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This is why HMO contracts can be really

dangerous. One stated that I needed to accept 500 patients. When I protested,

they stated the contract is not negotiable. I stated, “So, what your saying is that I will need to accept more patients than

what I feel comfortable accepting, therefore compromising the care of all the

patients enrolled to my practice?” The representative said, “No, we

just don’t need any more providers in your area.” The other real

danger with HMOs is that they can dump 100 or more patients on you without you

even knowing. Tricare did this when I first opened

(which I was grateful for then, but if they did it now, I would not be able to

handle the extra load). That is why reform of the practice also has to include

reform of insurance contracts.

Closing to new patients in primary care

I'm horrified to read that Annie is forced to accept

new patients from all plans based on their contract terms. Staying always

open to new patients forever is a logical and practical impossibility. At

some point the practice is full (with allowance for attrition). New

patients joining a practice that is full creates an unsustainable imbalance

that results in too much work poorly performed, medical error, poor

satisfaction, and eventually burnout for both the patients and the clinician.

While we see examples all around us of unhappy patients & clinicians,

burnout and medical error, we also see examples of practices that seem to

remain open to new patients ad infinitum. How is this possible? It

is possible if the rate of new patient acquisition matches the rate of

attrition. This is a practice that has achieved equilibrium.

Remember that the ultimate goal of open access scheduling is to match supply

and demand. Recognize that in an open access scheduling system we have

eliminated the delay and the distinction between " urgent " and

" routine " and that this is very attractive to new

patients. A practice with open access scheduling must turn

away new patient demand that exceeds their supply. The only other way to

maintain the supply/demand match and open access scheduling is to continually

grow to meet the demand.

Continual growth is a SYSTEM property, not the property of an individual

clinician or clinical team. Systems can grow by adding

clinicians/teams. At some point, an individual team will reach saturation

and MUST deflect demand that exceeds their supply. The system helps by

creating other supply.

So how does a practice with waits and delays achieve equilibrium?

In a typical practice, the delay for " routine " appointments stretches

out into the future to the point where established patients are no longer

tolerant and leave the practice at a rate that matches the influx of new.

The length of the delay is the natural " break " point at which the

attrition matches the influx of new patients.

We know that this passive approach does not come free. It creates immense

work for the practice of copying charts for patients transferring out, the

extra work of establishing a relationship with a new patient, and the endless,

ultimately pointless and uncompensated work of triage where we sort demand

based on " urgency. "

The lack of continuity over time for patients transferring practices creates

the increased probability of poor preventive and chronic disease care

(part of the reason behind the dismal 56% achievement rate in the McGlynn study

(The Quality of Health Care Delivered to Adults in the United States. McGlynn

EA, Asch SM, J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. New England

Journal of Medicine, June 26, 2003.)).

Each clinician has a choice: actively or passively manage demand. The

passive choice drives up the cost of health care for all and erodes

satisfaction as well as outcomes.

The active choice is awkward, especially for physicians. We see ourselves

as healers. Our ranks are rich with conflict-avoiders who just want to

make people happy. When we continue to accept new patients beyond our

capacity, we create the platform of harm for all we serve.

My bias is obvious. I choose to deliver superb care to the number of

patients I can serve and no more. I have the luxury in Rochester NY of

not being forced to continually accept new patients beyond my capacity.

If presented such a contract, I would not sign. Annie doesn't have that

choice.

Why would an insurance company do this bad thing? I suspect the

motivation is based on the desire to maintain access for members and to have

broad panels of providers when the insurer goes to market with employers.

The problem with this motivation is that it is an illusion that results in harm.

Once aware of the illusion and harm, insurers must stop this behavior or risk

the accusation that greed for contracts supercedes good health care.

So what can Annie do when the contracts stipulate behavior that is counter to

the best interest of her patients? The insurance companies force bad

behavior and bad patient care, but knowing Annie and the care that she

delivers, I trust her to do the right thing. We as a group

can help her argue for the right thing and can help raise the awareness of these

insurance rules that seem to help but ultimately harm our patients.

Gordon

At 11:50 AM 1/17/2006, you wrote:

All my major

contracts include provisions that I am not allowed to close to new

members. If I want to “officially” close, they require that I

terminate the contract. Apparently that is the standard around here, but

all the plans ignore it if you close to all new patients, unless someone

fusses. I have had to take a few REALLY insistent new patients who called

their carriers to complain that I wouldn’t take them. Then I get a

call from the ins co where they point out that I am in violation of my contract

by closing to new patients, but “we understand that you are closed across

the board, so we’ll ignore it if you will go ahead and take Mr. SoAndSo

as he is making such a stink.”….yada yada yada Great way to

start out on a good therapeutic relationship with a new doc, huh?

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Posted
Posted

This is why HMO contracts can be really

dangerous. One stated that I needed to accept 500 patients. When I protested,

they stated the contract is not negotiable. I stated, “So, what your saying is that I will need to accept more patients than

what I feel comfortable accepting, therefore compromising the care of all the

patients enrolled to my practice?” The representative said, “No, we

just don’t need any more providers in your area.” The other real

danger with HMOs is that they can dump 100 or more patients on you without you

even knowing. Tricare did this when I first opened

(which I was grateful for then, but if they did it now, I would not be able to

handle the extra load). That is why reform of the practice also has to include

reform of insurance contracts.

Closing to new patients in primary care

I'm horrified to read that Annie is forced to accept

new patients from all plans based on their contract terms. Staying always

open to new patients forever is a logical and practical impossibility. At

some point the practice is full (with allowance for attrition). New

patients joining a practice that is full creates an unsustainable imbalance

that results in too much work poorly performed, medical error, poor

satisfaction, and eventually burnout for both the patients and the clinician.

While we see examples all around us of unhappy patients & clinicians,

burnout and medical error, we also see examples of practices that seem to

remain open to new patients ad infinitum. How is this possible? It

is possible if the rate of new patient acquisition matches the rate of

attrition. This is a practice that has achieved equilibrium.

Remember that the ultimate goal of open access scheduling is to match supply

and demand. Recognize that in an open access scheduling system we have

eliminated the delay and the distinction between " urgent " and

" routine " and that this is very attractive to new

patients. A practice with open access scheduling must turn

away new patient demand that exceeds their supply. The only other way to

maintain the supply/demand match and open access scheduling is to continually

grow to meet the demand.

Continual growth is a SYSTEM property, not the property of an individual

clinician or clinical team. Systems can grow by adding

clinicians/teams. At some point, an individual team will reach saturation

and MUST deflect demand that exceeds their supply. The system helps by

creating other supply.

So how does a practice with waits and delays achieve equilibrium?

In a typical practice, the delay for " routine " appointments stretches

out into the future to the point where established patients are no longer

tolerant and leave the practice at a rate that matches the influx of new.

The length of the delay is the natural " break " point at which the

attrition matches the influx of new patients.

We know that this passive approach does not come free. It creates immense

work for the practice of copying charts for patients transferring out, the

extra work of establishing a relationship with a new patient, and the endless,

ultimately pointless and uncompensated work of triage where we sort demand

based on " urgency. "

The lack of continuity over time for patients transferring practices creates

the increased probability of poor preventive and chronic disease care

(part of the reason behind the dismal 56% achievement rate in the McGlynn study

(The Quality of Health Care Delivered to Adults in the United States. McGlynn

EA, Asch SM, J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. New England

Journal of Medicine, June 26, 2003.)).

Each clinician has a choice: actively or passively manage demand. The

passive choice drives up the cost of health care for all and erodes

satisfaction as well as outcomes.

The active choice is awkward, especially for physicians. We see ourselves

as healers. Our ranks are rich with conflict-avoiders who just want to

make people happy. When we continue to accept new patients beyond our

capacity, we create the platform of harm for all we serve.

My bias is obvious. I choose to deliver superb care to the number of

patients I can serve and no more. I have the luxury in Rochester NY of

not being forced to continually accept new patients beyond my capacity.

If presented such a contract, I would not sign. Annie doesn't have that

choice.

Why would an insurance company do this bad thing? I suspect the

motivation is based on the desire to maintain access for members and to have

broad panels of providers when the insurer goes to market with employers.

The problem with this motivation is that it is an illusion that results in harm.

Once aware of the illusion and harm, insurers must stop this behavior or risk

the accusation that greed for contracts supercedes good health care.

So what can Annie do when the contracts stipulate behavior that is counter to

the best interest of her patients? The insurance companies force bad

behavior and bad patient care, but knowing Annie and the care that she

delivers, I trust her to do the right thing. We as a group

can help her argue for the right thing and can help raise the awareness of these

insurance rules that seem to help but ultimately harm our patients.

Gordon

At 11:50 AM 1/17/2006, you wrote:

All my major

contracts include provisions that I am not allowed to close to new

members. If I want to “officially” close, they require that I

terminate the contract. Apparently that is the standard around here, but

all the plans ignore it if you close to all new patients, unless someone

fusses. I have had to take a few REALLY insistent new patients who called

their carriers to complain that I wouldn’t take them. Then I get a

call from the ins co where they point out that I am in violation of my contract

by closing to new patients, but “we understand that you are closed across

the board, so we’ll ignore it if you will go ahead and take Mr. SoAndSo

as he is making such a stink.”….yada yada yada Great way to

start out on a good therapeutic relationship with a new doc, huh?

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Posted
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Annie-

I also had most of my contracts stipulate a set number of patients and that I

must close to all plans if I closed. I recently was completely overwhelmed by

demand and my open access started to slip.

My solution was to tell new patient callers that I was " not scheduling new

patient appointments at this time. " I would tell them to call again in about 2

months if they still wanted an appointment. (This was actually a shorter wait

than the other local family practices for a new patient appointment!)I used

this line for about a month. I have since worked down my back log and am once

again offerring open access.

An interesting twist in my patient population is that it is quite seasonal

with my Medicare population. My older patients summer here and winter in

warmer places, so my summer demand is full of my sicker patients that require

more frequent follow up, but this particular demand evaporates in the winter

months.

I have been open since June 05 and my active patient charts are just shy of

800.

, M.D.

Durango, CO

On Wed, 18 Jan 2006 17:39:24 -0500

" Annie Skaggs " wrote:

> Hi Gordon,

> Thanks for your sympathy and support. I agree that the contract terms

> are not what I would prefer, but the good news is that they generally

> don't enforce it. I have been " closed to new patients " for most of the

> past year, except for the (thankfully very few) times when a provider

> rep called because one of their members made a big stink. It appears

> that they all have sort of a " gentleman's agreement " that if I don't

> selectively shut out any one plan, they will all let me " stay closed "

> for the most part. If it ever gets to the point that they start force

> feeding me beyond my capacity, THEN I will drop the worst paying plan

> entirely, even though I will hate to " abandon " those patients. So far,

> with a panel hovering around 900, my open access is still intact with

> only occasional need to schedule past 6;30pm to get everybody in. At

> the moment, the " leaking in " seems to about match the " leaking out " ,

> even with me taking a few pushed in from insurance offices. I also

> continue to accept anyone that another doctor in the community calls and

> asks me to take, but the doctor has to call me personally; I don't take

> cold calls from people off the street, even if they say " Dr Soandso said

> I should call you.

>

> I'm glad that you pounded this message into my head early on, because

> control of growth is absolutely essential to sanity, and because no one

> else is telling that message. At times it has been hard to look at a

> schedule with nothing on it after tomorrow and not lose faith. Had you

> not convinced me that a small panel CAN be enough to support a practice,

> I might have caved to all the prevailing conventional wisdom and loaded

> up my panel beyond what I can manage. As it is, I have wiggle room and

> could grow some, but I don't have to AND I don't have to struggle with

> trying to carry more than I can bear.

>

> Thanks for all you do to further the cause,

> Annie

>

> Closing to new patients in primary care

>

> I'm horrified to read that Annie is forced to accept new patients from

> all plans based on their contract terms. Staying always open to new

> patients forever is a logical and practical impossibility. At some

> point the practice is full (with allowance for attrition). New

> patients joining a practice that is full creates an unsustainable

> imbalance that results in too much work poorly performed, medical error,

> poor satisfaction, and eventually burnout for both the patients and the

> clinician......

>

>

> ...My bias is obvious. I choose to deliver superb care to the number

> of patients I can serve and no more. I have the luxury in Rochester NY

> of not being forced to continually accept new patients beyond my

> capacity. If presented such a contract, I would not sign. Annie

> doesn't have that choice.

>

> Why would an insurance company do this bad thing? I suspect the

> motivation is based on the desire to maintain access for members and to

> have broad panels of providers when the insurer goes to market with

> employers. The problem with this motivation is that it is an illusion

> that results in harm. Once aware of the illusion and harm, insurers

> must stop this behavior or risk the accusation that greed for contracts

> supercedes good health care.

>

> So what can Annie do when the contracts stipulate behavior that is

> counter to the best interest of her patients? The insurance companies

> force bad behavior and bad patient care, but knowing Annie and the care

> that she delivers, I trust her to do the right thing. We as a group

> can help her argue for the right thing and can help raise the awareness

> of these insurance rules that seem to help but ultimately harm our

> patients.

> Gordon

> At 11:50 AM 1/17/2006, you wrote:

>

>

> All my major contracts include provisions that I am not allowed to close

> to new members. If I want to " officially " close, they require that I

> terminate the contract. Apparently that is the standard around here,

> but all the plans ignore it if you close to all new patients, unless

> someone fusses. I have had to take a few REALLY insistent new patients

> who called their carriers to complain that I wouldn't take them. Then I

> get a call from the ins co where they point out that I am in violation

> of my contract by closing to new patients, but " we understand that you

> are closed across the board, so we'll ignore it if you will go ahead and

> take Mr. SoAndSo as he is making such a stink. " ..yada yada yada Great

> way to start out on a good therapeutic relationship with a new doc, huh?

>

>

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Great advice ;

thanks. You mean it’s not all “ski

in bikini” weather in Colorado? Your “snowbird”

demographics actually sound good, with fewer folks around during

cold/flu season. Not enough of my

folks fly south, so it can get pretty busy here about now. Thank goodness today was warm and sunny

and demand was light so I was able to do my tax stuff for the last payroll tax

period of 2005.

I have always tried to

treat my new patients just like established patients as far as same day

scheduling, but I like your idea. My

way means that if I am “taking new patients”, I get 4 or 5 per day

for about 3 days, then close again before I pull out every last hair on my

head. I think I will just say “one

per day” and let the wait act as a break on inflow. That will probably not raise red flags

with the insurers, because as you point out, it is still a shorter wait than

what is offered anywhere else in town.

Keep up the good fight!

Annie

Annie,

I also had most of my contracts stipulate a set number

of patients and that I

must close to all plans if I closed. I recently was completely

overwhelmed by

demand and my open access started to slip.

My solution was to tell new patient callers that I

was " not scheduling new

patient appointments at this time. " I would

tell them to call again in about 2

months if they still wanted an appointment. (This

was actually a shorter wait

than the other local family practices for a new

patient appointment!)I used

this line for about a month. I have since

worked down my back log and am once

again offerring open access.

An interesting twist in my patient population is

that it is quite seasonal

with my Medicare population. My older

patients summer here and winter in

warmer places, so my summer demand is full of my

sicker patients that require

more frequent follow up, but this particular

demand evaporates in the winter

months.

I have been open since June 05 and my active

patient charts are just shy of

800.

, M.D.

Durango, CO

On Wed, 18 Jan 2006 17:39:24 -0500

" Annie Skaggs "

wrote:

> Hi Gordon,

> Thanks for your sympathy and support. I

agree that the contract terms

> are not what I would prefer, but the good

news is that they generally

> don't enforce it. I have been

" closed to new patients " for most of the

> past year, except for the (thankfully

very few) times when a provider

> rep called because one of their members made

a big stink. It appears

> that they all have sort of a

" gentleman's agreement " that if I don't

> selectively shut out any one plan, they will

all let me " stay closed "

> for the most part. If it ever gets to

the point that they start force

> feeding me beyond my capacity, THEN I will

drop the worst paying plan

> entirely, even though I will hate to

" abandon " those patients. So far,

> with a panel hovering around 900, my open

access is still intact with

> only occasional need to schedule past

6;30pm to get everybody in. At

> the moment, the " leaking in " seems

to about match the " leaking out " ,

> even with me taking a few pushed in from

insurance offices. I also

> continue to accept anyone that another doctor

in the community calls and

> asks me to take, but the doctor has to call

me personally; I don't take

> cold calls from people off the street, even

if they say " Dr Soandso said

> I should call you.

>

> I'm glad that you pounded this message into

my head early on, because

> control of growth is absolutely essential to

sanity, and because no one

> else is telling that message. At times

it has been hard to look at a

> schedule with nothing on it after tomorrow

and not lose faith. Had you

> not convinced me that a small panel CAN be enough

to support a practice,

> I might have caved to all the prevailing

conventional wisdom and loaded

> up my panel beyond what I can

manage. As it is, I have wiggle room and

> could grow some, but I don't have to AND I don't have to

struggle with

> trying to carry more than I can bear.

>

> Thanks for all you do to further the cause,

> Annie

>

> Closing to

new patients in primary care

>

> I'm horrified to read that Annie is forced to

accept new patients from

> all plans based on their contract

terms. Staying always open to new

> patients forever is a logical and practical

impossibility. At some

> point the practice is full (with allowance

for attrition). New

> patients joining a practice that is full creates

an unsustainable

> imbalance that results in too much work

poorly performed, medical error,

> poor satisfaction, and eventually burnout for

both the patients and the

> clinician......

>

>

> ...My bias is obvious. I choose to

deliver superb care to the number

> of patients I can serve and no more. I

have the luxury in Rochester NY

> of not being forced to continually accept new

patients beyond my

> capacity. If presented such a contract,

I would not sign. Annie

> doesn't have that choice.

>

> Why would an insurance company do this bad

thing? I suspect the

> motivation is based on the desire to maintain

access for members and to

> have broad panels of providers when the

insurer goes to market with

> employers. The problem with this

motivation is that it is an illusion

> that results in harm. Once aware of the

illusion and harm, insurers

> must stop this behavior or risk the

accusation that greed for contracts

> supercedes good health care.

>

> So what can Annie do when the contracts

stipulate behavior that is

> counter to the best interest of her

patients? The insurance companies

> force bad behavior and bad patient care, but

knowing Annie and the care

> that she delivers, I trust her to do the

right thing. We as a group

> can help her argue for the right thing and

can help raise the awareness

> of these insurance rules that seem to help

but ultimately harm our

> patients.

> Gordon

> At 11:50 AM 1/17/2006, you wrote:

>

>

> All my major contracts include provisions

that I am not allowed to close

> to new members. If I want to

" officially " close, they require that I

> terminate the contract. Apparently that

is the standard around here,

> but all the plans ignore it if you close to

all new patients, unless

> someone fusses. I have had to take a

few REALLY insistent new patients

> who called their carriers to complain that I

wouldn't take them. Then I

> get a call from the ins co where they point

out that I am in violation

> of my contract by closing to new patients,

but " we understand that you

> are closed across the board, so we'll ignore

it if you will go ahead and

> take Mr. SoAndSo as he is making such a

stink. " ..yada yada yada Great

> way to start out on a good therapeutic

relationship with a new doc, huh?

>

>

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Hi Annie and all,

I wanted to ask a few questions. This was my first week at my new office ( I had to resist putting that in all caps!). I was in practice for 4 years in the next suburb over, about 6 or 7 miles away. I had 1400 patients "registered" to me there. I sent letters announcing my move to all of those and requested they return an enclosed card if they wanted me to take their charts with me to my new location. I got about 375 cards back. Some are still trickling in. (cards were sent about 6 weeks ago). I brought all those charts with me. I suspect there are lots of people who will call when they are sick and want me to go get their record from the old practice. So anyway, my schedule for Monday is completely full and I have stretched it to abut 6:00pm to accommodate people and have a few open for sick people but interestingly yesterday not one person called to be seen that day. I enjoyed my day off (I have 5 kids and they were out of school) but of course I am now worrying about it. I actually always had tues and fri of at the old place as I job shared, I wonder if I have just trained all my patients. I am not advertising as I want to see where my demand is first. On those days you are scheduling into the evening, what time are you starting? Any other advice you can give?

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Congratulations on your

move! Sounds like you are off to a

great start. If you have 375 charts

already, I doubt you will need to advertise at all because if you give great

care, your existing patients will recruit for you.

You seem to be expressing some concern

about the variability involved in open access. I sympathize completely. Even now, occasionally I will have a day

with only a couple visits: Thursday this week I saw only one patient! But if I don’t get in a twist

about it, it all evens out. I used

the day to get all my 2005 tax stuff in order for the accountant. An unplanned “light day”

like that allows me to do things I used to schedule as “administrative”

and block out so appointments couldn’t

be put there. Doing it that way

risked disappointing patients who wanted to be seen then; this way, the

patients get to schedule when they want and I just go with the flow. The main key is don’t let the

total number of patients get too large, because eventually you will run out of “light

days” and have to start carving out time that patients want.

The fact that Monday is full would worry

me just a tiny bit, because for me, Monday is the day with the most “I’ve

been sick all weekend, I need to come in now” calls. I try to direct folks who are scheduling

in the future to days other than Monday once there are 3 or 4 on there. Of course sometimes it doesn’t

work, and I don’t sweat it if the schedule just goes on til 7 or 8 or 9 pm. That doesn’t happen often, and I

don’t have 5 kids waiting for me for dinner: my two are both in college

and never home anyway, and my husband also often works into the evening.

You asked when I start. That is probably a big key to why I don’t

care if I have to stay late. I am

45 years old, and measure the rest of my life in terms of “How many more

times do I get to ride my horse?”

Doing an excellent job in my profession is important to me; maintaining

good relationships with my family is important to me; participating in my

community (local, state, national and world) is important to me. But the NUMBER ONE thing in my personal life, my greatest pleasure, greatest joy and

down-right addiction is riding. I

gave up horses for 15 years to raise my kids when they were little, and to get

thru my education, but now I am making up for lost time. After I went into

private practice and had the freedom to make choices, I observed that if I left

riding until after work, it often didn’t happen, so the choice I make is

that I get up at 6 and go ride FIRST.

Whatever happens the rest of the day, I can live with because I ALREADY

DID THE MOST IMPORTANT THING that I need to do to take care of myself. So I don’t start in the office

until 11:00 most days. I also don’t

take lunch, so my typical time available to patients is 11-6. Tuesday is the exception, with me in the

office 8-12 and my office mate using the exam rooms from 1-5. So folks who really want an early a.m.

appt need to come on Tuesday. I’ve

been doing it this way for a little over a year now, and it is working out

fine. I always have the option of making

exceptions, of course, but don’t often have to.

Hints I would offer:

Post

“Office Hours by Appointment Only” in your waiting room and

practice info. My attorney says

that offers some modicum of protection against liability for not being there if

someone drops dead on the doorstep after they failed to call ahead. Drop-ins are extremely disruptive to a

no staff practice because there is no one else around to “entertain”

them, so I have worked very hard to get people trained to call. And by and large, they are good about

not being abusive and calling in the evening when during the day would do.

When

people say “What’s your latest appointment?” my answer is “That

depends. What’s going on?” Then we negotiate. If they are sick, of course I say, “I

will get you in today, but if you are that sick, what are you doing at work?” If the real issue is that they need a

physical or routine follow up, but don’t want to take off work, we look

into the future and pick a day that will turn into an “evening clinic”

day. I don’t advertise “evening

hours”, but if I ‘save up’ a few of these, then I can plan a

day that I don’t start until 1 or 2, see the acutes

in the afternoon and the routine stuff in the evening. Patients are grateful, but I am not

committing myself to late hours on a regular basis.

I

practice what I call “nidus scheduling”. Even a year into open access, about half

my demand is for appointments in the future. I have cut the time frame down so they

don’t feel like they have to call in January to get a physical in May,

but still, about half the time people don’t want to “come today”. So if Ms says “what do you

have next Thursday?” and there is nothing on that day yet, I say “What

time were you thinking?” She

gets anything she wants from 11:00 to 4:00. Then the next person

who asks for something next Thursday will get offered a spot adjacent to

hers. If Ms picked 3:00, but the second person wants 11:00, then I try to negotiate for something later if they insist on

that day, or a different day if they insist on the 11:00 time. The point is to

avoid one at 11:00 and one at 4:00 with nothing in between.

As with everything else I do, it doesn’t always work, but most of

the time I get a schedule I like and they patients get what they want too.

I

don’t offer regular weekend hours, but I do tell people “if you are

sick on Friday night, don’t wait til Monday to

call. I can probably see you on the

weekend if need be.”

I end up seeing people on Saturday or Sunday 2 -4 times per month (and I

charge the 99050 for those visits)

Good luck with your new practice!

Keep us posted on how it is going.

Annie

Re:

Closing to new patients in primary care

Hi

Annie and all,

I

wanted to ask a few questions. This was my first week at my new office ( I

had to resist putting that in all caps!). I was in practice for 4 years

in the next suburb over, about 6 or 7 miles away. I had 1400 patients

" registered " to me there. I sent letters announcing my move to all of

those and requested they return an enclosed card if they wanted me to take

their charts with me to my new location. I got about 375 cards back. Some

are still trickling in. (cards were sent about 6 weeks ago). I brought

all those charts with me. I suspect there are lots of people who will call

when they are sick and want me to go get their record from the old practice. So

anyway, my schedule for Monday is completely full and I have stretched it to

abut 6:00pm to accommodate people and have a few open for sick people but

interestingly yesterday not one person called to be seen that day. I enjoyed my

day off (I have 5 kids and they were out of school) but of course I am now worrying

about it. I actually always had tues and fri of at the old place as I job

shared, I wonder if I have just trained all my patients. I am not advertising

as I want to see where my demand is first. On those days you are

scheduling into the evening, what time are you starting? Any other advice

you can give?

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Posted
Posted

This gave me a lot to think about. I have

resisted do far the suggestion to do something for one’s self outside of

the office. Finishing residency at age 50, I will finish paying my med loans at

age 80 (I hope to still be practicing) With my children well past college graduation-

its too easy to concentrate on seeing patients and paying the bills.

T.

Ellsworth, MD

Family Medicine

sdale, AZ

Mobile

The information contained in this message is confidential and

intended solely for the use of the individual or entity named. If the reader of

this message is not the intended recipient or the employee or agent responsible

for delivering it to the intended recipient, you are hereby notified that any

dissemination, distribution, copying or unauthorized use of this communication

is strictly prohibited. If you have received this by error, please notify the

sender immediately.

From: [mailto: ] On Behalf Of Annie Skaggs

Sent: Saturday, January 21, 2006

8:52 AM

To:

Subject: RE:

Closing to new patients in primary care

Congratulations on your move! Sounds

like you are off to a great start. If you have 375 charts already, I

doubt you will need to advertise at all because if you give great care, your

existing patients will recruit for you.

You seem to be expressing some concern

about the variability involved in open access. I sympathize

completely. Even now, occasionally I will have a day with only a couple

visits: Thursday this week I saw only one patient! But if I don’t

get in a twist about it, it all evens out. I used the day to get all my

2005 tax stuff in order for the accountant. An unplanned “light

day” like that allows me to do things I used to schedule as

“administrative” and block out so appointments couldn’t be put there. Doing

it that way risked disappointing patients who wanted to be seen then; this way,

the patients get to schedule when they want and I just go with the flow.

The main key is don’t let the total number of patients get too large,

because eventually you will run out of “light days” and have to

start carving out time that patients want.

The fact that Monday is full would worry

me just a tiny bit, because for me, Monday is the day with the most

“I’ve been sick all weekend, I need to come in now”

calls. I try to direct folks who are scheduling in the future to days

other than Monday once there are 3 or 4 on there. Of course sometimes it

doesn’t work, and I don’t sweat it if the schedule just goes on til

7 or 8 or 9 pm. That

doesn’t happen often, and I don’t have 5 kids waiting for me for

dinner: my two are both in college and never home anyway, and my husband also

often works into the evening.

You asked when I start. That is

probably a big key to why I don’t care if I have to stay late. I am

45 years old, and measure the rest of my life in terms of “How many more

times do I get to ride my horse?” Doing an excellent job in my

profession is important to me; maintaining good relationships with my family is

important to me; participating in my community (local, state, national and

world) is important to me. But the NUMBER ONE

thing in my personal life, my greatest pleasure, greatest joy and down-right

addiction is riding. I gave up horses for 15 years to raise my kids when

they were little, and to get thru my education, but now I am making up for lost

time. After I went into private practice and had the freedom to make choices, I

observed that if I left riding until after work, it often didn’t happen,

so the choice I make is that I get up at 6 and go ride FIRST. Whatever

happens the rest of the day, I can live with because I ALREADY DID THE MOST

IMPORTANT THING that I need to do to take care of myself. So I

don’t start in the office until 11:00

most days. I also don’t take lunch, so my typical time available to

patients is 11-6. Tuesday is the exception, with me in the office 8-12

and my office mate using the exam rooms from 1-5. So folks who really

want an early a.m. appt need to come on Tuesday. I’ve been doing it

this way for a little over a year now, and it is working out fine. I

always have the option of making exceptions, of course, but don’t often

have to.

Hints I would offer:

Post

“Office Hours by Appointment Only” in your waiting room and

practice info. My attorney says that offers some modicum of protection

against liability for not being there if someone drops dead on the doorstep

after they failed to call ahead. Drop-ins are extremely disruptive to a

no staff practice because there is no one else around to

“entertain” them, so I have worked very hard to get people trained

to call. And by and large, they are good about not being abusive and

calling in the evening when during the day would do.

When

people say “What’s your latest appointment?” my answer is

“That depends. What’s going on?” Then we

negotiate. If they are sick, of course I say, “I will get you in

today, but if you are that sick, what are you doing at work?” If

the real issue is that they need a physical or routine follow up, but

don’t want to take off work, we look into the future and pick a day that

will turn into an “evening clinic” day. I don’t

advertise “evening hours”, but if I ‘save up’ a few of

these, then I can plan a day that I don’t start until 1 or 2, see the acutes

in the afternoon and the routine stuff in the evening. Patients are

grateful, but I am not committing myself to late hours on a regular basis.

I

practice what I call “nidus scheduling”. Even a year into

open access, about half my demand is for appointments in the future. I

have cut the time frame down so they don’t feel like they have to call in

January to get a physical in May, but still, about half the time people

don’t want to “come today”. So if Ms says

“what do you have next Thursday?” and there is nothing on that day

yet, I say “What time were you thinking?” She gets anything

she wants from 11:00 to 4:00. Then the next person who

asks for something next Thursday will get offered a spot adjacent to

hers. If Ms picked 3:00,

but the second person wants 11:00,

then I try to negotiate for something later if they insist on that day, or a

different day if they insist on the 11:00

time. The point is to avoid one at 11:00

and one at 4:00 with

nothing in between. As with everything else I do, it doesn’t always

work, but most of the time I get a schedule I like and they patients get what

they want too.

I

don’t offer regular weekend hours, but I do tell people “if you are

sick on Friday night, don’t wait til Monday to call. I can probably

see you on the weekend if need be.” I end up seeing

people on Saturday or Sunday 2 -4 times per month (and I charge the 99050 for

those visits)

Good luck with your new

practice! Keep us posted on how it is going.

Annie

Re:

Closing to new patients in primary care

Hi

Annie and all,

I

wanted to ask a few questions. This was my first week at my new office ( I

had to resist putting that in all caps!). I was in practice for 4 years

in the next suburb over, about 6 or 7 miles away. I had 1400 patients

" registered " to me there. I sent letters announcing my move to all of

those and requested they return an enclosed card if they wanted me to take

their charts with me to my new location. I got about 375 cards back. Some

are still trickling in. (cards were sent about 6 weeks ago). I brought

all those charts with me. I suspect there are lots of people who will call

when they are sick and want me to go get their record from the old practice. So

anyway, my schedule for Monday is completely full and I have stretched it to

abut 6:00pm to accommodate people and have a few open for sick people but

interestingly yesterday not one person called to be seen that day. I enjoyed my

day off (I have 5 kids and they were out of school) but of course I am now

worrying about it. I actually always had tues and fri of at the old place as I

job shared, I wonder if I have just trained all my patients. I am not

advertising as I want to see where my demand is first. On those

days you are scheduling into the evening, what time are you starting? Any

other advice you can give?

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Posted
Posted

Nice to hear your story - I finished residency at 45 and am not sure I'll ever pay off those loans. . .We've all spent at least 7 years being trained to be workaholics and obsess about medicine. It takes alot of work to learn how not to do it. This gave me a lot to think about. I have resisted do far the suggestion to do something for one’s self outside of the office. Finishing residency at age 50, I will finish paying my med loans at age 80 (I hope to still be practicing) With my children well past college graduation- its too easy to concentrate on seeing patients and paying the bills.   T. Ellsworth, MDFamily Medicinesdale, AZ Mobile  The information contained in this message is confidential and intended solely for the use of the individual or entity named. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution, copying or unauthorized use of this communication is strictly prohibited. If you have received this by error, please notify the sender immediately.From: [mailto: ] On Behalf Of Annie SkaggsSent: Saturday, January 21, 2006 8:52 AMTo: Subject: RE: Closing to new patients in primary care Congratulations on your move!  Sounds like you are off to a great start.  If you have 375 charts already, I doubt you will need to advertise at all because if you give great care, your existing patients will recruit for you. You seem to be expressing some concern about the variability involved in open access.  I sympathize completely.  Even now, occasionally I will have a day with only a couple visits: Thursday this week I saw only one patient!  But if I don’t get in a twist about it, it all evens out.  I used the day to get all my 2005 tax stuff in order for the accountant.  An unplanned “light day” like that allows me to do things I used to schedule as “administrative” and block out so appointments couldn’t be put there.  Doing it that way risked disappointing patients who wanted to be seen then; this way, the patients get to schedule when they want and I just go with the flow.  The main key is don’t let the total number of patients get too large, because eventually you will run out of “light days” and have to start carving out time that patients want. The fact that Monday is full would worry me just a tiny bit, because for me, Monday is the day with the most “I’ve been sick all weekend, I need to come in now” calls.  I try to direct folks who are scheduling in the future to days other than Monday once there are 3 or 4 on there.  Of course sometimes it doesn’t work, and I don’t sweat it if the schedule just goes on til 7 or 8 or 9 pm.  That doesn’t happen often, and I don’t have 5 kids waiting for me for dinner: my two are both in college and never home anyway, and my husband also often works into the evening. You asked when I start.  That is probably a big key to why I don’t care if I have to stay late.  I am 45 years old, and measure the rest of my life in terms of “How many more times do I get to ride my horse?”  Doing an excellent job in my profession is important to me; maintaining good relationships with my family is important to me; participating in my community (local, state, national and world) is important to me.  But the NUMBER  ONE thing in my personal life, my greatest pleasure, greatest joy and down-right addiction is riding.  I gave up horses for 15 years to raise my kids when they were little, and to get thru my education, but now I am making up for lost time. After I went into private practice and had the freedom to make choices, I observed that if I left riding until after work, it often didn’t happen, so the choice I make is that I get up at 6 and go ride FIRST.  Whatever happens the rest of the day, I can live with because I ALREADY DID THE MOST IMPORTANT THING that I need to do to take care of myself.  So I don’t start in the office until11:00 most days.  I also don’t take lunch, so my typical time available to patients is 11-6.  Tuesday is the exception, with me in the office 8-12 and my office mate using the exam rooms from 1-5.  So folks who really want an early a.m. appt need to come on Tuesday.  I’ve been doing it this way for a little over a year now, and it is working out fine.  I always have the option of making exceptions, of course, but don’t often have to. Hints I would offer:            Post “Office Hours by Appointment Only” in your waiting room and practice info.  My attorney says that offers some modicum of protection against liability for not being there if someone drops dead on the doorstep after they failed to call ahead.  Drop-ins are extremely disruptive to a no staff practice because there is no one else around to “entertain” them, so I have worked very hard to get people trained to call.  And by and large, they are good about not being abusive and calling in the evening when during the day would do.            When people say “What’s your latest appointment?” my answer is “That depends. What’s going on?”   Then we negotiate.  If they are sick, of course I say, “I will get you in today, but if you are that sick, what are you doing at work?”  If the real issue is that they need a physical or routine follow up, but don’t want to take off work, we look into the future and pick a day that will turn into an “evening clinic” day.  I don’t advertise “evening hours”, but if I ‘save up’ a few of these, then I can plan a day that I don’t start until 1 or 2, see the acutes in the afternoon and the routine stuff in the evening.  Patients are grateful, but I am not committing myself to late hours on a regular basis.            I practice what I call “nidus scheduling”.  Even a year into open access, about half my demand is for appointments in the future.  I have cut the time frame down so they don’t feel like they have to call in January to get a physical in May, but still, about half the time people don’t want to “come today”.  So if Ms says “what do you have next Thursday?” and there is nothing on that day yet, I say “What time were you thinking?”  She gets anything she wants from 11:00 to 4:00.  Then the next person who asks for something next Thursday will get offered a spot adjacent to hers.  If Ms picked 3:00, but the second person wants 11:00, then I try to negotiate for something later if they insist on that day, or a different day if they insist on the11:00 time.  The point is to avoid one at 11:00 and one at 4:00 with nothing in between.  As with everything else I do, it doesn’t always work, but most of the time I get a schedule I like and they patients get what they want too.            I don’t offer regular weekend hours, but I do tell people “if you are sick on Friday night, don’t wait til Monday to call.  I can probably see you on the weekend if need be.”    I end up seeing people on Saturday or Sunday 2 -4 times per month (and I charge the 99050 for those visits) Good  luck with your new practice!  Keep us posted on how it is going.Annie -----Original Message-----From: [mailto: ] On Behalf Of mkcl6@...Sent: Saturday, January 21, 2006 7:29 AMTo: Subject: Re: Closing to new patients in primary care Hi Annie and all,I wanted to ask a few questions. This was my first week at my new office ( I had to resist putting that in all caps!).  I was in practice for 4 years in the next suburb over, about 6 or 7 miles away.  I had 1400 patients "registered" to me there. I sent letters announcing my move to all of those and requested they return an enclosed card if they wanted me to take their charts with me to my new location.  I got about 375 cards back. Some are still trickling in. (cards were sent about 6 weeks ago).  I brought all those charts with me. I suspect there are lots of people who will call when they are sick and want me to go get their record from the old practice. So anyway, my schedule for Monday is completely full and I have stretched it to abut 6:00pm to accommodate people and have a few open for sick people but interestingly yesterday not one person called to be seen that day. I enjoyed my day off (I have 5 kids and they were out of school) but of course I am now worrying about it. I actually always had tues and fri of at the old place as I job shared, I wonder if I have just trained all my patients. I am not advertising as I want to see where my demand is first.   On those days you are scheduling into the evening, what time are you starting?  Any other advice you can give?   

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Posted
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Annie --

I think that was a great post. Thanks. Very helpful in so many ways both

for our work and our lives. Some points we all need to think about

regularly.

" Nidus " scheduling... I like that. I'll need to think about how to work

that into my scheduling especially if I'm using appointmentquest.

Tim

> Congratulations on your move! Sounds like you are off to a great start.

> If you have 375 charts already, I doubt you will need to advertise at

> all because if you give great care, your existing patients will recruit

> for you.

>

> You seem to be expressing some concern about the variability involved in

> open access. I sympathize completely. Even now, occasionally I will

> have a day with only a couple visits: Thursday this week I saw only one

> patient! But if I don't get in a twist about it, it all evens out. I

> used the day to get all my 2005 tax stuff in order for the accountant.

> An unplanned " light day " like that allows me to do things I used to

> schedule as " administrative " and block out so appointments couldn't be

> put there. Doing it that way risked disappointing patients who wanted

> to be seen then; this way, the patients get to schedule when they want

> and I just go with the flow. The main key is don't let the total number

> of patients get too large, because eventually you will run out of " light

> days " and have to start carving out time that patients want.

>

> The fact that Monday is full would worry me just a tiny bit, because for

> me, Monday is the day with the most " I've been sick all weekend, I need

> to come in now " calls. I try to direct folks who are scheduling in the

> future to days other than Monday once there are 3 or 4 on there. Of

> course sometimes it doesn't work, and I don't sweat it if the schedule

> just goes on til 7 or 8 or 9 pm. That doesn't happen often, and I don't

> have 5 kids waiting for me for dinner: my two are both in college and

> never home anyway, and my husband also often works into the evening.

>

> You asked when I start. That is probably a big key to why I don't care

> if I have to stay late. I am 45 years old, and measure the rest of my

> life in terms of " How many more times do I get to ride my horse? " Doing

> an excellent job in my profession is important to me; maintaining good

> relationships with my family is important to me; participating in my

> community (local, state, national and world) is important to me. But

> the NUMBER ONE thing in my personal life, my greatest pleasure,

> greatest joy and down-right addiction is riding. I gave up horses for

> 15 years to raise my kids when they were little, and to get thru my

> education, but now I am making up for lost time. After I went into

> private practice and had the freedom to make choices, I observed that if

> I left riding until after work, it often didn't happen, so the choice I

> make is that I get up at 6 and go ride FIRST. Whatever happens the rest

> of the day, I can live with because I ALREADY DID THE MOST IMPORTANT

> THING that I need to do to take care of myself. So I don't start in the

> office until 11:00 most days. I also don't take lunch, so my typical

> time available to patients is 11-6. Tuesday is the exception, with me

> in the office 8-12 and my office mate using the exam rooms from 1-5. So

> folks who really want an early a.m. appt need to come on Tuesday. I've

> been doing it this way for a little over a year now, and it is working

> out fine. I always have the option of making exceptions, of course, but

> don't often have to.

>

> Hints I would offer:

> Post " Office Hours by Appointment Only " in your waiting room

> and practice info. My attorney says that offers some modicum of

> protection against liability for not being there if someone drops dead

> on the doorstep after they failed to call ahead. Drop-ins are extremely

> disruptive to a no staff practice because there is no one else around to

> " entertain " them, so I have worked very hard to get people trained to

> call. And by and large, they are good about not being abusive and

> calling in the evening when during the day would do.

> When people say " What's your latest appointment? " my answer

> is " That depends. What's going on? " Then we negotiate. If they are

> sick, of course I say, " I will get you in today, but if you are that

> sick, what are you doing at work? " If the real issue is that they need

> a physical or routine follow up, but don't want to take off work, we

> look into the future and pick a day that will turn into an " evening

> clinic " day. I don't advertise " evening hours " , but if I 'save up' a

> few of these, then I can plan a day that I don't start until 1 or 2, see

> the acutes in the afternoon and the routine stuff in the evening.

> Patients are grateful, but I am not committing myself to late hours on a

> regular basis.

> I practice what I call " nidus scheduling " . Even a year into

> open access, about half my demand is for appointments in the future. I

> have cut the time frame down so they don't feel like they have to call

> in January to get a physical in May, but still, about half the time

> people don't want to " come today " . So if Ms says " what do you

> have next Thursday? " and there is nothing on that day yet, I say " What

> time were you thinking? " She gets anything she wants from 11:00 to

> 4:00. Then the next person who asks for something next Thursday will

> get offered a spot adjacent to hers. If Ms picked 3:00, but the

> second person wants 11:00, then I try to negotiate for something later

> if they insist on that day, or a different day if they insist on the

> 11:00 time. The point is to avoid one at 11:00 and one at 4:00 with

> nothing in between. As with everything else I do, it doesn't always

> work, but most of the time I get a schedule I like and they patients get

> what they want too.

> I don't offer regular weekend hours, but I do tell people

> " if you are sick on Friday night, don't wait til Monday to call. I can

> probably see you on the weekend if need be. " I end up seeing people

> on Saturday or Sunday 2 -4 times per month (and I charge the 99050 for

> those visits)

>

> Good luck with your new practice! Keep us posted on how it is going.

> Annie

>

> Re: Closing to new patients in primary

> care

>

> Hi Annie and all,

> I wanted to ask a few questions. This was my first week at my new office

> ( I had to resist putting that in all caps!). I was in practice for 4

> years in the next suburb over, about 6 or 7 miles away. I had 1400

> patients " registered " to me there. I sent letters announcing my move to

> all of those and requested they return an enclosed card if they wanted

> me to take their charts with me to my new location. I got about 375

> cards back. Some are still trickling in. (cards were sent about 6 weeks

> ago). I brought all those charts with me. I suspect there are lots of

> people who will call when they are sick and want me to go get their

> record from the old practice. So anyway, my schedule for Monday is

> completely full and I have stretched it to abut 6:00pm to accommodate

> people and have a few open for sick people but interestingly yesterday

> not one person called to be seen that day. I enjoyed my day off (I have

> 5 kids and they were out of school) but of course I am now worrying

> about it. I actually always had tues and fri of at the old place as I

> job shared, I wonder if I have just trained all my patients. I am not

> advertising as I want to see where my demand is first. On those days

> you are scheduling into the evening, what time are you starting? Any

> other advice you can give?

>

>

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Posted
Posted

Annie --

I think that was a great post. Thanks. Very helpful in so many ways both

for our work and our lives. Some points we all need to think about

regularly.

" Nidus " scheduling... I like that. I'll need to think about how to work

that into my scheduling especially if I'm using appointmentquest.

Tim

> Congratulations on your move! Sounds like you are off to a great start.

> If you have 375 charts already, I doubt you will need to advertise at

> all because if you give great care, your existing patients will recruit

> for you.

>

> You seem to be expressing some concern about the variability involved in

> open access. I sympathize completely. Even now, occasionally I will

> have a day with only a couple visits: Thursday this week I saw only one

> patient! But if I don't get in a twist about it, it all evens out. I

> used the day to get all my 2005 tax stuff in order for the accountant.

> An unplanned " light day " like that allows me to do things I used to

> schedule as " administrative " and block out so appointments couldn't be

> put there. Doing it that way risked disappointing patients who wanted

> to be seen then; this way, the patients get to schedule when they want

> and I just go with the flow. The main key is don't let the total number

> of patients get too large, because eventually you will run out of " light

> days " and have to start carving out time that patients want.

>

> The fact that Monday is full would worry me just a tiny bit, because for

> me, Monday is the day with the most " I've been sick all weekend, I need

> to come in now " calls. I try to direct folks who are scheduling in the

> future to days other than Monday once there are 3 or 4 on there. Of

> course sometimes it doesn't work, and I don't sweat it if the schedule

> just goes on til 7 or 8 or 9 pm. That doesn't happen often, and I don't

> have 5 kids waiting for me for dinner: my two are both in college and

> never home anyway, and my husband also often works into the evening.

>

> You asked when I start. That is probably a big key to why I don't care

> if I have to stay late. I am 45 years old, and measure the rest of my

> life in terms of " How many more times do I get to ride my horse? " Doing

> an excellent job in my profession is important to me; maintaining good

> relationships with my family is important to me; participating in my

> community (local, state, national and world) is important to me. But

> the NUMBER ONE thing in my personal life, my greatest pleasure,

> greatest joy and down-right addiction is riding. I gave up horses for

> 15 years to raise my kids when they were little, and to get thru my

> education, but now I am making up for lost time. After I went into

> private practice and had the freedom to make choices, I observed that if

> I left riding until after work, it often didn't happen, so the choice I

> make is that I get up at 6 and go ride FIRST. Whatever happens the rest

> of the day, I can live with because I ALREADY DID THE MOST IMPORTANT

> THING that I need to do to take care of myself. So I don't start in the

> office until 11:00 most days. I also don't take lunch, so my typical

> time available to patients is 11-6. Tuesday is the exception, with me

> in the office 8-12 and my office mate using the exam rooms from 1-5. So

> folks who really want an early a.m. appt need to come on Tuesday. I've

> been doing it this way for a little over a year now, and it is working

> out fine. I always have the option of making exceptions, of course, but

> don't often have to.

>

> Hints I would offer:

> Post " Office Hours by Appointment Only " in your waiting room

> and practice info. My attorney says that offers some modicum of

> protection against liability for not being there if someone drops dead

> on the doorstep after they failed to call ahead. Drop-ins are extremely

> disruptive to a no staff practice because there is no one else around to

> " entertain " them, so I have worked very hard to get people trained to

> call. And by and large, they are good about not being abusive and

> calling in the evening when during the day would do.

> When people say " What's your latest appointment? " my answer

> is " That depends. What's going on? " Then we negotiate. If they are

> sick, of course I say, " I will get you in today, but if you are that

> sick, what are you doing at work? " If the real issue is that they need

> a physical or routine follow up, but don't want to take off work, we

> look into the future and pick a day that will turn into an " evening

> clinic " day. I don't advertise " evening hours " , but if I 'save up' a

> few of these, then I can plan a day that I don't start until 1 or 2, see

> the acutes in the afternoon and the routine stuff in the evening.

> Patients are grateful, but I am not committing myself to late hours on a

> regular basis.

> I practice what I call " nidus scheduling " . Even a year into

> open access, about half my demand is for appointments in the future. I

> have cut the time frame down so they don't feel like they have to call

> in January to get a physical in May, but still, about half the time

> people don't want to " come today " . So if Ms says " what do you

> have next Thursday? " and there is nothing on that day yet, I say " What

> time were you thinking? " She gets anything she wants from 11:00 to

> 4:00. Then the next person who asks for something next Thursday will

> get offered a spot adjacent to hers. If Ms picked 3:00, but the

> second person wants 11:00, then I try to negotiate for something later

> if they insist on that day, or a different day if they insist on the

> 11:00 time. The point is to avoid one at 11:00 and one at 4:00 with

> nothing in between. As with everything else I do, it doesn't always

> work, but most of the time I get a schedule I like and they patients get

> what they want too.

> I don't offer regular weekend hours, but I do tell people

> " if you are sick on Friday night, don't wait til Monday to call. I can

> probably see you on the weekend if need be. " I end up seeing people

> on Saturday or Sunday 2 -4 times per month (and I charge the 99050 for

> those visits)

>

> Good luck with your new practice! Keep us posted on how it is going.

> Annie

>

> Re: Closing to new patients in primary

> care

>

> Hi Annie and all,

> I wanted to ask a few questions. This was my first week at my new office

> ( I had to resist putting that in all caps!). I was in practice for 4

> years in the next suburb over, about 6 or 7 miles away. I had 1400

> patients " registered " to me there. I sent letters announcing my move to

> all of those and requested they return an enclosed card if they wanted

> me to take their charts with me to my new location. I got about 375

> cards back. Some are still trickling in. (cards were sent about 6 weeks

> ago). I brought all those charts with me. I suspect there are lots of

> people who will call when they are sick and want me to go get their

> record from the old practice. So anyway, my schedule for Monday is

> completely full and I have stretched it to abut 6:00pm to accommodate

> people and have a few open for sick people but interestingly yesterday

> not one person called to be seen that day. I enjoyed my day off (I have

> 5 kids and they were out of school) but of course I am now worrying

> about it. I actually always had tues and fri of at the old place as I

> job shared, I wonder if I have just trained all my patients. I am not

> advertising as I want to see where my demand is first. On those days

> you are scheduling into the evening, what time are you starting? Any

> other advice you can give?

>

>

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Posted
Posted

Annie --

I think that was a great post. Thanks. Very helpful in so many ways both

for our work and our lives. Some points we all need to think about

regularly.

" Nidus " scheduling... I like that. I'll need to think about how to work

that into my scheduling especially if I'm using appointmentquest.

Tim

> Congratulations on your move! Sounds like you are off to a great start.

> If you have 375 charts already, I doubt you will need to advertise at

> all because if you give great care, your existing patients will recruit

> for you.

>

> You seem to be expressing some concern about the variability involved in

> open access. I sympathize completely. Even now, occasionally I will

> have a day with only a couple visits: Thursday this week I saw only one

> patient! But if I don't get in a twist about it, it all evens out. I

> used the day to get all my 2005 tax stuff in order for the accountant.

> An unplanned " light day " like that allows me to do things I used to

> schedule as " administrative " and block out so appointments couldn't be

> put there. Doing it that way risked disappointing patients who wanted

> to be seen then; this way, the patients get to schedule when they want

> and I just go with the flow. The main key is don't let the total number

> of patients get too large, because eventually you will run out of " light

> days " and have to start carving out time that patients want.

>

> The fact that Monday is full would worry me just a tiny bit, because for

> me, Monday is the day with the most " I've been sick all weekend, I need

> to come in now " calls. I try to direct folks who are scheduling in the

> future to days other than Monday once there are 3 or 4 on there. Of

> course sometimes it doesn't work, and I don't sweat it if the schedule

> just goes on til 7 or 8 or 9 pm. That doesn't happen often, and I don't

> have 5 kids waiting for me for dinner: my two are both in college and

> never home anyway, and my husband also often works into the evening.

>

> You asked when I start. That is probably a big key to why I don't care

> if I have to stay late. I am 45 years old, and measure the rest of my

> life in terms of " How many more times do I get to ride my horse? " Doing

> an excellent job in my profession is important to me; maintaining good

> relationships with my family is important to me; participating in my

> community (local, state, national and world) is important to me. But

> the NUMBER ONE thing in my personal life, my greatest pleasure,

> greatest joy and down-right addiction is riding. I gave up horses for

> 15 years to raise my kids when they were little, and to get thru my

> education, but now I am making up for lost time. After I went into

> private practice and had the freedom to make choices, I observed that if

> I left riding until after work, it often didn't happen, so the choice I

> make is that I get up at 6 and go ride FIRST. Whatever happens the rest

> of the day, I can live with because I ALREADY DID THE MOST IMPORTANT

> THING that I need to do to take care of myself. So I don't start in the

> office until 11:00 most days. I also don't take lunch, so my typical

> time available to patients is 11-6. Tuesday is the exception, with me

> in the office 8-12 and my office mate using the exam rooms from 1-5. So

> folks who really want an early a.m. appt need to come on Tuesday. I've

> been doing it this way for a little over a year now, and it is working

> out fine. I always have the option of making exceptions, of course, but

> don't often have to.

>

> Hints I would offer:

> Post " Office Hours by Appointment Only " in your waiting room

> and practice info. My attorney says that offers some modicum of

> protection against liability for not being there if someone drops dead

> on the doorstep after they failed to call ahead. Drop-ins are extremely

> disruptive to a no staff practice because there is no one else around to

> " entertain " them, so I have worked very hard to get people trained to

> call. And by and large, they are good about not being abusive and

> calling in the evening when during the day would do.

> When people say " What's your latest appointment? " my answer

> is " That depends. What's going on? " Then we negotiate. If they are

> sick, of course I say, " I will get you in today, but if you are that

> sick, what are you doing at work? " If the real issue is that they need

> a physical or routine follow up, but don't want to take off work, we

> look into the future and pick a day that will turn into an " evening

> clinic " day. I don't advertise " evening hours " , but if I 'save up' a

> few of these, then I can plan a day that I don't start until 1 or 2, see

> the acutes in the afternoon and the routine stuff in the evening.

> Patients are grateful, but I am not committing myself to late hours on a

> regular basis.

> I practice what I call " nidus scheduling " . Even a year into

> open access, about half my demand is for appointments in the future. I

> have cut the time frame down so they don't feel like they have to call

> in January to get a physical in May, but still, about half the time

> people don't want to " come today " . So if Ms says " what do you

> have next Thursday? " and there is nothing on that day yet, I say " What

> time were you thinking? " She gets anything she wants from 11:00 to

> 4:00. Then the next person who asks for something next Thursday will

> get offered a spot adjacent to hers. If Ms picked 3:00, but the

> second person wants 11:00, then I try to negotiate for something later

> if they insist on that day, or a different day if they insist on the

> 11:00 time. The point is to avoid one at 11:00 and one at 4:00 with

> nothing in between. As with everything else I do, it doesn't always

> work, but most of the time I get a schedule I like and they patients get

> what they want too.

> I don't offer regular weekend hours, but I do tell people

> " if you are sick on Friday night, don't wait til Monday to call. I can

> probably see you on the weekend if need be. " I end up seeing people

> on Saturday or Sunday 2 -4 times per month (and I charge the 99050 for

> those visits)

>

> Good luck with your new practice! Keep us posted on how it is going.

> Annie

>

> Re: Closing to new patients in primary

> care

>

> Hi Annie and all,

> I wanted to ask a few questions. This was my first week at my new office

> ( I had to resist putting that in all caps!). I was in practice for 4

> years in the next suburb over, about 6 or 7 miles away. I had 1400

> patients " registered " to me there. I sent letters announcing my move to

> all of those and requested they return an enclosed card if they wanted

> me to take their charts with me to my new location. I got about 375

> cards back. Some are still trickling in. (cards were sent about 6 weeks

> ago). I brought all those charts with me. I suspect there are lots of

> people who will call when they are sick and want me to go get their

> record from the old practice. So anyway, my schedule for Monday is

> completely full and I have stretched it to abut 6:00pm to accommodate

> people and have a few open for sick people but interestingly yesterday

> not one person called to be seen that day. I enjoyed my day off (I have

> 5 kids and they were out of school) but of course I am now worrying

> about it. I actually always had tues and fri of at the old place as I

> job shared, I wonder if I have just trained all my patients. I am not

> advertising as I want to see where my demand is first. On those days

> you are scheduling into the evening, what time are you starting? Any

> other advice you can give?

>

>

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Posted
Posted

From Joanne, the old MD/DVM in Drain, Oregon: Think I've got you beat...I finished my residency at age 59. I laughed when the Feds insisted at my loan consolidation that it be a 30 year pay off, and said to myself that it was just as well that it is an insured loan; if I die first the kids won't have to pay it off. I was the oldest person at my residency, including the teachers. Now, my Mom retired at age 65 and wrote three books about geneology and family before her osteoprosis specialist MD put her on replacement estrogen at age 84 and she started getting ministrokes prior to dying at 88. Her aunts and grandma lived well into their 90s and 100s, living on their own and thinking pretty good. Now we all have about two lifetimes of work we could do compared to the people a hundred years ago, but it helps to keep on thinking about new things like

how to rebuild the health care system, one village at a time. I could go on and on about how residency and medical training work to insulate ourselves from our patients and our own psyche, but that is another story. Just learn to pay attention to the good things about your life, and think of the loan repayment as no more than it would cost to buy a summer home and is a much better investment than that would be. Joanne Guinn wrote: Nice to hear your story - I finished residency at 45 and am not sure I'll ever pay off those loans. . . We've all spent at least 7 years being trained to be workaholics and obsess about medicine. It takes alot of work to learn how not to do it. This gave me a lot to think about. I have resisted do far the suggestion to do something for one’s self outside of the office. Finishing residency at age 50, I will finish paying my med loans at age 80 (I hope to still be practicing) With my children well past college graduation- its too easy to concentrate on seeing patients and paying the bills. T. Ellsworth, MDFamily Medicinesdale, AZ Mobile The information contained in this message is confidential

and intended solely for the use of the individual or entity named. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution, copying or unauthorized use of this communication is strictly prohibited. If you have received this by error, please notify the sender immediately. From: [mailto: ] On Behalf Of Annie SkaggsSent: Saturday, January 21, 2006 8:52 AMTo: Subject: RE: Closing to new

patients in primary care Congratulations on your move! Sounds like you are off to a great start. If you have 375 charts already, I doubt you will need to advertise at all because if you give great care, your existing patients will recruit for you. You seem to be expressing some concern about the variability involved in open access. I sympathize completely. Even now, occasionally I will have a day with only a couple visits: Thursday this week I saw only one patient! But if I don’t get in a twist about it, it all evens out. I used the day to get all my 2005 tax stuff in order for the accountant. An unplanned “light day” like that allows me to do things I used

to schedule as “administrative” and block out so appointments couldn’t be put there. Doing it that way risked disappointing patients who wanted to be seen then; this way, the patients get to schedule when they want and I just go with the flow. The main key is don’t let the total number of patients get too large, because eventually you will run out of “light days” and have to start carving out time that patients want. The fact that Monday is full would worry me just a tiny bit, because for me, Monday is the day with the most “I’ve been sick all weekend, I need to come in now” calls. I try to direct folks who are scheduling in the future to days other than Monday once there are 3 or 4 on there. Of course sometimes it doesn’t work, and I don’t sweat it if the schedule just goes on til 7 or 8 or 9 pm. That doesn’t happen often, and I don’t have 5 kids waiting for me for dinner: my two are both in college and never home anyway, and my husband also often works into the evening. You asked when I start. That is probably a big key to why I don’t care if I have to stay late. I am 45 years old, and measure the rest of my life in terms of “How many more times do I get to ride my horse?” Doing an excellent job in my profession is important to me; maintaining good relationships with my family is important to me; participating in my community (local, state, national and world) is important to me. But the NUMBER ONE thing in my personal life, my greatest pleasure, greatest joy and down-right addiction is riding. I gave up horses for 15 years to raise my kids when they were little, and to get thru my education, but now I am making up for lost time. After I went into

private practice and had the freedom to make choices, I observed that if I left riding until after work, it often didn’t happen, so the choice I make is that I get up at 6 and go ride FIRST. Whatever happens the rest of the day, I can live with because I ALREADY DID THE MOST IMPORTANT THING that I need to do to take care of myself. So I don’t start in the office until11:00 most days. I also don’t take lunch, so my typical time available to patients is 11-6. Tuesday is the exception, with me in the office 8-12 and my office mate using the exam rooms from 1-5. So folks who really want an early a.m. appt need to come on Tuesday. I’ve been doing it this way for a little over a year now, and it is

working out fine. I always have the option of making exceptions, of course, but don’t often have to. Hints I would offer: Post “Office Hours by Appointment Only” in your waiting room and practice info. My attorney says that offers some modicum of protection against liability for not being there if someone drops dead on the doorstep after they failed to call ahead. Drop-ins are extremely disruptive to a no staff practice because there is no one else around to “entertain” them, so I have worked very hard to get people trained to call. And by and large, they are good about not being abusive and calling in the evening when during the day would do. When people say “What’s your latest appointment?” my answer is “That depends. What’s going on?” Then we negotiate. If they are sick, of course I say, “I will get you in today, but if you are that sick, what are you doing at work?” If the real issue is that they need a physical or routine follow up, but don’t want to take off work, we look into the future and pick a day that will turn into an “evening clinic” day. I don’t advertise “evening hours”, but if I ‘save up’ a few of these, then I can plan a day that I don’t start until 1 or 2, see the acutes in the afternoon and the routine stuff in the evening. Patients are grateful, but I am not committing myself to late hours on a regular basis. I practice what I call “nidus scheduling”. Even a year into open access, about half my demand is for appointments in the future. I have cut the time frame down so they don’t feel like they have to call in January to get a physical in May, but still, about half the time people don’t want to “come today”. So if Ms says “what do you have next Thursday?” and there is nothing on that day yet, I say “What time were you thinking?” She gets anything she wants from 11:00 to 4:00. Then the next person who asks for something next Thursday will get offered a spot adjacent to hers. If Ms picked 3:00, but the second person wants 11:00, then I try

to negotiate for something later if they insist on that day, or a different day if they insist on the11:00 time. The point is to avoid one at 11:00 and one at 4:00 with nothing in between. As with everything else I do, it

doesn’t always work, but most of the time I get a schedule I like and they patients get what they want too. I don’t offer regular weekend hours, but I do tell people “if you are sick on Friday night, don’t wait til Monday to call. I can probably see you on the weekend if need be.” I end up seeing people on Saturday or Sunday 2 -4 times per month (and I charge the 99050 for those visits) Good luck with your new practice! Keep us posted on how it is going. Annie -----Original Message-----From:

[mailto: ] On Behalf Of mkcl6@...Sent: Saturday, January 21, 2006 7:29 AMTo: Subject: Re: Closing to new patients in primary care Hi Annie and all, I wanted to ask a few questions. This was my first week at my new office ( I had to resist putting that in all caps!). I was in practice for 4 years in the next suburb over, about 6 or 7 miles away. I had 1400 patients "registered" to me there. I sent letters announcing my

move to all of those and requested they return an enclosed card if they wanted me to take their charts with me to my new location. I got about 375 cards back. Some are still trickling in. (cards were sent about 6 weeks ago). I brought all those charts with me. I suspect there are lots of people who will call when they are sick and want me to go get their record from the old practice. So anyway, my schedule for Monday is completely full and I have stretched it to abut 6:00pm to accommodate people and have a few open for sick people but interestingly yesterday not one person called to be seen that day. I enjoyed my day off (I have 5 kids and they were out of school) but of course I am now worrying about it. I actually always had tues and fri of at the old place as I job shared, I wonder if I have just trained all my patients. I am not advertising as I want to see where my demand is first. On those days you are scheduling into the evening, what time are you

starting? Any other advice you can give?

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Posted
Posted

Incredible, I am impressed.

T.

Ellsworth, MD

Family Medicine

sdale, AZ

Mobile

The information contained in this message is confidential and

intended solely for the use of the individual or entity named. If the reader of

this message is not the intended recipient or the employee or agent responsible

for delivering it to the intended recipient, you are hereby notified that any

dissemination, distribution, copying or unauthorized use of this communication

is strictly prohibited. If you have received this by error, please notify the

sender immediately.

From: [mailto: ] On Behalf Of joanne holland

Sent: Sunday, January 22, 2006

5:00 PM

To:

Subject: Re:

Closing to new patients in primary care

From Joanne, the old MD/DVM in Drain, Oregon:

Think I've got you beat...I finished my residency at age

59. I laughed when the Feds insisted at my loan consolidation that it be

a 30 year pay off, and said to myself that it was just as well that it is

an insured loan; if I die first the kids won't have to pay it off.

I was the oldest person at my residency, including the teachers.

Now, my Mom retired at age 65 and wrote three books

about geneology and family before her osteoprosis specialist MD put

her on replacement estrogen at age 84 and she started getting ministrokes

prior to dying at 88. Her aunts and grandma lived well into their

90s and 100s, living on their own and thinking pretty good. Now we all

have about two lifetimes of work we could do compared to the people a

hundred years ago, but it helps to keep on thinking about new things like

how to rebuild the health care system, one village at a time.

I could go on and on about how residency and medical

training work to insulate ourselves from our patients and our own

psyche, but that is another story. Just learn to pay attention to the

good things about your life, and think of the loan repayment as no more than it

would cost to buy a summer home and is a much better investment than that would

be.

Joanne

Guinn

wrote:

Nice to hear your story - I finished residency at 45 and am not sure

I'll ever pay off those loans. . .

We've all spent at least 7 years being trained to be workaholics and

obsess about medicine. It takes alot of work to learn how not to do it.

This gave

me a lot to think about. I have resisted do far the suggestion to do something

for one’s self outside of the office. Finishing residency at age 50, I

will finish paying my med loans at age 80 (I hope to still be practicing) With

my children well past college graduation- its too easy to concentrate on seeing

patients and paying the bills.

T. Ellsworth, MD

Family Medicine

sdale, AZ

Mobile

The information

contained in this message is confidential and intended solely for the use of

the individual or entity named. If the reader of this message is not the

intended recipient or the employee or agent responsible for delivering it to

the intended recipient, you are hereby notified that any dissemination,

distribution, copying or unauthorized use of this communication is strictly

prohibited. If you have received this by error, please notify the sender

immediately.

From:

[mailto: ]

On Behalf Of Annie Skaggs

Sent:

Saturday, January 21, 2006 8:52 AM

To:

Subject:

RE: Closing to new patients in primary care

Congratulations

on your move! Sounds like you are off to a great start. If you have

375 charts already, I doubt you will need to advertise at all because if you

give great care, your existing patients will recruit for you.

You seem

to be expressing some concern about the variability involved in open

access. I sympathize completely. Even now, occasionally I will have

a day with only a couple visits: Thursday this week I saw only one

patient! But if I don’t get in a twist about it, it all evens

out. I used the day to get all my 2005 tax stuff in order for the

accountant. An unplanned “light day” like that allows me to

do things I used to schedule as “administrative” and block out so

appointments couldn’t be

put there. Doing it that way risked disappointing patients who wanted to

be seen then; this way, the patients get to schedule when they want and I just

go with the flow. The main key is don’t let the total number of

patients get too large, because eventually you will run out of “light

days” and have to start carving out time that patients want.

The fact

that Monday is full would worry me just a tiny bit, because for me, Monday is

the day with the most “I’ve been sick all weekend, I need to come

in now” calls. I try to direct folks who are scheduling in the

future to days other than Monday once there are 3 or 4 on there. Of

course sometimes it doesn’t work, and I don’t sweat it if the

schedule just goes on til 7 or 8 or 9

pm. That doesn’t happen often, and I don’t have 5

kids waiting for me for dinner: my two are both in college and never home

anyway, and my husband also often works into the evening.

You asked

when I start. That is probably a big key to why I don’t care if I

have to stay late. I am 45 years old, and measure the rest of my life in

terms of “How many more times do I get to ride my horse?”

Doing an excellent job in my profession is important to me; maintaining good

relationships with my family is important to me; participating in my community

(local, state, national and world) is important to me. But the

NUMBER ONE thing in my

personal life, my greatest pleasure, greatest joy and down-right addiction is

riding. I gave up horses for 15 years to raise my kids when they were

little, and to get thru my education, but now I am making up for lost time.

After I went into private practice and had the freedom to make choices, I

observed that if I left riding until after work, it often didn’t happen,

so the choice I make is that I get up at 6 and go ride FIRST. Whatever

happens the rest of the day, I can live with because I ALREADY DID THE MOST

IMPORTANT THING that I need to do to take care of myself. So I

don’t start in the office until11:00

most days. I also don’t take lunch, so my typical time available to

patients is 11-6. Tuesday is the exception, with me in the office 8-12

and my office mate using the exam rooms from 1-5. So folks who really

want an early a.m. appt need to come on Tuesday. I’ve been doing it

this way for a little over a year now, and it is working out fine. I

always have the option of making exceptions, of course, but don’t often

have to.

Hints I

would offer:

Post “Office Hours by Appointment Only” in your waiting room and

practice info. My attorney says that offers some modicum of protection

against liability for not being there if someone drops dead on the doorstep

after they failed to call ahead. Drop-ins are extremely disruptive to a

no staff practice because there is no one else around to “entertain”

them, so I have worked very hard to get people trained to call. And by

and large, they are good about not being abusive and calling in the evening

when during the day would do.

When people say “What’s your latest appointment?” my answer

is “That depends. What’s going on?” Then we

negotiate. If they are sick, of course I say, “I will get you in

today, but if you are that sick, what are you doing at work?” If

the real issue is that they need a physical or routine follow up, but

don’t want to take off work, we look into the future and pick a day that

will turn into an “evening clinic” day. I don’t

advertise “evening hours”, but if I ‘save up’ a few of

these, then I can plan a day that I don’t start until 1 or 2, see the

acutes in the afternoon and the routine stuff in the evening. Patients

are grateful, but I am not committing myself to late hours on a regular basis.

I practice what I call “nidus scheduling”. Even a year into

open access, about half my demand is for appointments in the future. I

have cut the time frame down so they don’t feel like they have to call in

January to get a physical in May, but still, about half the time people

don’t want to “come today”. So if Ms says “what

do you have next Thursday?” and there is nothing on that day yet, I say

“What time were you thinking?” She gets anything she wants

from 11:00 to 4:00.

Then the next person who asks for something next Thursday will get offered a

spot adjacent to hers. If Ms picked 3:00,

but the second person wants 11:00,

then I try to negotiate for something later if they insist on that day, or a

different day if they insist on the11:00

time. The point is to avoid one at 11:00

and one at 4:00 with nothing

in between. As with everything else I do, it doesn’t always work,

but most of the time I get a schedule I like and they patients get what they

want too.

I don’t offer regular weekend hours, but I do tell people “if you

are sick on Friday night, don’t wait til Monday to call. I can

probably see you on the weekend if need be.” I end up

seeing people on Saturday or Sunday 2 -4 times per month (and I charge the

99050 for those visits)

Good

luck with your new practice! Keep us posted on how it is going.

Annie

-----Original

Message-----

From:

[mailto: ]

On Behalf Of mkcl6@...

Sent:

Saturday, January 21, 2006 7:29 AM

To:

Subject:

Re: Closing to new patients in primary care

Hi Annie

and all,

I wanted

to ask a few questions. This was my first week at my new office ( I had to

resist putting that in all caps!). I was in practice for 4 years in the

next suburb over, about 6 or 7 miles away. I had 1400 patients " registered "

to me there. I sent letters announcing my move to all of those and requested

they return an enclosed card if they wanted me to take their charts with me to

my new location. I got about 375 cards back. Some are still trickling in.

(cards were sent about 6 weeks ago). I brought all those charts with

me. I suspect there are lots of people who will call when they are sick

and want me to go get their record from the old practice. So anyway, my

schedule for Monday is completely full and I have stretched it to abut 6:00pm

to accommodate people and have a few open for sick people but interestingly

yesterday not one person called to be seen that day. I enjoyed my day off (I

have 5 kids and they were out of school) but of course I am now worrying about it.

I actually always had tues and fri of at the old place as I job shared, I

wonder if I have just trained all my patients. I am not advertising as I want

to see where my demand is first. On those days you are scheduling

into the evening, what time are you starting? Any other advice you can

give?

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Posted
Posted

Congrats on your new practice!

We have about 360 patients. We had

one day with no patients in our first month, which didn’t surprise us as

we only brought about 80 pts. But we had two days in December around

Christmas with no patients that surprised us. But we just had a new best

week ever last week. The schedule always has some variety, but evens out

some after a month or two. We are open 9-5 with lunch from 12-1:30.

We schedule people within 24 hours. We occasionally schedule during lunch

if our schedule is otherwise full (read four or five times since we opened five

and a half months ago.)

We don’t promise same day, just

within 24 hours. It is a different commitment, which leaves us with more flexibility.

We offer the early appointments when people want an appointment later in the

week or next week. Our highest demand days are Monday and Friday consistently.

We also seem to schedule quite a few appointments in advance in the

afternoon. (Although this is also because we are closed on Tuesday and

Thursday after 3:00.) We will see someone at 5 or 5:30 if their work

requires it, but have only done this a few times. We have also had a

couple of days where sick patients called and we stayed open late because our

schedule was otherwise full. But we usually don’t stay late just so

that their day would not be disrupted. The patients seem to expect to see

us during the day, during the week. It is not that we won’t see

them, just that they don’t expect/ask for it very often.

We will push people out a day or two for

routine exams if we have filled all but one or two spots in tomorrow’s

schedule. And since we almost never fill Tuesday through Thursday this

works well. I know it is not completely open access, but it allows us to

play with the kids after school two days a week, every evening, and every

weekend. We opened the clinic for our lifestyle and great patient care.

When we first opened, we were more

concerned with light days. On afternoons when we didn’t have anyone

scheduled or had a light day scheduled, we would look for people who should be coming

in and call them to schedule with them the next day. (Well childs, Well woman,

HTN, etc.) It works most of the time, and the patients are ecstatic that you

cared enough to call. We don’t do that as much as we should now, we

just enjoy the light day.

It doesn’t seem like you should

advertise for a while at least and probably won’t ever have to.

It sounds like a great start!

Ernie

From: [mailto: ] On Behalf Of mkcl6@...

Sent: Saturday, January 21, 2006

4:29 AM

To:

Subject: Re:

Closing to new patients in primary care

Hi Annie and all,

I wanted to ask a few

questions. This was my first week at my new office ( I had to resist

putting that in all caps!). I was in practice for 4 years in the next

suburb over, about 6 or 7 miles away. I had 1400 patients

" registered " to me there. I sent letters announcing my move to all of

those and requested they return an enclosed card if they wanted me to take

their charts with me to my new location. I got about 375 cards back. Some

are still trickling in. (cards were sent about 6 weeks ago). I brought

all those charts with me. I suspect there are lots of people who will call

when they are sick and want me to go get their record from the old practice. So

anyway, my schedule for Monday is completely full and I have stretched it to

abut 6:00pm to accommodate people and have a few open for sick people but

interestingly yesterday not one person called to be seen that day. I enjoyed my

day off (I have 5 kids and they were out of school) but of course I am now

worrying about it. I actually always had tues and fri of at the old place as I

job shared, I wonder if I have just trained all my patients. I am not

advertising as I want to see where my demand is first. On those

days you are scheduling into the evening, what time are you starting? Any

other advice you can give?

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