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

It’s hiring season at my compnay, ExtraMD, a “local locums.”  My group of doctors has too much work to cover, so it’s time to add to the stable.  I finally realize that I need to have more doctors that I think I need.

But how to find good, caring doctors that want to enjoy medicine, life, and a balance in between? How to find physicians that put integity as a core value?  How to find physicians that do what they say they are going to do?

Here’s what I have tried so far, and accompanying results:

Craigslist.org: best response from this.  Two physicians interested, will be interviewing one on Friday.

Linkedin: no response

Sermo: no response

Bounty offered for referral: two responses, no interviews.

Mass emails to my friends and acquaintences: no responses.

On the docket for more recruiting: a post card mailing, advertisement on the Colorado Medical Society site, placing ad on medical job websites.  My best results have come from referrals from my friends, but that well seems to be dry.  Any thoughts on how you have successfully recruited the right doctor for your practice?

I was getting a massage yesterday, and it struck me how simple the payment system was.  I paid for a twenty minute chair massage, told the therapist “my shoulders really hurt,” and away we went.  He worked the knots out, and I gratefully sat there in quiet bliss, face smashed against a paper towel on the massage chair.  At the end I said thanks, and gave him a tip.  I didn’t stop as I stood up and say, “But you know, I really hurt in my low back. Can you work on that too?”

Instead, I put my money in the tip jar, and listened as he told me to drink lots of water.  What if doctors were paid that way? What if the patient paid for a certain amount of time, and when it was over, it was over?  If the patient wanted more time, she would have to pay for it.  For instance, if I had wanted him to work more on my shoulders, I would have forked over the cash. Also, I made sure I was ready to start and didn’t waste time chit chatting.  Imagine: the therapist asks: “Are there areas you want to focus on?” and I answer, “well, yesterday, I was playing in my tennis league, and was serving really hard, and then didn’t stretch afterwards, but instead went right to the beverage table, and had snacks–and they were really good, they had those wraps with the turkey and swiss, and ranch, and I really love them. And then I had a glass of wine, red, I think, and then some of those brownies…And so my shoulder hurt, because it started to rain, and I didn’t have my jacket and the car was too far away to make it work my effort and then–.” You get the point.

And if I had chattered on, he would have taken it out of my chair time.

What do you think? A new billing system in the works?

I’m on an efficiency tear, because my plate is so darn full lately.  I’m loving my EMR consultant gig as EPIC champion, but still do doctoring and run my small locums firm, ExtraMD.

So for my sake, as well as yours, here are some efficiency hacks I found:

1. Answer the phone. Sounds pitiful, but I looked at my phone as it was ringing and almost didn’t answer it because I knew it would be a tough call. I sucked it up, and got the difficult conversation done, and saved myself the call back and the inevitable phone tag.
2. Corollary to above rule: emails are not always the most efficient way to get things done.  In my mind, emails begat emails.  Email is great for yes/no questions, but down right ridiculous for extended conversations that need to take place by phone or in person.
3. Make a to do list the night before. Yes, I’ve said it before, but do it!
4. Each day, think, “If there is just one task I need to do today to make today successful, what would it be?” Then go do that one task.
5. Don’t go to meetings if you won’t add anything/you won’t get anything from the meeting.  It’s okay to say no.
6. Impose time limits on discussions.  I was at a meeting where there were 150 items to go through (not kidding here!) Finally I suggested the group limit it’s discussion to 5 minutes per item. If we couldn’t decide what to do after 5 minutes, we moved on.  We actually had a time keeper to keep us on track. It worked.
7. Do NOT multitask!!! Do not be distracted by shiny objects! Focus on one thing at a time!
8. Don’t mindlessly surf the Internet.  (Hey, I was looking for tips on efficiency when I was surfing!)
9. Be happy! No, I’m not suggesting eating brownies from the  local baked good marijuana store.  Happy people have more energy and make less mistakes.
10. Take a break when you are overwhelmed.  When you get so buried and frustrated, you make mistakes and slow down. So, paradoxically, taking a break is probably just the ticket.

Alright, send me your efficiency hacks–c’mon I need all the help I can get!

I received a request to sign the following Letter to the Editor that will appear in the Denver Post on Saturday, March 14 edition.

“Doctors feel the consequences of unavailable or unaffordable health insurance every day. Uninsured and under insured patients forgo needed care, turning treatable conditions into complex and expensive health care events. Many can’t get insurance due to pre-existing conditions or over-priced individual plans. Our fragmented health insurance system creates administrative burden for patients and doctors alike, but does little toward improving quality, communications, or overall health in America. Our patients are seeing double-digit insurance premium increases and sky-rocketing deductibles.  More and more they cannot afford to come to the doctor.

Delaying health insurance reform would unnecessarily perpetuate lack of access to health care, financial hardship, and suffering. We urge passage of federal health care reform legislation immediately and call for continued executive evaluation and creative legislation until all Americans have access to affordable quality health care.”

Would you sign this? If you want to sign, go to http://bit.ly/aY9IuW.

It was a busy night at my local hospital.  I spent a lot of time in the ED, and the pager was in status.  The hospital I was at is a large tertiary hospital, and receives transfers from small mountain clinics that send us stuff like chest pain (easy) and hypertensive urgency/renal failure/barfing patients (hard.)  We get patched in to the Tiny Mountain Clinic Doctor, who gives us the skinny, and then we banter a bit about treatments etc, and then the helpful “connect” ombudsman arranges transport.

All good, so far. Except when the mountain doc wants to talk to me right as I am transferring a crashing patient to the ICU.  The helpful connect ombudsman calls me, and tells me that the Tiny Mountain Clinic Doctor needs to talk to me.  “I’m really busy,” I say, “I’m moving a patient to the ICU.  Can I call you back in 10 minutes?”  The helpful ombudsman agrees.  (BTW, our conversation is recorded, and we have all been warned to be polite as the powers that be will slap our hands if we are not.)

I’m busily assessing my patient, trying to get the transfer orders done, when the pager goes off again, not 5 minutes later.  It’s the helpful connect ombudsman.  “Tiny Mountain Clinic Doctor needs to talk to you,” she says.  Needless to say, Tiny Mountain Clinic Doctor takes first priority, even though I already said I would call back after the fire I’m putting out is taken care of.  (After all, we are being tape recorded!)

Oh how impatient we are.  But sadly, oh how impatient I am as well!  Could I just have a minute to think?

In my gig as Dr. EMR, I went to visit a hospital where they are using a version of the EMR my hospital will be transitioning to. It’s an EMR I am familiar with, and I wanted to see how the docs were coping. Rumor had it that it was rough going, with admissions and discharges taking up huge amounts of time. I wanted to see for myself and get the truth. I think what we are told is frequently very different than what is reality.

So, here is my reality check on what was really going on:

Doctors were treating notes in the EMR like a blank sheet of paper: forget all the templates available, the macros, the short cuts. They were doing what they always did, and that was to create a note from scratch. Down the drain went the huge power of the EMR, replaced solely by the inefficiency of typing everything.

Physicians were (remarkably!) resistance to change: I was not there on a training mission, but every once in a while couldn’t help but ask—“have you considered doing it this way?” or “did you know you could do this?” while demonstrating a nifty short cut. Many of the physicians would say, “But this is the way I’ve always done it.” (Always being relative—they’ve only had the *$%# EMR for 9 months!)

Physicians not using available hardware: the hospital had gone to a large expense to purchase dual monitors so that notes could be up on one monitor, while the physician looked at reports/labs etc. on the other monitor and added to their note. Many physicians never bothered to explore the benefits of the dual monitor, which would have made the whole note creation process easier. This is likely a combination of lack of training and well known physician hubris.

Conclusion: training, training and more training is necessary when adopting an EMR, but teaching an old doc new tricks may be darn near impossible! Woof!

We’ve talked before about billing for phone visits.  Only a few insurance companies will actually reimburse for this, but there are benefits to keeping track of calls.  Here are the rules.

The basics:

• Telephone service applies ONLY to established patients that initiate the call.
• If the patient is seen with in 24 hours after the call, the telephone service code is NOT reported.
• If the call is about a previous E/M service (e.g. a previous visit) within the past 7 days or post op period the code can not be used, as the phone call is considered part of the previously reported E/M work.

Sounds pretty useless, right? Medicare does NOT reimburse for phone calls BUT will allow the physician to “consider” this in determining the level of the E/M code at the next visit. So, it does make good sense to document those calls, and consider them at the next visit.  FYI: telephone codes for physicians (99441-99431) and non-physician practitioners (98966-98968).

Thanks modernmedicine.com for the tips!

Tweenager Daughter has a new accessory–a bright red long arm cast, applied at her orthopedic surgeon’s office. The past three days have been full of compassionate people that have cheered up T.D. (Tweenager Daughter!) immensely, with a single small exception.

Her appointment with the surgeon was smack dab in the middle of a swing shift I was supposed to work . I called four of my partners and EVERYONE of them said they would cover my shift so I could go the appointment. It was just a matter of picking which one! Wow! One of them even called back to make sure I got the shift covered.  What a great group!

T.D. was apprehensive before the appointment, as we all were, because there was a concern that she may require surgery.  (Dodged that bullet!)  Instead the cast was to be applied.  It was applied by  a “crabby” (T.D.’s word) lady who told T.D. that there was no way she could have a green and red cast for Christmas–one color only. The cast was applied in cherry red.

Later that night we went to T.D.’s gym, where her team mates rushed up to her, hugged her, and exclaimed over her cast.  Her coaches came over, hugged her and me, and anxiously asked for the report.  The gym owner reminded T.D. that the holiday party was coming up, and not to miss it. They were all so glad to see T.D. that it warmed me and took away some of the sting of the wounded wing. 

Looking at all of this, I am reminded to be compassionate.  It’s hard at the end of the day to muster enthusiasm for applying a two color cast, but sometimes it is these simple acts that go a long way.  Just as the hugs, phone calls and cards from T.D.’s friends helped patch a hurting heart, so do the simple acts we do as physicians every day.  I will try to remember that as I admit the alcoholic that broke his hip falling off a bar stool, and the COPD patient for her 10th admission who won’t stop smoking. I will try to push myself, and am greatful for those that were so compassionate to me these last several days.

It’s time to make the next 6 month marketing plan for my company, ExtraMD.  ExtraMD, based in Denver, is  a group of doctors that do fill in work for family practice and internal medicine practices through out the Denver Metro area.  I am the president, and run the group.  My biggest job is finding work for the 6 doctors that comprise the group.  We call ourselves a “local locums”, and our goal is to provide reasonably priced fill in doctors, build long term relationships with clients, and help their practices grow.  We have had a lot of our clients for 4+ years, as they use our group over and over. It takes about 3 months to build a relationship such that a client books shifts with us, so I have to plan accordingly.

As you may recall, I made a marketing plan back in January to combat the recession. It was made to go through June, but actually went through July.  Following is the plan for the next 6 months. 

The Goal: 60 shifts per month.  (Last January my goal was 50 shifts per month, and we didn’t make it.  However, we did get up to 40/month, double our slowest month ever, in which there was only 20 shifts.)  By the way–this goal is a “stretch goal” –it will really push the limits for me as chief (and only!) marketer.

August: postcard to potential/current clients reminding them that we provide fill in physicians when the practice is extra busy or if  a physician is on vacation.  I already did this, and did something I haven’t done previously–I reused a post card that I had sent out in June.  It was the most successful postcard mailing I have ever done, so I used it again.  Mistake:  didn’t check post card stamp rates.  They went up since June, and I mailed a whole bunch with a $0.26 stamp rather than $0.28 stamp.  Arggh! Moral: always check stamp rates as they seem to be going up rapidly!

September: email to clients on collecting co-pays.  I will do this as a blog post and recycle it in to a mailing.  My client list doesn’t seem to coincide with my blog readers, so it’s okay to reuse that content.

October: press release.  I haven’t picked a topic for the release, so will have to be looking and open for ideas.  (ExtraMD can help your practice cover increased volume of flu patients?)  I will also ask the other doctors in the group to leave business cards with the practice managers they are working with and with other people who are interested in our company.

November: Thanksgiving cards.  My company and our doctors have a lot to be thankful for! We survived our slowest 1st quarter ever, and I would like to send a gift card with the Thanksgiving card to our clients.  I have traditionally sent coffee cards, but would like to do something more healthy and fun, like coupons for stuff from Gaiam.  (I love this company, and one of my good friends is an accountant there….Hmmm…can I use that connection?)

December: email to clients on preparing for the January doldrums–the time when patients aren’t coming in because of deductibles etc.

January: a free webinar on medical practice management?  (My good friend and controller of our company, Suzanne, would have to help out with this one.)

For more on stretch goals and celebrating failure, visit Celebrating Failure.  For more on marketing, check out the Duct Tape Marketing blog and book.

I’ll keep you posted!

There is a book out, called The Cost of Bad Behavior.  I have to admit I haven’t read it, and it is on my list.  However, I think we need to nip bad behavior in the bud, especially in our clinics and hospitals.

I was eating lunch in the doctor’s lounge when I heard a young doctor harassing his secretary via phone. He sounded so self centered and paternalistic that I wanted to smack him with a news paper like one would do with a naughty puppy. He was doing stuff like raising his voice, and using words I can’t use in this blog.

I understand that we get angry.  But talking civilly to each other and our office staff needs to be a requirement.  It’s just not okay to vent your spleen onto a hapless office worker, no matter who has caused your ire to rise.  Unfortunately, it seems that it is more and more acceptable to use swear words and disabuse others in the work place.  However, if we are trying to build a better practice, not using expletives, calming down, and keeping our traps shut might just do the trick.

So to that end, I offer up the swear word I use (don’t laugh!).  I started using this when my daughter was born, in an effort to clean up my then potty mouth.  It actually did the trick, and I swear much less frequently, and never at work.

So when you are really, really angry, you may say, “Oh Poopy Dogs!”

Let me know how that works for you.