Small World, Gordon

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Gordon: The article (which I'd read before) brought me to a series of FPM articles on solo practice. One of them was a May 2002 FPM letter to the editor by Howe commending you. I met Howe as the FP I did a clerkship with in 1988 which led me to go into family medicine. I met you in San Francisco at Lulu's. Small world! O'Gradypractice@... wrote:

I got this article from http://www.aafp.org/fpm/20020200/29goin.html . It is a very intrique reading.Going Solo: Making the LeapWhy one family physician left the security of salaried practice topursue ideal patient care completely on his own.Gordon , MD Twelve months ago, I did what some physicians might describe as theunthinkable: I left the security of a salaried position and entered thewild world of solo practice. I walked away from an established officethat had given me generous paychecks with benefits for seven years. Ithad staff members to take care of everything from payroll to billing togreeting patients, making it generally easy for me to come in and justbe a family doctor.Now, I do all of that work myself. My practice is literally solo (Ihave no

staff), so I get to sweat the small stuff: submit claims,answer the phone, check in patients, turn over the room, give shots andreview EOBs. (If you're wondering what an EOB is, you're just as far outof the loop as I was before I made the jump.)KEY POINTS:* Frustrated by current practice and convinced of a better way, theauthor left his salaried position and opened a solo practice with nostaff.* Because his overhead costs are extremely low, the author is able tosee fewer patients per day and create more meaningful interactions.* By offering unfettered access, the author finds that his patientstrust him more and actually call him less.Why did I do it? Why did I leave the security of employed practice,simultaneously taking on all of the office activities I knew nothingabout and had thankfully avoided for the past seven years? Put simply,the current reality of practice had become untenable and the trajectorylooked no

better. What finally tipped the scales was getting a taste forhow good practice could be * and figuring out that the transition was alot simpler than I had imagined.The sad realityNot long after I finished residency, I began to realize that medicalpractice wasn't the bundle of unfettered joy for which I had yearned.Yes, the pay was much better and the call more sane, but I began to beembarrassed by the monotonous frequency with which I started patientencounters with, "Sorry I've kept you waiting." I was chagrined when myopen-ended question, "What can I do for you today?" was met with, "I wassick last week but thought I might as well come in today since it's sohard to get an appointment."The issues that arose during my employed phase were hardly unique to myorganization. Across the country, health care systems were creating newpractices and purchasing old ones, and private practices were bandingtogether in local networks to

become larger systems. To manage thesepractices, the health care systems created administrative arms, whichwasted no time in developing numerous policies and procedures. Theypurchased billing systems to maximize their returns on physician workand began to hire or rent billing experts, JCAHO experts and CLIAexperts. Expensive T1 lines were installed to pipe information betweenthe practices and the central billing office, and couriers were hiredand supplied with vans to move materials and meeting minutes (ofcourse, meetings were established to discuss all of the new policiesand procedures).The only measure of success was 'revenue.' A good doctor, it seemed,was one with high visit volume.On top of all of this added expense and bureaucracy, the money wasn'tas good as it used to be. The insurers were working to restrain premiumincreases and did all they could to pay us less. In turn, we were calledupon to increase revenue via

increased throughput (i.e., "see morepatients"). Then, we were asked to increase scheduled time withpatients. Then, our compensation plan changed from a salary guaranteeto a percent of revenue (i.e., "you eat what you kill"). And then wegot back to another round of "see more patients." It seemed that all ofthe conversations in our office were about money. The only measure ofsuccess was "revenue." A good doctor, it seemed, was one with highvisit volume.LOOK FOR PART TWOThis article is first in a two-part series. Next month, Dr. willexpand on his strategies for successful practice, will answer commonlyasked questions (e.g., "How do you provide uninterrupted patient careand answer your own phone?") and will report on his success to date.Of course, this pure pursuit of revenue eventually cuts into the timewe need to build trusting relationships with our patients. In turn, welose the joy in our work and can begin to feel

that we are no longermaking meaningful contributions to our patients' lives but are merelygoing through the motions to receive our paycheck.The fear of ending up this way was probably the most important factormotivating me to make a change. While the finances and the absurdity ofcurrent practice operations were maddening, I could put up with thestench if I felt I was able to deliver excellent, personal care. But Icame to understand that this is not possible in the way we haveconfigured our current offices. Our system is so broken that we mustcompletely redesign it if we are to achieve the results we desire. (Formore information, see the Institute of Medicine reports in the readinglist.)In the summer of 1998, I heard Don Berwick, MD, MPH, president and CEOof the Institute for Healthcare Improvement, describe the practice ofthe future and an IHI initiative called the Idealized Design ofClinical Office Practice (IDCOP). (For

more information, see thereading list.) Berwick made the obvious but necessary point that healthcare is all about the interaction with the patient and that fundamentalredesign would be the means to this end.I had arrived at the inescapable conclusion: I would have to beindependently wealthy to open a new office.Accepting a part-time administrative position under Panzer, MD,chief quality officer at Strong Health, I had the opportunity toparticipate in the IDCOP project and learn new ways of delivering care,such as offering same-day appointments regardless of urgency, usingcontinuous flow processing so that I could see all patients on time andusing 21st century technology to achieve breakthroughs in all aspects ofpractice.This is where I was in October of 2000: intolerable current realitythat only promised to get worse with time versus a compelling visionfor the practice of the future. Plsek, a guru of change

management(www.directedcreativity.com), teaches that the willingness to make achange is based on the balance between the pain of the currentsituation and the pain of making the change. Finally, I had reached thetipping point. I was ready to do anything to move toward that vision.Opening an office * the wrong wayOne final stumbling block remained in my way on the road to solopractice. I feared the unknown * that is, the difficulty and expense ofopening an office myself. Was it really as hard as I imagined it to be?For no discernible reason, I had the impression that I would need aloan of $125,000 to open a new practice. With my current practice modein mind, I built a mountain of expectations and expenses. I would needsomeone to manage the clerical work: incoming phone calls, mail, faxes,supplies, co-pays, referrals, etc. I would need clinical support staffto room patients, take vitals, give shots, assist during

procedures,etc.My space requirements would need to accommodate the three exam rooms Iused when at peak efficiency, a front office, a nursing area, a waitingroom, bathrooms, a break room, a storeroom, etc. Then, of course, Iwould need all of the equipment.Next, I began to look at office spaces to get a feel for thesquare-footage costs ($16 to $25). With the room needs I had stipulatedabove, I thought I could combine some of the spaces and perhaps get awaywith 1,100 square feet, which would require renovation of an existingspace. In the end, I was looking at spending $60,000 before I spent adime on office furniture.I was able to build a Norman Rockwell practice with a 21st centuryinformation technology backbone.I then began researching salary and benefit costs for nurses andsecretaries. I called billing software vendors to begin reviewing theirproducts and was pleased to find that one highly respected local

billingoutfit had developed a linked electronic record. But for just thebilling component and a few computers, I was looking at $40,000 upfront, then a percent of revenue to pay for ongoing services.Then, I priced an answering service, cell phones, pagers, telephonesystems and business and malpractice insurance. I looked intoaccounting firms and practice marketing strategies (newspaperadvertisements, mailings, etc.).By this time I had arrived at the inescapable conclusion: I would haveto be independently wealthy to open a new office. How did anyone evergo into private practice? No wonder the private docs sold theirpractices in droves when the hospitals and health care systems cameknocking.What happens when you challenge assumptionsJust as I was about to put my hopes for a new practice into the handsof Lotto, I decided to question all of my assumptions. What was Itrying to achieve? I did not want to recreate a mini

version of mycurrent practice. I wanted something better, a practice where I hadtime to interact meaningfully with patients, explore shared decisionmaking, listen to patient stories and address all of the issues thatarise during visits. I wanted an office where prescription refillrequests, messages and forms were all so easy to fulfill thatlast-minute requests could be met with the honest answer, "Sure, noproblem, I can do that right now." I wanted a practice with superiordata collection capabilities to prove superb outcomes in patient care.I wanted a better balance between work and home and didn't want tospend so much time doing paperwork. In short, I wanted the idealpractice, for both my patients and myself.To create this, I had to focus on what was essential. Health care is atits core a very local, personal process. When we function at our peak,we are available to patients when they need us. We treat each

patientinteraction as if it is the only one. We translate our understanding ofthe latest medical knowledge to the individual. If this is what healthcare is really all about * not "number of exam rooms," "productivity"and "staffing ratios" * we can strip away all of the assumptions builtinto current practice.Suddenly, opening my practice became so much simpler. I had only threeobjectives:1. Eliminate barriers between the patient and the doctor. I would makemy phone numbers and e-mail address widely accessible, and I wouldcreate a practice Web site to answer simple questions about mypractice. For appointments, I would use open-access scheduling andwould always be able to offer appointments "today" regardless ofurgency (for more information, see the reading list). As the IDCOPproject has shown, when we reduce barriers to access, our patients gaintrust in our ability to provide timely care and they demand fewervisits. This

creates room in our schedules for more robust visits andallows us to manage a larger population of patients, if we choose to doso.To handle after-hours call, I would follow the advice I had heard timeand time again from those in solo practice: Taking your own call isless onerous than sharing call with others. Your own patients will bemore respectful of your time, and talking only to "your own" is mucheasier than trying to create an effective care plan with an unknownpatient.2. Make time for meaningful interaction. Meaningful interaction is thefoundation of excellent health care, but in many practices, physicianscan't afford to spend the time it takes to create these interactions.How could I? I entertained a radical thought: If I were the only staffmember in my office, I could dramatically reduce my overhead costs,meaning I could dramatically reduce the number of patients I had to seeper day in order to be profitable. This

would give me the time Irequired to create meaningful interactions with my patients.To do this, I would rent an exam room (it would double as my office)from an existing practice. I would answer the phone, make appointments,greet patients and provide all of the care. I would be fully in the loopof all that happens between my office and my patients. They would beasked only once, "What can we (I) do for you today?" They would get tospend nearly 100 percent of their visit time with me, their doctor (asopposed to 20 to 40 percent in most offices). And above all, I wouldhave time to ask open-ended questions, allow patients to speakuninterrupted and listen to patient stories; time to create the kind ofrewarding interaction that is so totally lacking in the mills we haveestablished in the name of increased productivity.--

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