Practice Transformation

[Guest guest]

Greg --

A week or two ago someone described this list as feeling " like family " .

Now we are seeing the list act like family. As I don't yet have

experience making a solo (or small) practice succeed I can't tell you how

to make the office work. Ben, Gordon and everyone else have offered some

great advise. I hope that with those wise morsels of advise and anything

else you can think of, you move forward to a better place professionally

and personally.

What I can tell you is is -- You ain't alone! Many of us have been, or

are, just where you are with burn out. And from your description it seems

to me you've gotten into this predicament because you care alot for your

patients and your community. And that is a beautiful thing. Don't lose

that empathic edge to your work.

But remember the point someone made that people will ultimately realize

that some of you is better than none of you. We must always remember that

we can't " save the world " but if we help a good number of people, we've

done our part. And if they are better off for our effort, they'll be able

to help others and the ripple effect will make the world a little

healthier and better.

Also, I can tell you that your description of burnout and being

emotionally torn mirrors my recent experience. I'm just out of tough

situation and about to open a solo-solo office. I too felt torn about

" letting people down " . But I've been surprised by the reactions staff,

administration and patients have offered. I'm sure some people feel hurt,

but no one is communicating that to me. Mostly, people are wishing me

well and offering help if I ever need it. Some patients are following me,

others are not, but mostly they've seemed to say that they understood that

I had to make the change and they've communicated appreciation for our

time together. The administration in my old organization have been

pleasant, and even at my small going-away party, said they'd find a

position for me if ever I wanted to come back. And staff, the people I've

spent so much time with, depended on so much, and love so dearly have

remained close and supported my decisions.

I don't think I realized it before so well because I was too busy " being a

doctor " but really the personal relationships we have are so much more

important, and so much more powerful than the job we work. We are

doctors. But the power society places in that role is small and

superficial compared to the profound strength nature has placed in us

being human with spirits that reach out and bind us to others as people

without labels. We are blessed that our jobs actually offer us that

opportunity to connect so closely to others.

I've learned too that the only thing I can't change is time -- every day

has 24 hours and every hour has 60 minutes. How I use that time is what I

must manage. I'm just two weeks out of my old job and I'm feeling like a

new person because of the time I'm spending with my family more than the

things I'm doing to prepare the new office (yesterday I loved being with

my kids from 2-6pm as we ran errands to sign for my COBRA coverage, go to

the downtown library and go to Office Max to buy more supplies... I

haven't found the time to something like that in a couple years).

Now, for practical matters, I can't add much to the wisdom others offered

-- seems you have to decide to grow the staff to cover the work that needs

to be done or cut some insurers to improve the work load. Personally I

essentially chose the second by leaving the old practice and setting up

shop 10 miles away. But I'm actually going to try to keep all my

insurances so that patients who wish can follow me even if they have

medicaid or medicare, etc. What I will be limiting is the total number of

patients in my practice so in the end I'll have 1/4 to 1/2 as many

patients as before. My hope is that I can compensate for the insurance

hassles by taking a portion of my hours and making them more lucrative by

doing esthetic skin work (laser skin work, etc). This " Robin Hood " model

will hopefully allow me to have a financially viable practice where I can

offer fantastic care to my patients and where I can make each appointment

as valuable as possible with a clear focus on quality of care and not on

numbers seen. My hope too is that the better balance will allow me to use

my time differently and be physically with my family more as well as more

involved in the community (Rotary and coaching little league baseball,

etc) and other medical projects that I've let go by the wayside these past

few years. Perhaps in the long run you can consider that too... by making

a portion of your time for expanded service you may be better able to

serve the regular practice the rest of the time.

Greg, I wish you luck with these upcoming decisions and whatever course

you choose. I'm still raw from my personal burnout and have had real

visceral feelings reading everyone's responses/advise. I echo the feeling

that it's most important that you are aware of the problem and seeking

help. And I like that someone (Charlie?) reminded you to take care of

yourself physiclly/emotionally/spiritually to help the answers to be seen

and give you the strength to carry them out.

But remember, the personal relationships you have with everyone around

you, including patients and staff, are much more important than the job

you work. I would guess that the people closest to you will support you

in your efforts because they want you to be well even if it means they'll

have some new hassle to work through.

Good luck. And remember, this family is here to try to help.

Tim

> Dear Greg and colleagues,

>

> As Gordon so adeptly outlined, your choices are to

> shrink it or adjust your business model. Due to good

> service and growth the practice is admittedly

> overheated and what you have created is a moderate

> volume, low overhead, understaffed traditional FP

> practice. I would have to poll the group, but I'm

> pretty sure you won't go to FP solo practice hell for

> it. You will be more than welcome in this forum if

> you don't practice out of one room in an

> Neuro-optho-dermatologist's closet.

>

> If you can't bring yourself to shrink your practice to

> cash only micropractice level my thoughts are to do

> some strategic hiring. A slippery slope, but

> preferable to a narrow ledge. It will add variable

> costs, but if done right you will gain efficiency and

> enhance profitability. Being understaffed at your

> volume of services is a value trap. I've been there.

> Pay to get good people to help you achieve your health

> vision for your community. They should be among the

> best in town or forget it. Partner with standout

> performers that can give good service and think on

> their feet, but don't try to over-manage average

> performers in hopes of creating ideal employees.

> Won't happen. Be careful with hiring and let sub par

> performers go as sooner rather than later. Build an

> audit trail of performance concerns, warnings and

> efforts at remediation for anyone who is marginally

> effective, but not really working out before letting

> them go.(A hard lesson I learned at my expense.)

>

> It is my observation that you are understaffed in the

> back office.

> I know this because I have been understaffed in the

> back office. Hire an accountant to do your payroll

> processing and taxes. You need a book keeper to do

> the bill paying, medical billing and collecting

> functions. Not just a bookkeeper, but someone who

> knows exactly what they're doing with medical billing.

> Often these hidden gems are working for someone else,

> but haven't had their salary compensated at fair

> market value for awhile or their current work

> environment is toxic for some reason. If you are

> outsourcing billing, you are likely paying too much.

> If you add a partner seeing 20 patients per day and

> taking insurance, you will need two billers, not 1.

>

> You may need an additional staff person in clinical

> role of MA or LPN to assist patients. For a long time

> I had an efficient LPN in the clinical role. Between

> my NP and I, we saw 35-40 patients per day. I think

> overly relying on her led to her burnout and slowed

> the growth of my business over time. When she quit,

> my NP and I saw 600 patients per month for 4 months

> ultralight style + hospital + nursing home care for 30

> + OB. My overhead went down a little, but my practice

> didn't grow much and wasn't much fun. When we found

> qualified replacements we hired two. Our business

> grew 25% in one year after that against essentially

> the same fixed costs. Then I found a partner. Then

> this year we are adding another partner -In a rural

> area, in a malpractice crisis state (IL).

>

> My practice overhead is 40-42% of collections entering

> my 9th year of practice. I see about 20-25 patients

> per day with my EMR and do hospital work, some NH and

> 50-60 deliveries per year. I have an NP, a nurse

> midwife and an FP partner that share my vision of

> country doctoring. We share 2 front desk people, 2

> LPNs and 2 biller/book keepers at my main office. A

> ratio of 1.5 FTE support staff: provider.

>

> My best to all,

> Ben Brewer MD

> Forrest, IL

>

> __________________________________________________

>

[Guest guest]

---wrote:

>

> " should have taken your foot off the pedal BEFORE you went over the

cliff " ...

That's exactly what my problem is!

> Is there another solution? well, could you " work down a backlog

" even with

> a locums for a month -- or you can kill yourself even more for a

month,, and

> then do open access . That is ,if all these calls and messages are

backlog

> you COULD get rid of it.

> How many patietns do youhave?

> How many patietn- seeing hrs a day please Greg?

> are any of the phone thigns things that can and should be done at a

> visit- working downt he backlog would fix that yes?

I see about 25-30 patients per day (and another 15 for the NP). I

tried to do Open Access scheduling, but patients would go for it. They

would demand an appt. I don't, however, have much of a backlog. At the

start of any given day, I do have about a 4th of my slots kept open

for same day callers. I probably have about 1800-2000 charts. A good

percentage of the phone things, e.g., refills, advice to the mildly

sick, etc., could be office visits. I think the NP and I could

probably see another 10-30 people per day (depending on the time of

year), if I were able to do it. And I closed to new patients a year ago!

Can other practices absorb some folks?

> No option will be easy but I think much is possible.

>

This is part of the problem. The other practices are similarly

saturated. 3 out of the 4 of us are closed to new patients.

Thanks for the thoughts.