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Wednesday, November 29, 2006

I'd like to make an appointment, please.

I had this conversation this morning when I answered the phone (I sometimes do that).

"Good morning, Dr Schoor's office."
Pt: "Yes, I'd like to make an appointment for my husband. He needs a vasectomy."
"Sure, when would you like him seen?"
Pt: "As soon as possible!"
"Ok, we've had 2 openings today. How about today at 6PM?"
Pt: "Can't."
"Ok, how about tomorrow morning."
pt: "Can't"
"How about Friday? You tell me when he would like to come in, and we'll try to fit him in. A vas consult is generally quick."
pt: "Can't, But can he come on Saturday?"
"How about 11:00AM. Its my only opening on Saturday."
pt: "Can't. We need 11:30AM."
"Ok, I'll squeeze him in, but he may have to wait a bit."
pt: "Ok."

5 minutes later she calls back. "Sorry can't do it Saturday. How about next Saturday?"
"Can't"

What the !@#&

Monday, November 27, 2006

Going Solo? Keep track of your patients.

Have you ever sent a patient for a test or study only to have them not have it done? Have you ever had a patient lost to follow-up? Do you ever lose sleep at night worrying about what positive cytology result is floating around in the ether, unknown to you or your patient, waiting to give the patient--and you--a problem? I used to, but no longer. And that is because when I went solo I was able to really analyze in a comprehensive way how patients get lost to follow-up and why they don't comply with orders and then my staff and I developed a system to counteract this problem. We call it The No Worries Log, and here is how it works.

When I finish seeing a patient and have formulated my plan, I tell my staff to enter my orders into the outbound referral section of my practice management software, EMedware. This section is really designed for something else; to keep tabs on referrals from a primary care doc to a specialist, but I have customized it easily to fit my own needs as a specialist and a rapidly growing solo practice doc. For example, if I order a CT scan without contrast and a cytology on patient Richard Cockworthy, I tell my staff and they enter it like this: CT I-, cytology. If I send patient John Smith to a surgeon to rule-out a hernia, we log that as hernia ref to Dr J. You can accomplish the same thing with a log book and paper and pencil or with an Excel Spreedsheet, but that results in lots of wasted time and effort due to data entry duplication. Since our patient's data is already in the Emedware program, there are no issues regarding repeat data entry, and the date of the log entry is automatically noted by the program. Every few weeks I go through the list, check off labs and studies that I have returned and have my staff--or I do it--contact the non-compliant patients and gently prod them to get the tests that were ordered. Of course, we document these phone calls in the medical record.

The patients think its magic; they think that we are omnicient. We are not! They really think we are on top of things. We are! It's easy. We are simply using our existing software to its fullest extent.

This way I sleep well at night with the knowledge that I have minimized my liability risk by maximizing my power over a patient's non-compliance. It also makes for outstanding patient care and does not cost anything extra. Moreover, I can check the log from my laptop computer, while in bed at home, using a secure VPN connection, and can call the non-compliant patients from my Vonage office line that happens to be plugged in to my router at home. The caller ID that the patients sees says Dr Schoor's office.

Technology. It's wonderful!

Thursday, November 23, 2006

The enemy of good is better.

I first encountered this saying as a surgical resident and have come to believe it fervently. It basically means that when you try to improve something, your more likely to mess it up. This week I tried to improve my website, www.thexyfactor.com, and in doing so, FUBAR'd it. It was down for a week.
The enemy of good is better.

Friday, November 17, 2006

Going Solo? 5 steps to success

1: Set short and long term goals.
The start-up process ia an enormous undertaking. Defining your goals, both long and short term, will aide you tremendously.
2: Make expense projections.
Make a list of all of your expenses, such as supplies, rent, insurance, phone etc, and project your costs throughout the year. This will help you prioritize expenses and differential essential from non-essential ones.
3: Start your operational manual.
This well help you conceptualize and plan your practice and iron out bugs before you start seeing patients and making mistakes.
4: Surround yourself with good people.
I don't necessarily mean employees. Your medical supply rep, a non-medical entrepreneur friend, your chiropractor friend, etc. These "good" people can help you see things in new ways, find novel solutions to problems, and find perspective.
5: Stay positive
Start-up, in contrast to an established practice, has pronounced ebb and flow. During down periods, work on your practice; write a paper, blog, send letters to referring docs. Stay positive. It will pay-off.

Tuesday, November 14, 2006

Insurers Make Money by Not Paying Us.

Incredible and entirely believable at the same time. See Newsday Article of Nov 10, 2006.

Monday, November 13, 2006

Going Solo? Make your own EMR.

I have an inexpensive and effective EMR that is not commercially available. Read on!

Electronic Medical records (EMR) currently are, as Paris Hilton would say, hot. Just the other day, the New York Times ran a story on EMR and my national urology meeting had an EMR competition and symposium. In several years, all of us physicians may be required by law to have them. But who is going to pay for it? Before you buy a system, read on. Commercialy available EMRs are not quite ready for prime time. And for peanuts, you can take existing, mass produced, off the shelf software and customize it, by your self or with a little help, to produce your own EMR that will function effectively, efficiently, and inexpensively and grow with your practice. I am a urologist in start-up and I did it.

Windows XP has a feature that is known to everyone throughout the world who has ever turned on a computer. That feature is the folder. The folder! The Windows XP folder is just that, a folder. A chart! The icon even looks just like the charts from my old urology practice. You can open and close and add sections to it, just like a chart. Only you can always locate them and several people can access them at the same time. Inside each folder, you can store any type of data you want. Documents, pictures, graphs, hand written letters and diagrams, numbers etc. Simple to use and inexpensive software exists that can convert any type of data into digital format that can be read and stored on a Windows XP system. Any thing that you would keep in an actual physical chart can be stored in these FREE virtual charts and they can be organized in a manner that is familier to any physician. My charts have sections for patient demographics, progress notes, correspondance, old records, labs, radiology,ect. As my needs change, I simply adjust the template chart, in 2 seconds. Its easy. Even my staff can do it, and they came with no pre-existing computer experience.

After 6 years of research, I have concluded that existing EMR programs have several things in common. They are extremely expensive to purchase and to maintain and are incredibly complex programs that crash in unpredictable ways. In addition, these programs are written for the generic physician and they require the purchasing physicians and their staffs to customize it for their own specialty and practice directed unique needs. You have to do the customizing. And labs must be scanned in to boot!

My system is at least as inefficient as any out there and certainly better than any paper chart method. And it cost me less than $2000, all software, hardware, and tech support included.

Any questions, feel free to email me. rich@drschoor.com or http://www.thexyfactor.com/

Friday, November 10, 2006

Going Solo? The best advice that I received.

When you find yourself going solo, you will most likely experience what I did: people came out of the woodwork to give me advice. Most of these people had never and will never take the leap into solo practice, and their advice, though well intentioned, was often not helpful nor practical for my situation. But some people gave advice that was terrific; real pearls of wisdom. And I am going to pass some of it on, here and now.

1: Get Vonage
This advice was given to me by my friend Hugo, who went into solo practice neurosurgery 3 years ago. Vonage is a VOIP phone service provider that has a number of attractive features, but one feature in particular is most important for your start-up. When you sign up with Vonage, you get a router and the router itself contains your phone number. Where ever you plug in the router, that is where your phone is. So before you have an office, plug it in at your house or any other place that has access to a broadband conection. If you plug it in at home, your office phone will ring there, if you plug it in at your Dayton office, your phone will ring there, at the Cincinnati location, there, etc. This way, you'll have 1 permanent phone number for your patients and other important contacts to reach you by, no matter how many locations you have or how temporary these locations might be. For example,I left my old practice in February 2006, but did not have an office until April 1st. With my Vonage phone, I had an office phone number 6 weeks before I had an actual office and I started booking patients with it; my first 40 patients! Moreover, when I moved into my new office, I simply took the router with me and kept the phone number. No port charges, no connection fees, no disruption of service. It was easy. It took 2 seconds. Because of VOIP technology and Vonage, I was able to function and grow even before I had a physical space and as I have grown, the Vonage system has grown with me. I now have 4 VOIP and a IP fax line. The negative thing I have to say about VOIP phones is that, in my experience, calls drop more frequently than with traditional phones. But for me, the benefits far outweigh this sole drawback.

2: The Windows Folder Method
I knew I wanted electronic charts, but the price was, and still is, prohibitive. I had used EMR extensively in my training and knew what I liked and did not like about it and for the previous 5 years I had been tinkering with the folder (directory) system that is part of Windows OS (See EMR blog). I just was uncertain that it would function efficiently enough in fast paced medical practice. Then I read Christian Rainer's book on practice management and right in the book, he described his system, a system similar to mine. Voila, it would work! So I committed to the off the shelf, self-made Windows OS EMR, and on April 1st, 2006, my first day of seeing patients in my solo practice, I implemented it. That morning I saw 15 patients efficiently. And 300 new patients and 7 months later, I still use the system. I have been able to modify it and tweak it easily for my changing needs and this simple, custom system has grown beautifully with my practice. In addition, I have never had a single "down" minute. And I am not alone. The self-designed, custom, off the shelf EMR is used by other physicians like me. This advice was terrific, and it came from a book.

3: Fax the referral letter
Getting the referral letter to your referring physician is an extremely important aspect of private practice, both for optimal patient care and for good marketing purposes. When your letter arrives promptly and gives the referring doc the pertinent information in an efficient manner, your patient will get great care, you will look good and you will likely receive more patients from this doctor. Conversely, when the patient returns to the referring physician before your letter, the doctor will not have the information she needs for optimal patient care and will be upset. You will look bad. My problem in February 2006 was that I had no transcription service, no letterhead, and no good plan to perform this important detail of practice. Then I came across Neil Baum's book on medical practice marketing and he had already come-up with the perfect solution to this problem and published it in his book. He called it "the lazy letter" and to ensure that the letter arrives promptly, he faxes it to the referring doctor the same day he sees the patient. "The lazy letter" is a template that goes something like this: "Dear Dr A, I saw patient B for disease C and plan to do X, Y, and Z. . ." Then have your staff fax it. I actually fax it directly from my desktop with special internet fax software.
It is that simple, works like a charm, and has been uniformly praised by my referring docs. 'The lazy letter" was Dr Baum's pearl of wisdom that he passed to me via his excellent book. Thanks Neil!

4: Cultivate your sub-specialty
This may seem like a no-brainer, but I assure you it was not for me in February of 2006. At that time limiting the practice actually seemed counter-intuitive to me since I wanted to grow as fast as possible and to minimize what I thought would be tremendous financial losses in my first year of solo practice. But my father suggested otherwise, and he was right. I do have sub-specialty fellowship training in male infertility and microsurgery as well as significant andrology laboratory experience and my father, a retired solo practice periodontist of 30+ years, encouraged me to aggressively cultivate that aspect of my practice and market it. It turned out to be great advice and in doing so, I have been able to get a toe-hold in a medical community that is otherwise as hard as granite to break into. Moreover, as a general urologist, I was 1 of 50+, just in my county, and now I am 1 of 3 on all of Long Island that does male infertility and has an on-site CLIA andrology lab. Instead of competing with the mass of urologists in my community, they are now my potential referral sources! By focusing my practice I have, in essence, turned the tables in my favor and have been thriving. Thanks Padre'.

5: Blog
Like many people I first heard of blogging and bloggers during the Bush-Kerry Presidential election of 2004 but I certainly did not understand what blogging was and why bloggers did it. Now I do and it is because of advice from my good friend Steven Krein, an Web 1.0 and now 2.0 successful entrepreneur and founder of OrganizedWisdom. Steve set me up with a blog in March 2006 and told me to just start writing on topics on male infertility, ED, etc. My first blog went something like, "Dr Schoor, male infertility specialist, has moved to Smithtown." In May 2006, a prospective patient googled "male infertility specialist smithtown", got my blog www.drschoor.com, and called to make an appointment. And then I understood the power of blogging. Since then my blogging efforts have resulted in increase website (www.thexyfactor.com) traffic, search engine presence, and an increase in new patient business. In addition, I use my www.drschoor.com blog to educate patients about selected topics in male infertility, ED, and urology and to point them towards useful and pertinent articles that are written by others. Third, I enjoy blogging and despite concerns--legitimate and real concerns voiced by my attorney--I have continued to do it. I have come to feel that the benefits of blogging offset any potential risks, and isn't risk-benefit analysis what we doctors do everyday.

Thanks for listening and I hope you find this advice useful. Please feel free to comment on your own pearls of wisdom for small medical practice management or anything else you feel like commenting on.

The Independent Urologist.

Tuesday, November 07, 2006

Going Solo? Get the Box.

During orientation week as a freshman at the University of Maryland, I learned what has become one of my most valuable organization lessons; the box method. The box method ensures that your important documents will never get lost, as long as you place them in the box. Here is what I was told in 1984. Buy yourself a box large enough to hold a years worth of papers. As you get documents regarding your course work, for example class enrollment or drop confirmations, put them in the box. No need to file or order them. Just put them in the box. That way, they will always be there. If you need proof that you dropped a course, no need to panic. Your proof is in the box. Every year, you buy a new box, and put the old one on storage. It’s that easy. In my 4 years of college, I never lost anything! I still use the box method today for both my home and office.

Now that you’re on your own, a solo physician, you too will need to have easy and ready access to all of your important personal and professional documents; bills, receipts, tax information, etc. But your method of filing must be so easy to do that you can do it by yourself with a minimum of time and effort. So here is how it is done. Buy 1 large box and 4 medium size accordion folders. Label each accordion folder 1st quarter, 2nd quarter, 3rd quarter, 4th quarter. All bills, receipts, and bank statements, credit card statements etc that come in are dealt with appropriately, then they are shoved into the accordion folder of the appropriate quarter, in no particular order. Just put the piece of paper in the folder. The folders go inside the box. At the end of every quarter, before your quarterly accountant meeting, you can organize the folder, if you want. At the end of the year, you’ll have 4 accordion folders inside your box. Store the box in a safe placed and buy a new box and 4 new accordion folders. You must store the boxes for 7 years. This is not the method that experts—bookkeepers, accountants, and professional practice managers—use or recommend, but you don’t need to do it their way, and even if you wanted to, you couldn’t. The box method works just fine. The box method is better for the cash poor, busy, and lazy solo physician.

Any credentialing paper work, your diplomas, medical license, DEA certificate, etc, go in their own separate box, but they are also kept as digital copies on your hard drive in a folder labeled personal folder. You can make digital copies of your framed diplomas by simply taking a picture of them, without flash, with an inexpensive point and shoot digital camera. The digital files must be given names that you’ll recognize, like med license. When you need to re-credential, which occurs quite frequently, all you need to do is go into your personal file and print out copies of your documents. It’s that simple. When I need to re-credential, using this method, I can prepare a re-credentialing packet in under 5 minutes.

By the box!

Monday, November 06, 2006

Oh, Hello Doctor!

I love patients who introduce themselves as Dr. ___. I believe one can gain insight regarding what kind of patient they are going to be by asking them what type of doctor they are.

  • Chiropracters: They uniformly introduce themselves as Dr____. In addition, they are most likely to ask for professional courtesy and to have their co-pays waived. (see copay)
  • Dentists: Almost always introduce themselves as Dr and are most likely to "Know from dental school" as much as you do about their problem, especially the older ones.
  • PhD's: Always, always, always introduce themselves as Dr. ___. I don't mind this, because they are usually much smarter than I am and aside for PhDs in one of the sciences (see dentist and older physician), they are pretty easy going patients.
  • Psychologists: Approximately 50% of the time will introduce themselves as Dr. ___. Otherwise, they typically make for very pleasant patients.
  • Medical doctors: Only about 1/3rd will introduce themselves as Dr. ___, and, like the older dentist, the older physician oftens "knows" all about their problem.

Urologist Suicide Over Medical Malpractice Verdict!

I read with interest a case from May in which a urologist committed suicide after a $1 million jury award to a plaintiff. The urologist was a very well regarded and successful doctor who specialized in male infertility, vasectomies, and vas reversals. According to the article, Dr Grey, 51, performed several hundred vas reversals per year, created a unique instrument--the microbeam--to aid in the vas reversal procedure, and was known as Vas Doctor, online.

The law suit alleged that Dr Grey left a surgical sponge in a patient's scrotum post-operatively. The patient needed subsequent surgeries to remedy the problem and claimed damages. Despite attempts by the plaintiff's attorney to settle the case for the limits of Dr Grey's malpractice insurance policy, $250,000, the case ultimately went to trial and the jury awared the patient $1,000,000. Later that night, Dr Grey hung himself at his home.

Why would this urologist, this exceptionally successful urologist, commit suicide over a malpractice verdict? Well, I am sure there is more to the story than what is written in the article, but I view it as a cautionary tale. Doctors get sued. Period. One must try, as hard as it is, not to take a law suit personally, especially not to this degree. One must view these things--law suits--in their proper perspective, learn from them, and move on!

Perhaps he was financially ruined as a result of the award. This is possible, but unlikely. The most likely outcome of the award, according to attorney friends and family of mine, would have been an appeal followed by a settlement for a figure far below the $1 million sum. Even if he ultimately was forced to pay the $1 million, his reaction was certainly not rational. Finally, why did he only have $250,000 in insurance? In NY, physicians are required to carry more than this, but not in Florida. Moreover, in Florida, due to high insurance premiums and no obligation to carry insurance, many physicians are going bare--having no coverage--or keeping minimal coverage. I believe this approach is foolhardy and penny wise and pound foolish.

I don't have the answer to what happened to Dr Grey nor why it happened and I don't have an opinion that would interest anybody regarding medical liability reform. I do know that Dr Grey's death was senseless and in many respects tragic, not only for his family, but for all the would-be-parents who can no longer benefit from his expertise. The tale of Dr Grey is indeed a cautionary one that we physicians should heed.

Richard A Schoor MD FACS

Friday, November 03, 2006

Good Fridays!

I like leaving the office Friday in a good mood. I'm leaving today in a good mood. Here is why.

I have the occassional propensity for self-pity. This afternoon I was lamenting to Janet that there is so much in male infertility that I am unable to treat. So many patients that I have to give unhappy news to. This afternoon, however, I saw a patient who was written by other infertility specialist, and almost written off by me. But he never had 1 test, the prostate sonogram, that would have completed his evaluation. I did the sonogram, which showed dilation of his seminal vesicles, consistent with ejaculatory duct obstruction. He otherwise looked clinically like testicular failure. I could not believe my eyes and even counseled him that success with TURED was a long shot. He and his wife had faith and adamantly wanted to proceed.

You know what. It worked! His sperm count is now 20 million, and they are motile. Lets hope she gets pregnant now naturally.

I'm happy.

http://www.thexyfactor.com

Thursday, November 02, 2006

Solo Medical Practice: What Can Be Better!

Richard A Schoor MD FACS
Medicine is great profession and calling with a rigorous educational and training period but many practicing physicians admit that a doctor’s real education, medical and otherwise, starts when they enter practice. Seeing patients for real, as a certified, licensed doctor is exciting, but can be scary at first. Being in a group setting can help during this transition phase, but ultimately you will get very comfortable and competent in your new role and you may find your self longing for the sleepless nights of endless possibilities and entrepreneurial dreams that only solo practice can provide. Or you may be forced there involuntarily. Either way, when you find yourself on your own, you can be comforted by these five myths regarding group practice and why solo is actually better.

1. Solo practitioners are on constant call:
Not true. I have been in 7 man and 4 man groups and have been solo. Let me tell you; call for a group is worse, much worse. When I was in a group, I literally lived my life around the call schedule. So did my partners, and so do my friends now who are in group practice. In fact, as the group size becomes larger, the call becomes worse. By worse, I mean more phone calls, more emergencies, more hours rounding, less sleep, less time with your family, and so on. Less happiness, more anger. Call for groups becomes a real issue that can break groups apart. Partners often bicker about who has more call on which days and what weekends and how many holidays and on and on and on. And physicians in large groups dread call far more than small group or solo physicians because in a large group each individual call is that much more painful. From my own experience, my anxiety level would rise as the call day or weekend loomed closer and by Sunday evening, I’d be exhausted! And most physicians, solo or group, feel as I did. Now, as a solo guy, I never get called, do not take hospital ER call, and have no emergencies. I sometimes work on weekends, but only if I feel like it. I can chose to accept or reject consults, but on my own terms. I sleep well, have no stress, and spend time with my family, friends, and my hobbies. In short, I have no call.

2. There is safety in numbers.
While this may be true for wildlife on the Sahara, it is blatantly untrue in medical practice. I had been told, without exception, that being in a group offered protection and insulation from one of the unpleasant aspects of medicine—malpractice litigation. Untrue, untrue, untrue! This is perhaps the biggest myth and potentially the most dangerous to the young physician. As part of a busy group, not only will you get sued for things you did, but you’ll also get dragged into your partners’ mishaps. How about job security? People think that once you are partner, you're safe...on easy street. WRONG! I know several groups, personally, that have jettisoned full partners, not associates, when the firing was perceived to be advantageous to the group's survival. Solo practice is actually the safest place to be.


3. The economy of scale is better in a group practice.
The economy of scale means that the busier you get, or your group gets, the less it costs per encounter with a patient and the more profit you see. This is because, in theory, your fixed costs stay the same while your productivity (seeing patients) increases. While in certain ideal situations this might work, for the overwhelming majority of practices it is simply not true. The larger a group gets, despite the best intentions, the more that the operating and administrative costs run out of control. This is because individual doctors are individual companies with individual needs and costs. And some companies run with a high profit margin, some with a low profit margin, and some at a loss. Therefore, a well run group will always have more waste than an efficiently run solo practice.

4. Partners help you manage complex cases and the: “I like to run things by my partners” myth.
This is the one of the biggest farces. In the current age of telecommunication, internet, email, IM, video conferencing etc there is absolutely no barrier to collaborating with colleagues on complex cases. I discuss complex cases with colleagues of mine in Indiana, Chicago, India, and Great Neck on a routine basis. I can even send radiographs and histology images over the internet, of course after removing any identifying patient information. It is a fast, cheap, effective, and efficient. And you can choose colleagues who are real experts in their respective fields who are typically eager and willing to help you.

5. You need partners if you want to do complex surgery.
This is a myth. In the past, assistant surgeons received handsome reimbursements; they got paid well. Not anymore! In fact, when 2 partners double scrub, the practice loses income. In current surgical practice, an economic incentive exists that encourages surgeons to operate either by themselves or with PA’s or other paraprofessionals. So for the most part, you’re on your own anyway. But don’t worry about this. Operating independently from partners on complex cases is doable and enjoyable, and it is done frequently and safely.

Going Solo: Should you listen to the experts?

I like reading the Urology Times (http://www.urologytimes.com/urologytimes/). I like the format in which it is written. It allows me to rapidly scan through it and learn new things. I like the Urology Times especially for its articles on practice management. Usually they are written by practice management consultants, many of whom have written books, and who claim to have helped many practices find financial success. In general I have found their advice to be helpful and certainly interesting to read. However, a common thread runs through all of the experts' advice: hire more staff!
If your phones are not being answered, hire people to answer phones.
If patients are queing up in the waiting room, hire additional reception staff.
If you need help exiting patients, hire an exit staff.
If you need help in your lab, hire laboratory personell.
If you need to see more people, hire a scribe.
And etc.

News Flash:
Medicare and the Commercial Payors pay the same whether you have 2 or 20 or 200 employees. Repeat: Medicare and the Commercial Payors pay the same whether you have 2 or 20 or 200 employees.

Last night I was playing tennis with a buddy of mine who owns his own high tech manufacturing business (http://www.ijwhite.com/). Interestingly, he and I have some of the same problems and we began talking about consultants. And you know what he said. Consultants in his field say the same things as in the medical field: hire more staff!
Interesting! And he said that when ever he hires more staff, he ends up working harder! Interesting! In my own experience, this is true as well.

I am not sure that hiring more is the answer. And others agree with me. (see
www.idealmicropractice.org Is the micropractice the answer and is it feasible? We'll see.

Dr S
http://www.thexyfactor.com/