated at patients and families that can’t see reality, and who think that I am holding back some magic medicine that will cure their family member.  Now, I’m a positive person and can even be optimistic sometimes.  But I hate beating a nearly dead horse and thinking it will change in to Seabiscuit.

In the church bulletin I was struck by three prayer requests: one was a request for prayer for a woman diagnosed with stage 2 breast cancer who is now status post surgery,one for a patient in pain from a herniated disk, and the last for a patient that had a knee replacement.

“For God’s sake,” I though, wearing my hospital acquired cynicism like a suit of armor, “what the he** are they worrying about?  That’s all minor stuff.  I can’t believe they are so stressed out they put in a prayer request!”

But then something switched.  Maybe it was the music, or the sermon, or the communion wine, but I lost my cynical coat.  For those families, and the ones I met the past week, what they were going  through was huge, significant and scary.  It might not have felt that way to me, but to them, these were all huge crises, involving a loved one, and with unbelievable stress.  Sometimes, I (we–admit you do it too!) forget what it is like on the other side of the bed, when something really horrific is going on, and it all seems so bewildering and unfriendly and sterile, and most of all, uncaring.

I will try to better, to use the other perspective of the patient and family as well as my crisp, efficient doctor perspective.  I really do care, and I bet you do too.

God bless.

PS: I actually had the communion “grape juice.”

Readers who follow this blog probably know that my husband is a pilot, and that we fly around in his small plane.  He avidly follows up on plane crashes, near misses and other hazards of general aviation.  Along the way I have learned a lot about aviation that can be applied to medicine.  Hubby tore out an article from the June AOPA (Aircraft Owners and Pilots Association) magazine and insisted I read it.  It was titled, “The Aviation Safety Reporting Program.”

His point: physicians need an agency to which we can report “near misses.”  General Aviation has the Aviation Safety Reporting Program, which allows pilots to anonymously report flying “incidents.”  The pilot is then granted immunity from loss of pilot’s certificate provided the violation was inadvertent, not deliberate, and didn’t result in an accident.  The FAA investigates the incidents and looks for systems problems. After analysis, the FAA issues ‘alerts’ and guidelines in attempt to correct the problem.

Heath care would benefit. If physicians could report freely, with out penalty, the mishaps that occur through the day, and report them in a standardized fashion, much progress could be made.  Systems errors could be analyzed and corrected.  This would require lots of reporting to make a robust data base, but having an unbiased investigator and the “no penalty” aspect would encourage reporting.  From that data base much would be gleaned about recognizing and preventing mistakes that occur from systems errors.

We have learned a lot from aviation–read backs and checklists are great examples.  We should also learn how to meticulously analyze our own near misses and crashes so they don’t happen again.  We need an entity similar to the Aviation Safety Reporting Program.  Perhaps the “Medical Safety Reporting Program?”

For interest, check out the safety blog, which details  JFK Junior’s fatal crash in to the waters of Cape Cod.

The hospitalist groups I work for are both trying to cut costs as hospitals are clamping down on the payment to hospital owned groups. Both groups are stretched thin, and rely heavily on locums to fill the gaps. Here are some ideas on how hospitalist groups can save some mula as we continue to weather the economic storm. I admit some are ridiculous, but others should have happened long ago.

• Wash own coats. (I already take mine home because I don’t like the starch!)
• Print on white paper (for some reason the administrative staff prints our patient lists on blue paper-more expensive then recycled white!)
• Cut CME money-go ahead and give the time off, but reduce the amount for educational expense.
• Cheaper business cards-go cheap on the ones we give out to  patients.
• Cut excess staff. The two groups I work for have way too many administrative staff.
• Avoid locums staff-this may sound downright stupid coming from the owner of a locums staffing service, but here is my point: all my docs (including me) are local and more reasonably priced then the big companies. See if you can find physicians like me who fill in for less, live in your area and provide great patient care. (A little shameless self promotion,eh?)
• Buy cheaper pens.
• Cut down on computers. One office I work in has way too many computers for the EMR-the computers seldom get used to capacity.
• Consider ER hospitalists. Let me explain myself. Many of our admission are the so called “garbage” admissions-those patients that are admitted for social reasons, or because the ED is too busy to work them up fully. Admissions cost money. Why not have an ED Hospitalist that does the “borderline” or “garbage” admissions and tries to get those home that don’t belong in the hospital? This would cut back on physician staffing requirements, and heck, would even save health care dollars!
• No more free food. Sorry, don’t kill the messenger.
• Look for cheaper phone systems and pager systems.
• Up staff during day to take the 2 pm ED patient bolus. Evening and night time physician coverage is usually more expensive than day time coverage. Up staff the rounders during the day, with the expectation that with fewer patients to see rounders will also do 2 or 3 admits. This will help take care of the 2:00 pm patient bolus most hospitalists get from the ED. (There are usually two bolus times: 11:00 and 2:00 pm-with the 2 pm bolus being the biggie.)

I need to bleach my coat, so I gotta go.

My Tweenage Daughter and I went to her well child check up this past week, and watched her pediatrician’s office transition to an EMR.  We have been going to this group since her birth, and her old pediatrician was a personal friend.  We were switching to a female in the group because, well, she was female. Things commenced normally as my daughter was weighed and measured and peed in the cup.  (I didn’t have to hold the cup this year!)  No hint of an EMR as the MA wrote down her vitals and escorted her to the “tweenager” exam room.

Tweenage Daughter changed in to the too big shorts and top and  then we waited.  The new pediatrician came in, clutching a tablet PC.  The room was not set up for her to use the tablet, and I watched as she struggled to find out where she should put the tablet.  First she tried the exam table, but it was too high.  Then she tried the mayo stand, but it wasn’t right either.  She finally ended up with it on her knees, with her feet up on the foot rail at the bottom of the stool she was sitting on.

Our usual yearly check ups are chatty affairs, with Dr. M, our old doctor and I gossiping,  Tweenage Daughter chatting and the exam progressing amongst all of this.  This year there was no chit chat as New Doctor pointed and clicked at a template.   With a slight exclamation, she pushed a couple of buttons and produced the growth chart, at which point she happily shared it us as we ooohed and aahed appreciatively.

She barely glanced up as she asked my daughter how she was doing in school.  Tweenager-with-attitude answered that she was getting Ds and Fs.  (She’s an honor roll student.)  New Doctor barely looked up as she hunted for the macro for “Ds and Fs,” missing the motherly “stop the attitude” look to Smart Mouth Daughter.

Next we reviewed the medicines, as she clicked away, e-perscribing a new Epipen.  (She forgot to tell us that she sent in the script, but I asked the receptionist at the end.)  We reviewed how much activity Tweenager did and what she ate, and decided she would live another year.  With that, the exam concluded, and New Doctor left.  I am not sure if she ever smiled, as I didn’t see much of her face.  I do know, however, that computers don’t smile much, and definitely don’t appreciate tweenager humor.

Intuit thinks that medical practices are high risk for non-payment of credit card debt.  Following is my encounter with Intuit, in which I try to set up a merchant account so my company can accept credit cards from our clients–medical practices.

My company, ExtraMD, is a “local” locums–there are several physicians in our group, we live in the Denver area, and we fill in at medical practices through out the area.  Our business model is simple, but effective: we act as subcontractors to the practices that use us to fill in.  Practices email or call our trusty assistant with shift requests, we fill the shifts, and the practice gets invoiced, and ExtraMD gets paid.

Pretty simple, huh?  Well, not according to Intuit.  We are in the process of converting to a credit card model to make invoicing and payment easier.  We are asking our clients to let us invoice their credit cards.  They have all agreed, and I, as the president, was in charge of finding a merchant account that would be affordable.

I looked at several, and settled on Intuit, partly because it would mesh with QuickBooks, our accounting software.  I filled out the application, and waited.  And then waited some more.  They sent an email requesting more information.  I complied instantly, and waited.  And waited.  They emailed me again, saying they needed more information (which was actually included in the FIRST email I sent.)  This time I called, and reviewed the account with the nice Intuit customer service agent.  They would process my request, they promised.

Two weeks went by. Nothing, not a peep, no email, no phone call, zippo! 

I called back. “I’m sorry,” said Intuit lady, “but medical practices and medical practice staffing are just too high risk.  We are worried we won’t get paid, due to the risk.”

“What?!”  I asked.  “I’ve been in business for 5 years, and our time in AR is probably one of the shortest in the business world!”

“Well, you are a service industry, and medical staffing is too risky.”

I asked to speak to a supervisor, which she wouldn’t let me do.  I sputtered along for a few more sentences and then finally hung up.

The take home: Intuit considers medical practices high risk for non-payment, or late payment.  That’s you,  my friend–hard working physician and practice owner.  This is the cold reality–and so much for loosening up credit with bank bail outs! 

Needless to say, we won’t be using Intuit.  If you have a vendor for a merchant account that you recommend, please feel free to comment.  I’m still looking!

Just when you thought it couldn’t get worse, it just did.  I don’t know about you, but I went in to medicine to help people regain their health, and that vision  includes maintaining and increasing patients health and well being.  Unfortunately, Americans seem bent on eating, smoking and driving their way to chronic illness.  However, there is a movement afloat called “Health Coaching.”  What is a health coach?  Well, my intrepid reader, I went off to find out.

As far as I can tell, a health coach is someone, not necessarily a health professional, that will coach/mentor a client (not a patient) towards increased wellness.  Geez, I thought that was my job.  According to my research, Duke University offers some training in this and lists the following as an explanation of what a health coach does:

• Help people clarify their health goals, and implement and sustain behaviors, lifestyles, and attitudes that are conducive to optimal health.
• Guide people in their personal care and health-maintenance activities.
• Assist people in reducing the negative impact made on their lives by chronic conditions such as cardiovascular disease, cancer, and diabetes.

Hilarious.  Isn’t that the definition of what primary care is supposed to be about? But HOW on earth could you do that in 15 minutes?  Answer: You can’t.  And that is the crux of what is wrong with medicine.  We spent years learning about diseases process, pharmaceuticals, pathology and zebras, but we didn’t learn the basics of positive psychology, encouraging change and guiding patients towards optimal health.  Instead, this field will be taken over by ‘health coaches’ who have minimal training, little medical back ground, and no share in liability.

Here is what one be-a-health-coach website promotes:

1. …earn at least $121 per hour (with out having to leave your home).
2. how to find all the coaching clients you can handle.
3. How your life can take on new meaning as you begin making a HUGE difference in people’s lives and the Health Care industry in general.
4. …How you can immediately make money as a Professional Health Coach.

Now, I think we physicians SHOULD ALL BE HEALTH COACHES.  What I find so frustrating was that this is why I went in to medicine, and I can’t do it because I am constrained by the medical/legal/government/insurance bureaucracy that is today’s medicine.  Maybe I should forget that I am an MD, and focus on being a “Health Coach”.  I’d like to earn $121 per hour from home.  I think it would be invaluable to my patients to have me as a physician BE their health coach along with managing their medical problems.  Hmmm, do I smell “retainer medicine ”?

I can smugly say I have gotten all my check ups out of the way, the well woman, the dentist, the mammo, the eye appointment.  What about you?   But wait–what about the business?  Doesn’t your practice deserve a check up?

First: remember the PookieMD rule of business: you can’t see patients if you can’t keep the doors open!

Here are bench marks to apply to  your practice.  Go ahead and see how your practice does!  (Don’t worry,  it won’t hurt a bit!)

1. Your schedule is full.  Yes, it should be.  If it’s not, you MUST fill it.  Have your receptionist call and remind people of their appointments, and consider a fee if patients miss their appointments.
2. Your front desk collects 100% of co-pays.  Yup, ya’ gotta do it.  I know two internal medicine offices that are closing because they can’t meet ends meet.  Will you be next?
3. Your billing company is a bull dog.  Insurance companies are taking even longer to pay claims, and making doctors fight harder for what is owed to them.  Hire the best and you won’t look back.
4. You have a budget for the next year, and have a cash flow budget.  What the heck is that, you ask?  If you have to ask, you need it more.  Read a book, attend a webinar, get savvy!  Now, more than ever, primary care needs to know how the business of medicine is conducted.
5. You code appropriately.  Note, I said appropriately!  Get an audit of your coding, and get paid for the work you do.  You deserve it.
6. Your staff naturally looks for bargains, and you shop for supplies at the big ware houses, you turn down heat at night, and turn off all the electric appliances.  (See previous post on the TightMD Gazette.)
7. You know who your best and worst payors are.  You can up the ante and drop low paying payors in certain circumstances.  If we primary care docs are as busy as we say we are, we should be able to pick and chose some payors.  Check it out before you say it is not possible.

Now, score your practice:  for each item that you (honestly!) could say your practice met the bench mark on, give yourself a point.

Score:

6-7: What are you reading this for?  Go write your own post on managing a medical practice.

4-5: Time for some work.  Your practice can move up the scale towards financial security with some attention.

2-3: Your practice is in the ICU.  Call in the experts or call for bankruptcy.  Seriously, get help.

0-1.  CODE BLUE! Get help now before you lose your livelihood and everything you have worked so hard for!

Okay, you’ve made it through.  At least I didn’t recommend the colonoscopy!  Let me know how you scored, and what you will do to go further down the road of financial health.

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.

Photo: starpulse.com

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.