Wednesday, December 27, 2006

2006: Things that I've learned.

2006 will undoubtably go down as one of my greatest years. Here is a list of all the things (maybe not ALL) that I have learned the past 12 months.
  • How to set-up a blog
  • How to set-up a website
  • The difference between a Cat 5 and Cat 3 cable
  • What VPN stands for
  • What VOIP means and how to use it
  • How to insert a meta-tag
  • How to develop a good system to keep track of outgoing patient labs, studies and referrals
  • How to maximize patient compliance with follow-ups
  • How to set-up an andrology lab for semen analysis
  • How to write a QC manual for a lab
  • How to do QA and QC for my lab
  • The difference between QA and QC
  • How to extrapolate lab QA to overall practice management QA
  • How to enroll in PT
  • How to report a semen analysis result by CLIA standards
  • How to get a CLIA ID
  • How to become a lab director of a moderate complexity CLIA lab
  • What CLIA'88 is
  • What COLA is
  • How not to write an operational manual
  • How to write an operational manual
  • How to collect a copay
  • How to get a Federal TIN
  • How to incorporate
  • Why to incorporate
  • Why to elect an S-corporation
  • How to manage cash flow (still learning that one)
  • How to autoclave instruments
  • How to disinfect a flexible scope in cidex
  • How to install a reticle in a microscope
  • A more efficient way to do a semen analysis
  • The code 257.8
  • How to use Iweb
  • How to use FrontPage
  • How to use an FTP client
  • An in-depth meaning of the Quarter
  • How to set up a medical practice
  • How to quickly set up a credentialing packet
  • How to design an inexpensive an efficient EMR for a solo practice doc
  • How to develop a near paper-less office
  • How to bill for a sperm retrieval
  • How to interpret an EOB
  • How to submit a claim
  • What a clearinghouse is, though not why
  • How to hire
  • How to fire
  • How to "sniff out"a really bad employee
  • That I have no clue about how to interview a prospective hire
  • How to build a practice
  • How not to run a practice
  • How to market a practice in a non-"cheesy" way
  • That I really like Thai food
  • An efficient and effective way to do a scrotal sonogram
  • A great way to do a painless, no scalpel vasectomy in my office
  • How to do a "Q"urine, who to do it on, and why I seldom do it any longer
  • The value of "nickles and dimes"
  • The real value of money
  • The value of independence
  • The BS of the buy-in
  • The worth of a medical practice
  • The value of myself
  • How to be mentally tough as nails
  • That I possess skills I never knew I had
  • That I can live on much less
  • That money and income do not equal happiness
  • That difficulty paying bills stinks
  • The value of surrounding myself with really good people
  • That creating a successful endeavor that had never existed before I got there is awesome
  • That it truly is the struggle that makes success so sweet
  • That I have an amazing wife
  • That I have an amazing family
  • That I miss Granpa George more than I thought I would
  • That I have a lot more to learn

Have a happy, healthy, and successful new year.

The Independent Urologist

Sunday, December 24, 2006

Santa came to my office!

Santa must have come to my office, and instead of toys he brought a whole bunch of EOB's. Wow. I believe, I believe!
Or maybe its because the 4th quarter is about to end, and the insurance companies want to offset their incredible gains before the year is up through disbursements owed to their payees, the doctors.
Nahhh. It's Santa!
Have a Merry Christmas, Happy Hanakah, Happy End of Year Tax Planning.

Saturday, December 23, 2006

Going Solo? Understand the EOB.

EOB stands for explanation of benefits and is the perhaps the most important aspect pertaining to the financial health of your practice, perhaps more important even than the amount printed on the disbursement (reimbursement) check. Understanding the EOB will allow you to develop an appreciation of how much you get paid per service--per encounter--and can serve as a gauge for how effective you--or your team--are as billers. Here are several EOBs that I recently recieved that I find illustrative.

  • EOB 1: The Check amout was for $160. Not bad. Now lets look at the EOB. Oh, I see that this check represents payment for 3 encounters. Encounter 1 was a level 4 visit. I was payed $36, and I see here that the patient had no copay. Therefore from this particular plan, I get $36 for a new patient consult. Shabby! Encounter 2, on this same EOB, is also for a new patient visit, for which I recieved $120 and the patient had a $15 copay. Therefore, my contracted amount, the amount I get per encounter on patients with this exact plan is $135. Interesting, the patient from encounter 1 and 2 had the same insurance company, but different plans within the plan. Encounter 3 was for a urine analysis, an 81000 in CPT talk, for which I got $3.70. Not bad for a UA.
  • EOB 2: Check amount was for $28. Looking at the EOB, it was for 1 encounter. The patient paid $20 in copay. Therefore for an extablished visit, I got $48.
  • EOB 3: Check amount was for $0.00. Looking at the EOB, this was a denial because the claim occured during a global period for a 52000, a vasectomy.
  • EOB 4: The check amount was for $38. It is for 1 encounter, an established office visit. The patient paid $15, and the insurance paid $38 + $3.70 for a UA. Therefore, from this carier, on this particular patients sub-plan, within the plan, within the plan, I get ~$50 for an established patient level 3 visit.
  • EOB 5: The check was for $240. By examining the EOB (often more complex than examining the patient), I can determine that the payment was for a 52000, a vasectomy. So now I know that from this insurer, at least on this patients subplan within the plan within the plan, I "contracted" to recieve $240 for a vasectomy. In addition, the carrier did not pay me for a visit on the same day as the vasectomy.

So there you have it. If you add up the total devided by the number of encounters, you can get an analysis of dollar/encounter, which as an important number to know. In this case, I made, on average, $99 per encounter. So as you can see, it takes a lot of encounters to make just overhead, not to mention take home a salary.

Good luck!

Thursday, December 21, 2006

Going Solo? Where do claims go and how do I get paid?

When I first entered solo practice, I had no idea how I was supposed to go from seeing a patient to the point that I actually get a reimburesment check in the mail. I knew the terms, like charges and claims and submissions, and electronic filing, but that was basically it. I now have a somewhat better understanding of the process, and what I have learned I find, well, somewhat disturbing. Here's how it works.

Lets start with our hypothetical patient, Richard Cockworthy.

  • Richard enters the office, fills out forms and give us his insurance card. We then get the copay. So far so good. (When I first started, I did not even know how to do this!)
  • Do what I studied/trained 11 years to do; see patient.
  • Fill out encounter form, the form that has the ICD9 and CPT codes.
  • Give Richard his next appointment then exit him.
  • Open up practice management software, and enter charges, i.e. enter into the appropriate fields the CPT codes (99213, 81003 etc) with the corresponding ICD-9 code (257.8), along with all other vital info, such as referring doctors UPIN, site code (office, hospital ,etc).
  • Now it gets really interesting! I can either print the claim on a HICFA 1500 or submit it electronically using, yes its true, a 56K dial up modem (Their choice, not mine.)
  • If I use a paper claim, HICFA 1500, the form is mailed directly to the payer, ie the insurance company.
  • If I decide to submit electronically, I press the e-file button, and the claims go over the internet via my dial-up to a clearinghouse.
  • What, pray-tell, is a clearinghouse. Well a clearinghouse is a middleman. And you guessed it, he has his hand out.
  • The clearinghouses--many of them exist, such as Webmd, which is the largest--provide "services" such as adjutication of claims, what ever that means, and "cleaning" of claims (I'm not sure if I like that).
  • Then the clearinghouses submit the claim on to the actual payer.
  • Electronic claims, from what I've heard, get processed more quickly than paper claims, but for this priveledge, you must pay a fee. The fee varies based on volume of claims submitted and the clearinghouse.
  • Paper claims do not have fees associated with them, other than stamps and printer ink, but some payers take extra-time to process these claims. Some simply never seem to recieve them the first time around and you must follow-up and re-submit the claim with the notation, 2nd attempt on the claim.
  • If all necessary boxes are filled, all ICD-9's and CPT's match, all UPINs are correct, and the stars align, the check gets drafted and either mailed along with the EOB to you directly or are auto-deposited into your bank account.
  • EOB means explanation of benefits, and the EOB lets you know how much you were paid per service, what you were not paid on, and sometimes why.
  • Then you enter the reciepts into your software, and voila!

Complicated, convoluted, redundant, expensive, and ours. A system only a middleman could love.

Sunday, December 17, 2006

Going Solo? Embrace Technology.

A long time ago, 20 or 25 or more years ago, a doctor coming out of training had the option to just "hang a shingle." Perhaps the costs were low, or there was not such a saturation of physicians as today, or practice management was simpler then. But I don't actually believe that. Having spoken to physicians and dentists and lawyers who hung their own shingles years ago, it was pretty hard and pretty scary in those days, just like it is now. While costs for them were low by today's standards, these professionals assured me that they were financially stretched to the limit during their own start-up years. I actually believe it is easier today, or at least not anymore difficult.

People starting out today have 1 advantage over our yesteryear start-up counterparts. One huge advantage. Today we have amazing and inexpensive technology that can do for us meaningful work in an efficient manner; work that enables us to be more profitable, more available, more productive, more independent more quickly and more easily. Technology such as electronic faxing, EMR, VOIP, cell-phone, miniturization, IM, e-mail, FTP, fiber optics, OCR, etc, if you know how to use them, can help you substantially not only throughout the start-up phase, but beyond. Here are some examples of how.

  • Miniturization: Electrical components that formerly would take up a room's worth of space are now available, at an affordable price, that are the size of a lap-top computer, even smaller. Whether these components are client computer stations, handheld PDA's, sonographic equipment, or light sources, the small sizes frees up valuable square footage for more efficient and profitable usage.
  • Electronic Medical Records: From issues relating to paper management to the physical space required for chart storage, and everything in between, the advantages of an electronic medical record system are obvious. Recently some vendors have come down in price so that a physician can afford it, but perhaps even better, an industrious and resourceful solo person can make his/her own system using off the shelf software.
  • Communications: I can't imagine what doctors used to do before cell phones. I guess they needed to travel with a wad of pocket change or tell the maitre'd at a restaurant that "Dr Schoor is over there." Now it is truly an amazing time to put the power of technology to your advantage and nowhere is this more apparent than in the area of communications. Cell phones, VOIP, VPN, voicemail, instant messaging, text-messaging, video conferencing, electronic faxing are all realities, inexpensive ones at that, and are all available using nothing larger than an inexpensive laptop computer. These technologies may all have their role in your start-up. All you need to do is evaluate your situation and then try them out.
  • Billing: Billing used to take a team of people, just on your end. People to enter charges, submit claims, follow-up on claims and denials, and people to follow accounts recievable. Now all this can be done electronically by no more that 1 or 2 people, including the doctor/owner. With electronic you no longer have the not-insignificant-expense of tonors and printer ink and postage and proof of mailings. By the very of nature of the electronic submission process, all transactions leave their electronic footprint so that "I'm sorry, we never recieved it" no longer applies. In addition, claim turn-around-time is faster than with paper claims, and that helps with cash flow.
  • Advertising: Many years ago doctors never dreamed of advertising, but now many of them do. Traditional advertising, print, radio, TV, is extremenly expensive, and frankly, for most of us, is not cost-effective. Fortunately, the internet exists and has revolutionized commerce. E-commerce, the new word that describes internet based businesses, can apply to your start-up as well. For relative peanuts, you can have your website hosted and quickly start to sell items from it or to book appointments from it, and by learning basic source code, you can make your site more search engine friendly with metatags, and keywords, and etc. In addition, if you embrace the new blogging technologies, you can help drive even more traffic to your site.

Embrace technology!

Friday, December 15, 2006

Going Solo? 5 reasons why you would benefit from a SINGLE PAYOR SYSTEM.

The United States has terrific health care for people with good insurance, yet millions of Americans who pay taxes and have jobs do not have adequate health coverage. Most of these people, in fact most Americans whether they know it or not, are 1 severe illness away from personal bankruptcy. Though most of us agree that a problem exists, people have not been able to come to a consensus regarding the solution to the problem. Single payor health insurance has been discussed by many as a possible solution to the health care problem that exists and it has many supporters as well as detractors. As a solo practitioner, you should be a supporter of a single payor system that covers everybody. Here are 5 reasons why.

  • Overhead reduction: Anyone in solo or group practice will tell that they spend huge sums of money not on the delivery of health care, but on its administration. In fact, 45% of GDP health care dollars go towards paying administrators, be they CEOs, call center workers, claims processors, billers, managers ect. Countries that have single payor systems spend far less on this beuracracy than we do in the US and practices in regions of the US that have less managed care penetration have lower administrative overheads than similar practices do in other, more MCO saturated environments. Practices that see a predominantly medicare population can operate at a fraction of the cost of a practice that takes 30+ plans, period.
  • Improved cash flow: We already have national health insurance, it's called medicare, and not only is it now one of the best payors, it is one of the fastest payors. Since payroll comes every 14 days, and bills come every 30 days, cash flow requirements dictate that payors pay at 30 days as well. In the wonderful world of managed care, most payments come not at 30, but at 45, and sometimes 90 days, despite electronic submission. Medicare payments come in the quickest and with the least hassle factor. With medicare alone can I estimate cash flow accurately and plan accordingly.
  • Practical Practice Simplification: Medicare, our national plan, does not care if I send a urine specimen to OurLab, or Quest, or Sunrise, or if I do it myself. As long as the claim is submitted correctly and it meets their requirements, medicare will pay. In addition, medicare does not care if I do a surgery at hospital 1 or hospital 2 as long as both participate. Finally medicare does not care if I send a patient for a CT scan at Medical Arts Radiology or Zwanger or Zilka or even if I do it myself. They'll pay regardless, as long as the claim is sent correctly and I meet their well documented requirements. Now contrast that to the managed care world where there are plans within plans within plans, each one with different, ambiguous requirements, preferred providors and labs, preferred meds, providor ID numbers, PRIS#'s, TIN's, etc. Some patients have plans that require pre-certs from many things, while other patients, often with identical ID cards, do not need such pre-certs. Finally, with medicare, you easily know what is and is not covered. Now contrast that to the commercials where coverability is often not known until after the fact, despite bonafide attempts to find out otherwise.
  • You'd make more money: Combine the effects of overhead reduction, practice simplification, amd improved cash flow with an absence of forced pro-bono work, and the math becomes easy to see. This is most true for physicians like orthopedists and general/trauma surgeons who do lots of ER work, especially in poorer areas. Because of a good law called EMTALA, these same surgeons must work very hard for these patients and neither the surgeon not hospital has any guarantee, nor prospect, or payment. Under a universal coverage plan, single payor or not, these doctors and hospitals would get paid.
  • It is the right thing to do: Enough said.

Thursday, December 14, 2006

Going Solo?: 5 things I've learned about human resources.

I personally know doctors who have had employees that caused havoc on the doctors' practices and careers. Here are 5 things I've learned.

  • If you suspect, eject! If you suspect that an employee is dishonest trust your intincts and act quickly. It is human nature, bacause you are a good and honest person, to look the otherway, turn a blind eye, or give the benefit of the doubt. But resist this temptation. IF YOU SUSPECT, EJECT! Whether or not you wish to catch them in the act or simply terminate them is your personal choice. Employess think that showing up late or leaving early when you are not there, or stealing a copay, or downloading an illegal music file on the computer will go unnoticed. They are wrong! They always get caught, eventually. At the earliest signs of dishonsesty, you must act, either by setting up a sting, firing the employee, calling the authorities, or any of the above. Certainly theft of a large sum of money warrants involving the police. If you suspect, eject.
  • Good behavior is often short lived. Most people put their best foot forward at the interview. However, it has been my personal experience with employees that bad habits which become noticable within the first few weeks of working will never go away and you must act accordingly. Employees who show up late in their first 1-2 weeks, especially more than once, will never be punctual despite their agologies, protestations, and sob-stories. If you value punctuality, you must act accordingly. Similarly, employees that behave in non-professional manners early on will not change EVER. Get rid of them before they hurt you.
  • Effort and intentions are everything. Every body learns at different rates and has different skill sets coming into a new job or environment. But I have found that almost anyone can learn almost anything if they apply the effort and approach the task with the best intentions. I'll take the former high school drop out with desire and amibition over the IVY league college student who just wants to coast for a while until they move on to something else. I'd take the former person any day of the week and twice on Sundays. But there is a corrolary (see below)
  • Some people just can't learn. In my experience, this applys most to the aquisition of new computer skills. Of course everyone writes on the resume that they are proficient in computers; Windows and Office Suite, medical manager, databases, etc. But on the job, well, they don't know right click from double click from a whole in the wall. I actually have started to make prospective new hires open and close documents, fax things, open emails use IM, etc during the interview process. Of course it applys to other skills as well. If an employee just can't learn a very simple skill, such as doing a urinalysis, either they lack the intelligence for the job or are not making the effort. Either way, show them the door.
  • Keep the good ones happy! Good employees can be very hard to find and when you get lucky enough to find a person that shows up on time, takes pride in her/his work, and can learn new things, you best keep them happy. This does not necessarily mean that you must keep giving them raises or bonuses. But a simple "thank you" or "good job" or "strong work" goes a long way. Keeping them happy means repecting them and their personal time and their requests for personal time. Keeping them happy means showing them that there work is important and meaningful and helpful to you.

Tuesday, December 12, 2006


I'm skeptical. Read NYT article from todays NY Times.

Saturday, December 09, 2006

Going Solo: Practical Document Management.

Even in a small EMR friendly medical practice, such as mine, document management can become problematic. When I first started, I had an EMR (see previous post) that easily handled 95% of paper in my office, such as notes, labs, studies, correspondance letters, etc. But we still needed copies of the patients' insurance ID cards, drivers licenses, HIPAA forms, and patient demographic information forms. While this may, or may not, seem like a mountain of paper, it quickly grew into a management problem. We found ourselves, on a growing number of occassions, having to expend time and energy on filing, copying, and retrieving documents.

Not what I had in mind!

So in order to overvcome this hurdle, I brainstormed.

  • Buy expensive copier that copies and scans quickly and automatically inserts into EMR. Awesome, but can't afford ("Oh but Dr, we have attractive leasing options!").
  • Buy flatbed scanner, and have staff manually scan documents daily or weekly into appropriate folders in EMR. No way!
  • Once a week or month, I or staff can place the mound of paper into the ADF of my multifunction scanner and then manually separate the digital copies into the appropriate folders in the EMR. Yeh!! It took forever just to write that down. Actually doing it, impossible!
  • Use my old digital point and shoot camera and take photos of the cards against a black background. Tried it. Staff didn't like it. I liked staff. Nixed camera!
  • CardScan! Yes, now this may work. For $99 I purchased a business card scanner with OCR software included and tried it out. It has worked beautifully. My staff and I can scan patients' insurance cards, front and back, and driver's licenses quickly and easily, and the software extracts the information into unique, searchable fields. We can even make re-prints of the crads or just insert the data extracted from the card into a form. Yes, this works great.

So I still have HIPAA forms and patient demographic forms, and this is managable for now. Yes I do have ideas to eliminate even these forms.

Any suggestions from the blogosphere?

Friday, December 08, 2006

Doctors beware!

Patients can get their revenge on us if we don't prvide them with a positive experience.
See article.

Tuesday, December 05, 2006

Going Solo? 6 steps to getting new patients.

An established medical practice, chiropractor, transcriptionist, etc, can survive on repeat visits or business from their existing patients or clients. But for a start-up or a specialty practice, such as an infertility specialist or plastic surgeon, new patient business is essential. But how do you attract new patients.

1: WORD OF MOUTH--This is no doubt the best way, but it takes years to get there in the best of circumstances. While waiting, you'll go broke or into deep debt or both. Do not rely on this method alone, in my view, ever. I believe it is essential to actively attract new patients thoroughout the life of your business or practice.

2: PRESS THE FLESH--This is a great way. In my opinion and, with all things considered, it is the best way. It involves literally going door to door to referring doctors and introducing yourself. It requires a car, gas, business cards, and a very thick skin. Be prepared to be treated rudely by staff who mistake you for a drug rep. Be prepared to be turned away. Be prepared for failure! But every so often, in my experience, 1 in 10, you'll hit it and convert your visit into a new referral. The rest is up to you and if you provide a good service, you'll get more. After several months and persistence you can generate 10-15 good referral sources who can support you, and aside for gas and guts, it cost you nothing.

3: ADVERTISE--I was told this would be a good way, but in my experience, it was not. In fact, I spent approximately $10,000 on traditional print media advertising (newspaper, yellow book, etc) and from it got 2 patients. In retrospect, it was a mistake, and not one I'm likely to make again. There are much better, more cost effective approaches. In fact, I believe that I would have had more publicity and more enjoyment had I taken the $10,000 and burned it! Or better yet, donated it to an infertile couple. But this is just my opinion.

4: ACCEPT INSURANCE--Sorry to say this, but participation with health insurance, while no doubt an evil, is a necessary one. And actually, I don't even think insurance is an evil, and I, like most physicians, actually does better because of insurance. Insurance companies direct new patients into your office by listing you in their "books." It's free and effective advertising. As long as you feel their reimbursement rates are fair and the companies actually pay you, you can grow because you take insurance.

5: TAKE ER CALL--I didn't do this for personal reasons, namely because I don't like ER call. Moreover, for urology, we don't have enough ER business to make it worth our while. But I have a friend who is in start-up practice as an orthopedist and a hand surgeon and he has built up his practice at an incredibly fast pace by taking ER call. In fact, he approached older orthopods with established practices who no longer wished to take ER call and offered to take call for them. Good for him!

6: HAVE A WEBSITE--This is good advice namely because hosting has become so cheap and easy. But is is certainly not enough because your website, without proper SEO, will be lost in the crowd. You can hire SEO firms, but these are $$$$. I chose to blog, which works quite well and has resulted in increase website exposure and new patient business. Plus, I like it.

Friday, December 01, 2006

An Interesting Question.

If you could prevent a potential competitor from entering the market place, would you?

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?"

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,, 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. or

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, and called to make an appointment. And then I understood the power of blogging. Since then my blogging efforts have resulted in increase website ( traffic, search engine presence, and an increase in new patient business. In addition, I use my 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.

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 ( 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 ( 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 Is the micropractice the answer and is it feasible? We'll see.

Dr S

Wednesday, October 25, 2006

Going Solo: why you need an operational manual

Ray Kroc, the founder of McDonalds, was able to create his enormous franchise empire, in large part, by establishing a uniform process of doing business. Every step in the daily operations of McDonalds restaurants were documented and written down in an operational manual. This is true today and has become a standard in the franchise model. There is predictability and uniformity for customers and employees alike and it is the prime reason why a person’s experience in the McDonalds in Cherry Hill NJ is identical to his experience in Peoria IL or in downtown Chicago. Sipping a Tall Mocha Latte in a Starbucks in Long Island feels and tastes the same as in a Starbucks in Seattle or Cleveland or Timbuktu.

Having an operations manual in your medical practice is important as well, but not because you plan to franchise or because you think you have the business savvy of Ray Kroc. No, writing an operations manual is critical to your start-up because it forces you to develop a mental blueprint for how your practice will operate on a daily basis. It is a dry run; a practice run. Practice runs help other professionals as well, including athletes, actors, firefighters, policemen etc. Good golfers conceptualize putts before actually putting. Downhill ski racers take mental practice runs before the race. Tennis players develop game plans prior to the match. In medicine, surgeons perform surgery mentally, in their mind’s-eye, before doing the actual surgery on the patient. This practice makes the surgery go better. Working on an operational manual is like taking a practice run, only on a grander scale. Writing an operations manual will tell you what you know, but more importantly, what you don’t know and make your start up process go more smoothly and less expensively. You’ll make fewer mistakes. Having an operations manual will make your new practice go better.

Your practice manual should cover everything you can possibly think of, like how your receptionist will answer phones and greet patients, how to autoclave instruments and clean a scope, and how to make up a new patient chart. Your operations manual should detail how you back up your digital records, what you do in case a person collapses in your office, of if there is a fire, and how to forward your phones at the end of the day. Literally you must brainstorm your process for dealing everything from the mundane to the fantastical and put it in writing in your manual.

From a more practical standpoint, the operations manual can assist in training new employees and the manual itself can become a de-facto practice manager, only one that doesn’t cost $50, 000 per year. When employees have questions about, for example, how to autoclave instruments, refer them to the manual. When they want to know how to forward the phones at day’s end, refer them to the manual. Employees like it because they know what is expected of them and you’ll like it because it allows you to focus on other issues.

You do not need to write the manual in one day or even have it completed before you start to see patients. But start writing it. I started to write mine 6 weeks before I opened my doors for new patients and the first entry dealt with the only thing I knew at the time about practice management, which was how I wanted my staff to answer the phone. Adjust, edit, and update the manual as needed. It is a living document that helps you critically evaluate your process of practice management. It will make your practice better.

For legal reasons that are unclear to me but clear to my attorney, your manual will need to make certain disclaimers and statements, such as an At-will policy, a harassment policy, an ADA policy etc. You can get the legal wordings for these sections from your attorney or insurance company.

Wednesday, October 11, 2006

How to start up a solo medical practice, deNovo!

From my hopefully upcoming book, Going Solo: What to do when you find yourself out on your ass!

The “to do list”—Getting started

In February 2006 I found myself, as I had predicted 5 years earlier, on my own. Solo. No more W2 income. It was the start of my dream! I had been in a larger group of Urologists and was unhappy. Luckily, I had savings, good credit, and a supportive family that enabled me to pursue my dream of going solo. While it has been the best thing I have ever done, professionally, it was not easy. Any young physicians who are considering going solo, as I have done, may benefit from reading on.

I had spent most of my medical career doing medicine; seeing patients, checking labs, rounding, operating etc. I came to work, did my thing, got paid. Period. When I found my self solo, the enormity of what I did not know from a business perspective became painfully apparent and caused for me a great deal of stress. What seemed to be basic issues, like how to go from seeing a patient to actually getting paid, how to collect co-pays, how to submit a claim, how to get a phone system, do payroll, FICA, and on and on now seemed impossibly complex. To make things worse, I had very few places to turn for advice on medical practice start up and management and what advice I did come across often was not practical for my situation. I was overwhelmed and panicked. You don’t have to be.

Medical practice is a small business just like any other. We may have issues that are unique to us, but the essence, obstacles, and, often, the solutions are the same for doctors, dry cleaners, pizza men, gardeners, chiropractors, dentists etc. In fact, a business entrepreneur friend gave me the best advice—the key to start up. What is key? The key is to define your ultimate goal, identify obstacles between you and your goal, and then to brainstorm solutions. List, actually list--on paper--obstacles on the left, goals on the right, and solutions in the middle. Do this, because it really, really works. Brainstorming relieves stress and enables you to focus, accomplish goals, and feel pride over reaching milestones. It is the first step in start-up.

Obstacles include everything that stands between you and your goal. My obstacles in February 2006 included lack of office space, little practice management knowledge, not enough money, no patients, no hospital staff privileges, no referring doctors, etc. Your obstacles may be similar to mine, but might be different, but you will have obstacles. Identifying them will help you to overcome them. It is essential that you list all--I mean all---of your obstacles. Slowly but surely, in a systematic fashion, you’ll overcome them.

Solutions encompass everything you are going to do to overcome the obstacles. My solutions in February 2006 included taking a loan, finding a real-estate broker, personally picking up an application for staff privileges at the local hospital, etc. I had a list of solutions on paper that corresponded to an each obstacle. As goals were accomplished and obstacles overcome, I would feel pride and relief. Make the list. You’ll feel better!

Finally, you must have goal. And not something like “to make a lot of money.” You’ll never have enough money. I mean to set a professional goal. What you want from your practice, profession, life, etc. My goal was my ideal practice—my dream practice. The practice I always wanted, but never thought I could have. If you don’t have a goal, get one. If your goal is nebulous, focus it, on paper. As you progress through the start up process, and beyond, the obstacles change and you must find new solutions, but the goal remains the same. Your goal is your rock. Your goal practice is your beacon of light that guides you through a very turbulent process—starting up, growing, and maintaining a modern medical practice. Without a clearly stated and written out goal, you will drift. Referring back to your goal will enable you to get back on course, complete the task at hand, and find happiness.
After making your list, you can start ticking off solutions. The list method is nothing new. In fact, my mother-in-law uses it quite frequently. And it may seem simplistic and juvenile, but it is not. Opening up a practice from scratch is an enormous undertaking and is best accomplished by breaking the process up into many smaller steps. The list method is a mental exercise and practical way to do this. You will find that with this method, you can be up and running, in business, seeing patients in 6-8 weeks, start to finish. Every day will have a goal directed purpose and you will make measurable progress with minimal stress.