Sunday, December 30, 2007

Just Doing My Part



Take Action Now!


Dear Patients,

New York State is currently in a health care crisis that threatens all of our abilities as patients to get affordable healthcare. The threat comes from a tort system in New York that has run out of control. Jury awards have risen dramatically over the years and are often out of proportion to the nature of the injuries. The problem is only getting worse.

I support tort reform that retains our rights to seek reasonable compensation when injured by a negligent act, but the system must prevent excessively high awards for pain and suffering that is limited in intensity and duration.

I call on you to take action and contact your local representative in the state assembly and ask them to support liability reform. I have pre-printed, addressed, and stamped envelopes; all you need to do is sign.

Please become involved in this grass roots effort to save New York from an impending health care implosion and in doing so, help to lower health care costs for the majority.

If you have any questions, please feel free to contact me.


Richard A Schoor MD FACS

Wednesday, December 19, 2007

Taking Notes From a Plumber

I just had a great experience with. . .a plumber! Yes, that is right, a plumber. And I paid $680. How is that. Well, I took notes. Not on his plumbing technique, but on how the business was run. Terrific from first contact to last. Let me tell you about.

We have a leaky pipe in the basement of our house. Though we have a contract with a plumbing service for our boiler and AC, I forgot their name and did not feel like looking it up. Plus, this pipe would not be a "covered" service anyway. As I was about to blow off the whole thing for another day, my wife handed me my 5 month old and a flier from a plumbing company. I get tons of these things, but timing is everything, right. I looked at it and liked the message: on-time service, up-front pricing, no surprise or hidden costs, all credit cards accepted, all work guaranteed in writing for 1 year (that's hell of a global), and a coupon. On the bottom of the flier was their phone number, clearly visible. I called—7:15AM—and, voila, they answered. Sold!

Over the phone, the receptionist had a friendly voice and she offered me a number of scheduling options, that day, or any other day. She had one of those great phone voiced that makes you feel like she is on your side. I should have offered her a job. Anyway, I took an appointment for the following morning, between 8 and 10AM.

At 8:30AM, the plumber arrived. He parked his truck so to not block my car, and when he entered the house, he had his own door mat with him. Nice: makes for good style points. I showed him the problem, along with several others that have been lingering, and after an inspection he came up with a solution, a guaranteed price, and the 1 year guarantee on the work. Plus, he turned off some pipes to the outside, gratis, and wore shoe covers so he would not dirty the rug. Again, nice style points and demonstrated that he was on my side and cared about details.

The work was completed quickly, but not too quickly. He made a soft up-sell on some biological cleaner, and I declined, and here's the kicker: when it came time for payment, we completed the transaction with a mobile, cellular credit card processor. Payment to him guaranteed. No accounts receivable. Not only relatively painless to me, a technological talking point.

Lessons for the doctor.

1: Answer the phones.

2: Hire excellent phone personnel and train them well.

3: Make the patient know that we are on their side.

4: Embrace technological advancements, especially when it comes to accounts receivable.

5: Attend to the details. They really matter.

Anyway, thanks for listening and if you want their number, send me an email.

The IU.

Tuesday, December 18, 2007

What Medicare cuts could mean

It looks like Congress will not intervene and that Medicare cuts of 10.1% on average are imminent. Urology is slated for an 11% cut. What does this mean in real dollars. Let's take a look.


Practice A sees 1200 patients per month = 14,400 visits per year x 25% Medicare = 3600 Medicare visits per year x average visit value of $150 = $540,000 reimbursed per year from Medicare x 11% = [$59,400 - $540,000] = $480,000 lost income if Medicare is dropped completely.

Practice A sees 1200 patients per month = 14,400 visits per year x 10% Medicare = 1440 Medicare visits per year x average visit value of $150 = $216,000 reimbursed per year from Medicare x 11% = [$23,700 - $216,760] = $193,000 lost income if Medicare is dropped completely.


Practice B sees 400 patients per month = 4800 visits per year x 25% Medicare = 1200 Medicare visits per year x average visit value of $150 = $180,000 reimbursed from Medicare x 11% = [$19,800 - $180,000] = $160,200 lost income if Medicare is dropped completely.

Practice B sees 400 patients per month = 4800 visits per year x 10% Medicare = 480 Medicare visits per year x average visit value of $150 = $72,000 reimbursed from Medicare x 11% = [$7,920 - $72,000] = $64,080 lost income if Medicare is dropped completely.


Practice C sees 200 patients per month = 2400 visits per year x 10% = 240 Medicare visits per year x average visit value of $150 = $36,000 x 11% = [$3,960 – $36,000] = $32,040 lost income if Medicare is dropped completely.


So as you can see, the numbers are large indeed whether a group or solo urologist keeps or drops Medicare. However, based on my calculations, a urologist or urology group would still do better remaining par with Medicare. Out and out dropping of Medicare would be tantamount to suicide for the business.

Though it is tough for me as a urologist to admit, Medicare has me by the balls.

Good luck to everyone else.


Monday, December 17, 2007

Speak of the devil.

The new HIPAA rules for practices such as mine.

Can't wait to read through them.

Results of my survey

I just sent a survey to an admittedly un-scientific sample of my patients, yet the results were interesting. The survey, sent to 24 patients selected at random, asked respondants 9 questions relating to the practice, the patient's experience here, and asked for suggestions for improvement. Here is a preliminary result that I'd like to share with you, as I find it interesting.

  • 16 out of 24 respondants stated that email was their preferred method to communicate with the doctor or staff, and this was not age dependent.
  • 24 out of 24 respondants stated that they had NO concerns regarding email security.
  • 24 out of 24 would refer me to a friend or famlily member.

Interesting. I am not sure what it means, but I believe that:
  • HIPAA is perhaps a bit overblown.
  • People want to communicate by email.
  • I'm pretty awesome.

I plan to send more surveys to try to get some real scientific data with hope of publishing it here on my blog.

Until then,
The IU.

Tuesday, December 11, 2007

The Paradigm Shaft

Several years ago a wise man said something to me that really impacted my life. He was a Pharma drug rep, but prior to that, he was an accountant for a financial service company. One day, during his old career, he had an epiphany of sorts when he was conversing with an investment banker. The accountant lamented to the banker, "How come you make so many times what I make?" The banker responded, off handedly, "Because I make money and you cost money."

"Because I make money and you cost money." Wow!

Several weeks later, this accountant left his company and went into sales so he could "make money."

He told me that story over dinner one night and I had epiphany of my own. There are 2 types of people in the world: those who make money and those who cost money. People that make money will always be worth more than those who cost money. Most of us fall into the cost money category. Think about it. The dichotomy really has truth to it. Movie stars, investment bankers, top professional athletes, even top doctors and lawyers, all validate their incomes because they produce wealth for others as well. They make money. Nurses, medical assistance, accountants, teachers, police officers, fire-fighters, in fact most of the rest of us, are in more of a support role and don't really bring in the bacon. Not to say that our jobs are not important. They are. It is just that we cost money, rather than make it.

Doctors used to be in the "make money" category. Throughout the 1960's, 70's, and 80's, doctors not only made money, we were seen as having the ability to generate wealth for others. The perception was that we made money. Beginning in the 1990's--though it's roots actually started under Nixon & Reagan--physicians came to be seen as cost centers rather than revenue centers. This shift in perception, a paradigm shift really, put us in the very precarious position we sit today. In fact, to the extent that there has been the downfall of doctors, this paradigm shift led directly to it.

People that make money are always worth more than people who cost money. It is really that simple.

Again, I don't have a solution for the problem. I only have the observation. I suppose that if you are a physician, you may benefit from re-tooling your practice so that you can be seen as a revenue generator, rather than a cost center.

Remember, 2 types of people exist in the world: those that cost money and those that make money. Try to be the latter.

Good luck.

The IU.

Monday, December 10, 2007

Why I Hate No-Shows

For most of us in the service industry, no-shows are a part of life. For most of us in the service industry, no shows are an exasperating and costly part of life. People that no-show don't think it is a big deal. Here's why they are wrong.

1: Lost revenue: I see patients sparingly on Saturdays, ie I reserve the day for people that really have a difficult time making it to my office any other day. This Saturday, I had office hours from 8-11, staffed by 2 people x ~$28 per year = $84, not including my time. I had 4 no-shows, each worth ~$50 x 4 = $200 lost revenue for that day. I saw 4 other patients, 2 new and 2 follow-ups = $350. Total income for this day was $350- $84- $200 = $66. Now it may be worth my time to come in to the office for $550 - $84 = $466, but not for $66.

2: Increased liability: Unlike people that no-show to a restaurant, established patients that no-show to a doctor's office can cause future problems for themselves and for the doctor. Even though they--adults all, mind you--no-showed, it is our—the physician's—responsibility to make a reasonable attempt to contact them. To do this, we have to pull their charts, review them, make phone calls to the patients, and send them certified letters. What does all this cost? It costs a lot if you factor in the following: chart review = 10 minutes per chart X 4 charts = 40 minutes x my time + staff time to call x 4 + certified postage $5.39 x 4. Plus, a no-show patient that is lost to follow-up yet resurfaces several years later with a tumor that "you missed" can bankrupt you. No, no-show's ain't cheap.

3: Increase in uncompensated work: All of the above work by the doctor is uncompensated.

4: Inconsiderate: I call to cancel reservations at restaurants and for haircuts. It's just the right thing to do.


The IU.

Thursday, December 06, 2007

Damn December

December! Everyone loves it, right. The holidays, parties, joy, peace and love on earth.


The holiday season can be a difficult time for many people. The depressed or lonely are the obvious people that come to mind. But I'm talking about the small business owners. Whether you are in retail, food service, or health care, the holiday season brings many challenges to your business. In retail, for example, experts project poor sales for this year, and owners, managers, and employees of retail chains and mom & pop stores alike may suffer the consequences.

Medicine, contrary to what I was told as a pre-med student, is far from recession proof. In medicine, we suffer right along with everyone else, minus the insurance execs.

I am not going to get into the economics of whether or not we are in a recession. We are, however, in a period of difficult economic times for many people. This economic downturn, in addition to consumer pressures that the holidays bring, mean less money spent on health care. i.e., we, the doctors, suffer.

Let's take the example of a typical patient of mine, a 35 year old man who wants a vasectomy. He works for someone else, most likely a big, faceless corporation or government agency, and his employer pays for his health insurance. His family income is $150,000 per year, which does not go very far in the New York metro area. Like everyone else, his co-pays or deductibles have risen dramatically in recent years. Far from being 5 dollars, now they are in the $35 to $50 range. His children, like my own, have had one cold after the next, after the next, and he has paid several hundred dollars in co-pays for his kids' pediatrician visits. His oldest daughter wants a new dance leotard and a Webkins doll for Christmas and his younger girl wants a Fiona doll and a Bella Dancerella video. Perhaps he and his wife agreed to not spend money on each other, but knowing that this really means "get me something," he buys his wife some inexpensive jewelry and plans to take her out for sushi. On top of all that, the pre-school/day care tuition for his toddler is due by Jan 1, or else, and that ain't cheap.

So how does this affect me? Well, he and his wife have decided that 2 children are enough and that he should have a vasectomy. Most likely, his insurance will cover it. But he still has co-pays. And I don't waive those. I simply cannot do that. Since he has all these other bills to pay, does not relish the idea of paying the 2 or more co-pays required for the vasectomy. In addition, he can't afford to take any time what-so-ever off from work, even though vasectomy patients recover quickly. He thus decides hold off for now on his vasectomy.

Multiply this times 20 vasectomies per month, times God know's how many other elective things that I do in urology, and you can see why December can be a difficult month for a urologist or any other doctor.

But Happy Holidays.

The IU.

Monday, November 26, 2007

Cost Consciousness and Medical Practice

An interesting article in the NYTimes on air travel reminded me of what has become of the experience of seeing a doctor. Basically, the article talked about levels of service on airlines and who gets what type of service and why. In the airline business, the overwhelming majority of travelers chose carriers based solely on cost. I include myself in this category. As a result, we have become loyal to the price of the seat, rather than to the airline itself. The airlines know that our loyalty and our business come only with low fares, and that our business will leave with higher fares, and they have determined that keeping us happy is no longer important. Now, the airlines can cut out perks that once made flying enjoyable, or at least tolerable. The fact that we complain privately and publicly is not important, since they can always get our business back by running a special deal. On the otherhand, people who are willing to pay for business or first class get treated like royalty. Wine, no lines, chateau-braind. Very nice. While both coach and first class passengers arrive at the destination at the same time, the high paying customers have a better experience.

Like the airline industry, people that can afford better care, either on their own or via the best of the best insurance plans, get better treatment. They can be seen without referrals, go to out-of network providers, and get any medication the doctor prescribes. They can even go to a concierge model physician practice. This is like flying business or first class. For the rest of us, we have to fly coach.

The costs associated with running an airline have risen dramatically over the years. So has the cost of administering health care or purchasing health insurance. In the airline industry, at one end of the spectrum low cost carriers exist that cater only to the cost conscious traveler. At the opposite end of the spectrum is the corporate jet industry that caters to the high end, low volume traveler that cares solely about convenience and comfort. In the middle, we have the typical airline company, like United Airlines or American, that have first and business class for the "out-of-network" travel and coach for the rest of us in-network only customers.

Comparing the airline industry to the medical profession is easy. Flying low cost only carriers is like going to a clinic. You'll get to your location, or get your care, but it won't be pleasant. Flying business class or first class is like going to a concierge medical office or a medi-spa. Not only will you get to the location, you'll have a great experience on the way. Flying coach on a major carrier is like going to the typical doctor. It used to be nothing fancy, nothing great, but pleasant enough. Now it is horrible. As the airlines get squeezed, and as the doctors get squeezed, and as we the consumers let everyone know that we care only about cost, the experience is becoming less and less tolerable.

I don't have a solution for any of this. It is just my observation. I suppose that if you want premium medical care, like air travel, you will have to pay for it yourself. Otherwise you can join the rest of us in the coach section of modern medicine.

Sunday, November 18, 2007

The world's cheapest full featured EMR-PM

Since my last post on my DIY EMR, readers have given me tips on how to make it even less costly. How does $0.00 sound for the software. Here's how:
This list ought to get you going and leave enough cash left over to pay the insurance bill.
Good luck.
The IU.
Disclaimer: While I have tried some of these programs, I vouch for none of them. I have no affiliation with any of these products and can not attest to their functionality or security.

Friday, November 16, 2007

MS Word & Your DIY EMR

Here are some features of MS Word 2007 that make it so attractive for a homegrown EMR:
  • Insert signature line: once inserted, you can sign it with the stylus. The program then locks the document to prevent any changes.
  • Built in PDR conversion tool: No need to buy acrobat. PDF is a great format for an EMR for a variety of reasons.
  • Insert inbedded files: The user can easily insert inbedded files, like bitmaps, with things such as illustrations, photos, notes, etc.
  • Change tracking: This feature is also on older Word versions. Allows the user to make changes with cross-outs, rather than erases. Makes for good transparency, ie spoliation accusation resistant.
  • Can easily create templates and record macros.
  • Phrase finishing: user can train program to complete phrases and sentences. Useful when documenting encounters quickly.
  • User friendly: very little training required.
  • Ubiquitous: Is pre-installed on most computers, and is compatatble with google documents and MAC OS.
  • Inexpensive.

In other words, it is an excellent tool for the homegrown EMR. AND, from what I've seen from many vendor sold EMR's, the basic platform that they use in their products. Kevin's right: why pay so much more?

The IU.

Thursday, November 15, 2007

DIY EMR: The essential elements

It's been almost 2 years with my homegrown EMR. Works great. For any of you in the 'sphere who might want to do as I have done, here are the essential or helpful elements:
  • Tablet PC with Windows XP Tablet edition
  • MS Office Suite 2007
  • Adobe Acrobat Reader
  • Efax Pro
  • Canon Multifunction F80 scanner/copier etc with included software or other brand
  • Cardscan business card scanner with included software
  • Linksys VPN manager
  • MySecureDoc encryption software
  • 1 DVD writer
  • 1 external hard drive
  • 1 off-site automatic back-up facility
  • Your own courage to go for it!
  • Adobe Photoshop Elements
  • Adobe Acrobat Standard
  • OmniForm
All the above is off the shelf, inexpensive (relatively so) and easily customizable and scalable. Each of the above programs are also very powerful and user friendly.

Give it a whirl. Let me know what you think.

The IU.

Wednesday, November 14, 2007

Going Green in Medical Practice

With all the talk about the environment, I was wondering how one could "go green" in a medical practice. Here's how.

  • Go paperless/EMR

  • Set the computers to power saving mode

  • Recycle shredded paper (even a paperless office has some paper!)

  • Practice the judicous use of antibiotics

  • Install water saving toilet flushers

  • Develop creative scheduling that promotes decreased medical waste

  • Do procedures with the lights off (joke)

A green medical practice.

The IU.

Saturday, November 10, 2007

Some Mistakes I've Made

Mistakes are part of life and cannot be avoided. As my grandfather, Pop Pop, used to say with his thick Russian accent, "Vichie, my mistake column is longer than my good decision column." Here are some mistakes I made over the last 18 months.
  • Makler Chamber: These are counting devices for semen analysis. $500 bucks each. Too labor intensive with regards to cleaning. I haven't used them in over 1 year.
  • Olympus Cx41 microscope: reticle counting grid compatibility issues with microcell counting chambers. Better to have gone with scopes used by RSofNY.
  • Overhead light source/OR light: waste of money $1200. Should have gone with a $50 lamp from Bed Bath & Beyond.
  • Bayer Automated Urine Anlayzer: $800 with 2 bottles of Multistix Pro dipsticks. Bad investment. Multistix Pro not reimbursed at higher level, except by M'Care. Lost money.
  • Phone system: $3000. On retrospect, still don't need it and could have gone cheaper with Cisco VOIP phones.
  • Cidex trays: Used for disinfection. $300+ dollars. Really glorified plastic trays. I don't know that I could not have just gone tupperware for much less.
And other still in progress and yet to be discovered. I will say before I go, however, that at the time, those purchases were well thought out and good intentioned, they just turned out to be wrong.
Hey, at least I didn't start a war by mistake!
Hope you enjoyed this post.
The IU.

Friday, November 09, 2007

My letter to Senator Clinton

Dear Senator Clinton,

Please accept my apologies in advance for interrupting you from your campaign for President of the United States with this letter, but I feel impelled to do so. I am a solo practice urologist in Long Island who sees many patients with Medicare. As you may be aware, the costs of practicing medicine in Long Island are high and proposed cuts in Medicare reimbursement would have detrimental effects on my ability to remain in business. Please vote against them so that I may continue to practice the profession that I love and to serve the people who have served our nation.

Our nation faces many challenges both domestically and abroad. Perhaps the struggles of our nation’s urologists seem petty and provincial when compared to the struggles faced by our military, our citizens without any health insurance, and our economically pinched working and middle classes. But urologists are vital members of any community. As employers and business owners, we give much back to the society that gives to us. Please vote no to Medicare cuts that would hurt urologists in general but solo urologists like me disproportionately.

Again, please accept my apologies for interrupting you on your campaign trail and I wish you the best of luck in the race. I certainly have been and will continue to be a supporter of you.


Richard A Schoor MD FACS

Wednesday, November 07, 2007

Automate, Automate, Automate

Automation is key, I've come to realize. Automation makes things go better. It allows for the staff and management to concentrate on things that require a human brain, such as judgment calls. At first glance, it may appear that a medical practice is not a great fit for automation. Certainly an auto plant lends itself better to robotic processes, but if you re-analyze your own medical practice, you can find processes that can be automated, and can thus become mindless and effortless. Here are some things that can, and should be automated.
  • Data entry: Forms can be scanned with an OCR reader and the data can be extracted and imported into PM software, all with a key stroke.
  • Communications management: Macro software exists that can reduce complex, redundant tasks to a simple mouse click. Items that come to my mind in this category are call forwarding, voice mail retrieval, and fax management.
  • Document management: This is where an EMR really helps, but even without one the process itself can be automated, only the robot must be a person.
  • Laboratory services: automated lab analyzers exist and are reasonably priced for good ROI. These devices can be run be someone with only a high school degree.
  • History taking: forms, whether they are digital or paper, can assist in data capture that is consistent, accurate, and efficient. Patients can complete the forms themselves or with assistance from doctor or staff. Forms can be automatically imported into the EMR with a simple mouse click.
  • Back-up: of course
  • Billing: charge codes (ICD-9 and CPT) can be captured directly from the digital encounter form and can then be exported automatically into the PM software to be submitted electronically and effortlessly to the clearance house.
  • Bill pay and EOB-check depositing are all ripe processes for automation.
  • Payroll, a no brainer
  • Savings: automated, continuous forced savings. Slow and steady wins the race.
And probably others.
Thanks for listening,
The IU.

Friday, November 02, 2007

On getting paid.

Occasionally patients just don't want to pay. Insured patients don't want to pay the co-pays. Self-pays don't wish to pay anything. "Why should I pay, you only talked to me." I don't understand this. As professionals, we make our money by dispensing advice, ie by talking.

It can be difficult to convince get someone to pay you. We are doctors after all, and people can tug at our heartstrings so that we "do the right thing." They'll give us all sorts of sob stories, and your staff will wish to waive your fees or to "bill them later." Resist this temptation. You have bills and obligations and are in no position to waive anything. If staff wishes to lower fees for a particular patient, they can take it out of their own salary rather than yours. Just my opinion. Here is how to minimize getting stiffed from patients.
  • Take credit cards
  • Have pay plans through outside companies (eg CareCredit)
  • Get the co-pay before the the patient is seen
  • Unable to verify coverage equals no coverage equals money up front
  • Unsure of benefits equals no coverage equals money up front
  • Don't be afraid to play hardball, which includes collections and litigation
The IU.

Monday, October 29, 2007

The MRSA Panic: This time, it's real!

My wife and I were having a discussion this weekend about the MRSA scare. We are both physicians, so we tend not to panic over these things.

We are also parents, so we tend to panic over these things.

In addition, as physicians she and I have had patients who are panicked. She asked me how I deal with their questions. I answered that I like to put the scare into perspective. Here's how I view it.
  • Fall 2007 MRSA
  • Fall 2006 Bird Flu
  • Fall 2005 Influenza, with no available vaccine
  • Fall 2004 SARS
  • Fall 2003 Mad Cow
  • Fall 2002 Anthrax
So in other words, the media for some reason that I just can't seem to understand, likes to scare us, in a public service sort of way.

In my view, the most significant impact of the MRSA scare has been on the cost-per-click amount for the keyword phrase MRSA. 1 week ago, I could have had my google adword banner shown for 10 cents per click at the top of the page. Now I am priced out of the market. In 3 weeks, after the media moves on to the next story, the keyword price will return to its usual levels. But by that point, MRSA profits will have dried-up.

So here's my take. If you have lots of money tied up in an anti-MRSA counter-top spray and you can't cash-out, panic. Otherwise, you have little to fear from MRSA.


The IU.

Saturday, October 27, 2007

My VONAGE experience summarized

I finally switched from VONAGE, my VOIP phone service provider, to Optimum Voice, a local Long Island company and branch of Cablevision. In the end, I switched because my 2 office VONAGE lines went dead and VONAGE customer service was unable to remedy the problem. I think the lines died because of incompatibility issues with my VPN router, but this is just my own, admittedly ignorant, speculation. Since I use the VPN router daily for billing purposes, and reconfiguring the router's settings would cost me hundreds of dollars, I decided to switch to Optimum Voice.

But please do not misinterpret my impression of VONAGE, which is this. It is an absolutely fabulous system. If I had to do it all again, I would pick VONAGE again, and again, and again. In fact, I kept my third VONAGE line, which I have in my house as another office line.

Here are some of the great features of VONAGE.
  • Cost: cheap
  • Simulring: I found this feature indispensable. As far as I know, only VONAGE has it.
  • Portability: Just re-locate the router
  • Caller ID: many phones have this, but not as good as VONAGE's. Trust me.
  • Call tracking: ALL inbound and outbound calls are logged. Other's services have this as well, but not quite as good as VONAGE.
  • Voice Mail-Email notification: This came in handy once in a while.
  • Network availability: great feature. If your internet goes down, VONAGE automatically forwards to a number of your choosing.
  • Others that I did not need, but are really cool. Go to the site.

Here are the disadvantages:

  • Unreliable: let me add a caveat. It is really only unreliable if the VONAGE routers are in line with other routers and switches, in my experience. My home VONAGE works fine.
  • Technical support: Only by phone, so if you have a major issue, your SOL. For minor issues, their phone support is OK.
  • Dropped calls: I had lots, but I think this had to do with my set-up, and not really with VONAGE per se. My home VONAGE phones does not drop.

That's it. In summary, I liked VONAGE and still do. I can contribute lots of my success to their ingenuity. Over 19 months, I never missed one call. Not one. I would recommend them to any small business.

Thanks for listening,

The IU.

Thursday, October 25, 2007

A load of garbage

I was surprised to see this headline on MSNs search page: Healthy Outlook. The article talks about an economic boom in the healthcare industry. Jobs a plenty.

There's only one problem: No money, horrible hours, difficult work environment. I wonder who sponsored the article?

Wednesday, October 24, 2007

My lab has achieved prestigious accreditation

Great news! My lab achieved the prestigious accreditation from COLA, a major accomplishment. In order to become accredited, a lab must adhere to strict standards of quality control and quality assurance. The accreditation process took 18 months, involved an on-site survey, completion of a 20 hour lab director course, and continuous commitment to quality laboratory processes.
Not easy, but well worth it.
The IU.

Friday, October 19, 2007

Threats from all sides

Recently someone recommended that I do a SWOT. A WHAT? A SWOT. In other words, an analysis of my practice's Strengths Weaknesses Opportunities and Threats, ie SWOT. I enjoyed doing the S and O portions of the SWOT, but the T was very disturbing, both in raw number and in ratio form with the O. In other words, my T/O ratio appears out of whack. Not good.

My threats include:

  • rising insurance costs
  • rising rent
  • rising payroll
  • rising administrative costs
  • increasing oversight
  • increasing regulation
  • declining reimbursements
  • litigation threats

Then yesterday, KevinMD ran a link the following post:

Damn! I guess I now need to add that to my SWOT list. What if I just bought product A then United Health Care demands I buy product B, then Blue Cross demands I buy product C? Then what? Sheer craziness. I suppose it is legal for them to do that, but it strikes me as problematic.
In any case, I'll add it to the T's, which now vastly outweigh the O's.

Most of my threats are similar to threats to other doctors. Some may find some perverse comfort in the fact that we are all on a sinking ship together, but not me. I believe that when the bow of the ship goes under water, and the stern rises into the air, it'll be every man for himself. And it won't be a pretty picture.

Threats from all sides. How will it end. . .?

Wednesday, October 17, 2007

Have a problem? Talk it out.

My MA has been causing me some aggravation. As I said, she is fresh out of school--in school actually--and is doing her externship with me. She is a blank slate. Blank slates are good for many things, but they cannot be relied upon to send urine specimens to the lab.

As a urologist, I see many people with UTI's, or UTI related symptoms. I send many urine specimens to the various labs for culture. For my first 1 1/2 years on my own, our accuracy in sending patient specimens to the correct lab at the correct time was 100%.

Now that accuracy has fallen, and with that my headaches have returned. What am I to do?

Well, only one thing in my experience works with people, and that is talking. I asked her, "What can I do to make your job easier and improve your accuracy?" 60 minutes later she walked into my office and asked "Can I make a suggestion." Absolutely.

Her suggestion was to keep a running tally of the patients seen and the specimen to be sent, and at the end of the day she and I would spend 5 minutes confirming that patient A needed a urine culture, patient B needed a cytology, and patient C needed only a UA, ect.

Good suggestion, and you know what; it works.

Talking! Who knew?


The IU.

Tuesday, October 16, 2007


Much has been written, recently, about the positive effects of apologizing. Some risk managers tell us to say "I'm sorry" when we mess-up. They believe that these words can prevent a law suit from being brought forth, and thus recommend that we do it. Maybe. To that effect, every so often I read in the paper about a plaintiff who said something to the effect of, "Had the doctor just apologized, I would never have sued." Yeh, yeh right! At the risk of seeming cynical, which I am not, I believe that these people do not understand forgiveness.

I believe that we, as people, apologize because it makes us feel better. And sometimes it gets us off the hook. I think we learn this as children.

I do believe that the recipient benefits from an apology. Namely it makes them--the recipient--feel better. Most importantly, the act of forgiveness is very therapeutic to the forgiver, rather than to the person who is apologizing. It is simply unhealthy for people to hold onto anger and internalize it. So lets say that I am a big believer in the power of the apology. I'm just realistic about it what an apology can accomplish and when it ought to be used.

For example, should people be absolved of their wrongs simply because they apologize? I don't believe so. Recently, in NY, a woman had a bilateral mastectomy due to lab error. I don't think an apology would suffice in this case. Moreover, the error was the result of short-cuts taken by the technician in the lab. Something tells me, that his apology to the boss found deaf ears, as it should have. The technician may have been fired, but the owners of the lab may lose their livelihoods over this incident. No, I don't believe that an apology means much in this case.

In my own office, I had a receptionist download a file sharing program on the office computer. I discovered it instantly. She immediately apologized, but I fired her on the spot. Her contrition would not have corrected the many problems her act could have caused, such as data loss, data theft, or an RIAA lawsuit. Her apology meant nothing to me.

Two years ago, my 4 year old pushed my 1 year old, who fell down a step. The 4 year immediately apologized, because she saw that I was angry. I responded, "I don't care that you are sorry" and then I explained to her that her apology does not undue the pain she caused on her sister. The 4 year old--an exceptional 4 year-old--understood, and she has never pushed her younger sister again.

I think we need to re-learn the purpose of "sorry." If you find yourself apologizing for personal gain, you are doing it for the wrong reasons. The goal ought to be for healing. If the goal is for healing, and healing alone, then it'll be accepted.

Anyway, just my thoughts.

I thank you for your time.

The IU.

Friday, October 12, 2007

Memory Lane

I just found this picture.
My first day of surgical internship at Northwestern Memorial Hospital.
July 1994.
I was 26 years old. Bright eyed and bushy tailed. Eager and energetic.
I am holding up my rounds list, the first of many.

A band aid to the rescue

Sometimes your organization can be in such disarray that you need major surgery to fix it. Other times, a band aid is all you need. Recently, I applied a band aid to my own practice. I purchased a cart.

The cart is stainless steel, has 3 shelves, and sits on 4 wheels. It is approximately 24 inches wide by 36 inches long, and 36 inches high. I keep my portable sono unit on the top shelf and I keep the various probes on the middle shelf. On the bottom shelf I keep the phlebotomy kit, fully stocked, and the power cord for the sono unit.

I do a lot of scrotal sonograms for male infertility in addition to performing pelvic/bladder sonograms for post-void residual urine assessment. Often I have to change probes several times per day, or I need to re-charge the portable battery on the unit at random times. Because evrything sits on the cart, I can do these chores quickly and effortlessly "on the fly."

When I have a vasectomy, I place the sono unit on the middle shelf, then drape the entire cart in a sterile drape. I then place the vasectomy instruments on the spacious top shelf. I usually begin my vasectomies on the patient's left side, then I move on to their right side. I just wheel the cart along with me.

Within arms length of the cart, on the right side, is the counter top. On the counter top I leave open the paper wrap from the sterile gloves. As I use up the sharps, I place them on the paper wrap to my right side. At the end of the vasectomy, all that remains on the cart is non-sharp garbage, the soiled vas instruments, and the vasa themselves. Within 1 minute after completing the vasectomy, I can have the used instruments in the sink, the vasa in the specimen bottle, the sharps in the sharps container, and the remaining waste--wrapped in the sterile drape--in the garbage can. Voila! Done.

No wasted motion. Efficiency. And as far as a vasectomy can be, a thing of beauty.

And all because I purchased a cart with wheels.


The IU.

Tuesday, October 09, 2007

Gone Digital? 6 Essentials of Back-up

Though I'm no computer expert, I have an EMR, and I have had crashed drives and lost data. I've learned the hard way how to prevent data loss. Here are 6 crucial elements for back-up systems.
  1. Automatic: Your system should back-up without your needing to ask it to do so.
  2. Redundant: You must not leave all "eggs in one basket." This way, you will never lose your data.
  3. On-and Off-site: What if you have a fire or flood in the office?
  4. Daily: If you see more than 5-6 patients per day, you will not be able to remember encounters, let alone billing details.
  5. Versioned: If files are corrupt, versioning will prevent the corrupt file(s) from being propagated to subsequent back-ups.
  6. Recoverable: Back-up is only as good as your ability to retrieve the lost data.

If you have an EMR, you need to back-up.

Any other suggestions?


The IU.

Tuesday, October 02, 2007

A decent way to send and document certified letters

Remember Mad Libs, those funny word games available when we were kids. They were basically stories in which the critical verbiage, adjectives, or nouns were left blank, to filled in by you. Depending on your own creativity, it was possible to create some pretty funny things.

Sending certified letters to non-compliant patients is not funny business, but can be made easier by applying a Mad Lib approach to it, only without the funny adjectives, adverbs, and nouns.

Before I had an EMR, I had to dictate the letter, have it transcribed and printed, then I'd have to review it, make any necessary changes, then repeat above process. That is how I used to do it when I was part of a group. Worked well so long as you can afford a huge staff.

Now that I'm solo, I'm more frugal, and I have an EMR--a home grown one--but an EMR nonetheless.

Here is how I did it until recently. I created a template letter with the date, patient name, DOB, and Dear SoAndSo fields left blank. When generating a letter, I would simply insert the above information, print the letter, sign it, scan a copy back to chart, and send the original. Of course, we would save all the USPS documentation for proof.

Now I think I have even improved the process some more. Currently, I simply print out the blank template letters, have my staff write, by hand, the name, date, and etc onto the letter. The staff then brings the letter to me. I sign it. The letter goes back to staff, who then scans it into the patient chart, places it in the envelope, and then mails it with certified forms attached. We retain USPS forms, which are scanned into the patient charts as well. Takes about 10 seconds per letter, if that. Scanning time for the staff, with an automatic document feeding scanner, is only slightly longer.
My system certainly lacks the prettiness of what you'd expect from an expensive EMR, but what it lacks in style points, it makes up for in efficiency.
Let me know what you think,
The IU.

Monday, October 01, 2007

Can't sleep? Audit yourself.

Are you certain that your documentation is good? Are you sure that all labs have been received and filed correctly? Have all your bladder cancer patients had their cystoscopies and cytologies?

Well, though I'm sure you pride yourself on your recall systems, documentation, audit proof EMR's, and lab follow-up processes, despite the best of intentions, things will slip through the cracks. So if you are worried, and you should be, do an internal audit before someone else does it. You'll be surprised at what you find.

  • Do your consults have associated referral letters
  • Do your no-shows have documentation regarding attempts to contact them
  • Are all the ordered labs and studies in the charts
  • Are certified letter documents in the charts
  • Do all encounters have written notes
  • Are informed consent discussions documented
  • Are phone conversations documented
  • Are all email communications saved in the chart
  • Does the documentation fit the coding level

I know that good EMRs can do lots of this for you, but I still believe that random audits are warranted. We do them and find things frequently. I recommend it.

The IU.

Tuesday, September 25, 2007

A check-list to the rescue!

I recently hired a medical assistant. She came to me fresh out of school. Actually, she is still in school, technically, because she is doing her externship in my office. I am training her.

I like her. She is eager and honest, and for me, nothing else matters more. Otherwise, she is blank slate and knows NOTHING! That is how I wanted it.

However, blank slates don't know how to properly clean exam rooms, sterilize instruments, set-up for procedures, forward phone-calls, dip urines, or anything that is required and basic to medical practice. Despite my repeated efforts to train her, she just could not quite seem to "get it" and was messing up left and right.

Now I had 3 options.

  1. Fire her

  2. Promote her

  3. Study her

I decided that the substrate was there and that I would need to figure out why she was failing me, or actually, why I was failing her. After a brief period of observation I learned that she was simply overwhelmed by the volume and was unable to remember her duties and to prioritize them.

The solution: a check-list.

I spent approximately 20 minutes brainstorming her duties and compiling them into a check-list format, which I then printed out and reviewed with her. I was afraid to insult her, so I told her that I used check-lists in college and medical school, and found them to be indispensable. All of which was true. She took the list in the vain that I had offered it and something amazing happened.

Her performance has taken a 180 degree turn immediately. Tasks are being completed on-time, without prompting, and I am free to pursue my duties. She is less stressed and happier, and so am I.

A check-list! Give it a try.


The IU.

Friday, September 21, 2007

The Free Market and Medicine

I often overhear in the physician lounges, or read on the internet, about many doctors' views on the free market. Typically, the doctors argue that "standard free market principles" do not apply to medical practice. Their arguments go something like this:
  • I charge $180 for an new patient consult, but only get paid $90, and therefore, free market principles do not apply.
  • I charge $5000 for a total knee, but only get $1200, and therefore, free market principles do not apply.
  • A radical prostatectomy is worth $4000, yet I only get $900 and therefore, free market principles do not apply.

Over the past 7 years, I have heard this line of reasoning hundreds of times.

I don't think they understand the free market. Let's use another industry to elucidate and clarify the problem. Let's use the toy industry.

Mattel designs, markets, and sells toys, but they don't make them. Since Mattel is a corporation, it's fiduciary responsibility is to maximize profits. One way to do this is by minimizing costs. A great way to minimize production costs is to outsource manufacturing to countries that can do it more cheaply. Mattel outsources toy manufacturing to Chinese factories.

Mattel, like United Health Care, has lots of money and thus leverage over the manufacturers. Mattel uses this leverage to negotiate production costs for its toys. The Chinese factories can either take it or leave it. Since the factories can not remain viable without a contract from Mattel, they choose to accept the terms of the contract, and then attempt to maximize their own profits by cutting production costs and increasing production rates. The Chinese factory does this by paying workers extremely low wages, using cheap materials, and, as we have now learned, using inexpensive lead based paints on the toys.

Mattel pays the factories cut-throat rates, which forces the factories to cut corners to make a profit, which, unfortunately, can ultimately impact the consumer negatively. On the other hand, however, the consumers in the USA and Europe, don't want to pay a lot for their toys, so the cycle continues.

Sounds familiar, right.

United Health Care does not produce health care, it only pays for it. As a corporation, its fiduciary responsibility is to maximize profits. One way it can do this is by minimizing production costs. United Health uses it's leverage, much like Mattel and the Chinese factories, to negotiate cut-throat production rates to the factories, which in this case are the providers. Unable to remain viable without the contract, we chose to take it, rather than leave it.

Now, to maximize our own profits, we attempt to cut our costs and increase production. We do this by outsourcing services, downsizing office (factory) sizes, and hiring low wage personnel and then we see more and more patients. The downside of this is that ultimately the consumer--the patient--can get hurt because in our efforts to cut-corners and increase production, we may make mistakes and hurt people. As a society, we accept this because, like toy purchasers, consumers of health care don't want to pay a lot for the product and the cycle continues.

See, our health care model is the epitome of the free market, and anyone who suggests otherwise is wrong.

Thanks for listening,

The IU.

Another Blogging Success Story

I got a new patient today. . .from India. He has been a devotee of Dr Schoor's Urology Blog, and is town on business. He has liked what he has read, and is coming to see me as a patient.

Cost to me: $0.00

Not Bad.

Monday, September 17, 2007

A View From My Window

I have a corner office, 2nd floor, that has a commanding view of my parking lot and road that leads up to it. I often use the window onto the lot as a sort of extension of my physical examination. Here are some things about patients that I have seen and learned from my window view.
  • Angry: On several occasions I have seen patients of mine honk, yell, or gesture angrily at other drivers in the lot. These people are uniformly lambs in my office, but this tells me that they are not very nice people at their cores.
  • Unethical: Once in a while, people park in the handicapped spots, yet are not physically handicapped. I know this because I take their histories. What they don't know is that I witnessed them committing these acts. Again, these people are always nice to me, but dishonesty is dishonesty, and their actions point towards their ethics.
  • Aggressive: Long Island has no shortage of aggressive drivers. So does my parking lot. Aggressive drivers cause many problems for society in general and basically these people think that they own the roads.
  • Selfish: Taking up 2 spots: People do this for 2 reasons: they have a nice car or they don't care about others. Either way, I think it suggests that they are either selfish or vain.
  • Inattentive: I can tell this when I see patients leave my office, go to their cars, then pull out of their space without looking, while simultaneously smoking a cigarette on the cell phone. Multitasking has it's place, but not while driving. It also suggests to me that I may want to have another informed consent discussion with the patients.

Maybe I'm overreaching, but I think that private behaviors go towards personality types in general. I just feel like I know these people better by witnessing an admittedly small sample of their driving.

Hope you enjoyed the post.

The IU.

Thursday, September 13, 2007

Four Sure-Fire Methods to Go out of Network

Every physicians' dream is to go out of network and really "stick it" to the insurers. Just follow these 4 steps, and you too can do it.
  1. Become a regional, national, or better yet, international name in your specialty. Have patients travel from far and wide to see you. It'll help if you write a book that becomes an international best-seller and in the process, you become Oprah's friend and confidante. Alternatively, you can invent a truly life saving or life- improving medical device. Either way, this'll get you there.
  2. Change to a specialty that sees predominantly emergencies and relocate your practice to a hospital that sees only well insured, non-medicare patients, then gouge the hell out of the patient's insurance policies. Also, hope that state legislators continue to turn a blind eye to this consumer-unfriendly practice.
  3. Become an out-of-network anesthesiologist and price gouge off the backs of your hard working in-network surgeons and hospitals.
  4. Join a top-tiered academic medical center, then rise through the ranks of your department until you are a huge national or international name. Also, see method #1.

See, it's easy.

The IU.

Wednesday, September 12, 2007

Cost Containment: Here's some tricks

With declining reimbursements, the only way to to remain viable is through revenue generation coupled with cost containment. I'd like to talk a bit about costs, and some obvious--and not-so-obvious-ways to minimize them.

Fixed Costs: These are items like rent and insurance. While you probably have little negotiating power in this area, with regard to rent you can keep costs down the following ways:

  • Maximize productive use of space. I pay $26 per square foot, and use all of it productively. An EMR helps here, because I don't need to dedicate several hundred square feet to chart storage. Also, mobile units, such as portable sonogram machines, client computers, and portable lab equipment, also helps. And of course, I have VPN, because it essentially converts my house or Starbucks, or anywhere with an internet connection into an extension of the office.
  • Maximize revenue generation areas of the office. These areas include exam rooms, your office, and the lab. Back office functions, such as insurance claims submissions and billing work, can be virtual, via your VPN, yet remain "in-house" as opposed to being outsourced. With a well networked office, exam rooms can serve as exit offices while you go to the patient in the adjacent room.
  • On-demand Supply Ordering and Smart Storage: Closets = Square footage = $$. With some thought and planning, shelving, exam tables, cabinets, and closet space can be used for maximal storage at minimal square foot usage. In addition, I order supplies as needed, since my vendor, PSS Worldwide Medical, always delivers next day.

Variable costs: These include costs for items such as medical supplies, payroll, utilities, stamps, etc, and can be determined by examining the profit-loss statements prepared by the accountant. here are some ways to keep variable costs down.

  • On-demand supply ordering. DELL Computers uses this concept. I do as well, just make sure you don't run out of Foley drainage bags after you've already placed the Foley.
  • Part-time employees: Simple. They cost less than full time employees, plus no overtime.
  • On-demand staffing: I staff heaviest on the busiest days. Plus, since I am capable and willing to pick-up slack on days that we are inadvertently short staffed, this method works out well. Busy days or light days, open or closed, phones are always!!! staffed.
  • Amortization of utility payouts. Most utility companies will estimate a fixed monthly cost for you to pay based on a prior years consumption. I like it for cash-flow management.
  • Have your phones (VOIP), cellphones, & internet on fixed plans, so that costs do not soar with usage. Get the maximum minutes for cell phones, since the incremental costs of the plan are much less than overage payments. VOIP is cheap, plus never varies with usage. On the balance, I've been happy with it, yes, even for the "mission critical" functions. I'm talking to you, Sunrise.
  • Fax. Why snail mail when you can fax the referral letter. Not only is it faster, more efficient, and trackable, it is cheaper. I love my fax. Yeh, yeh, yeh, I know, HIPAA. But it can be done and still be in compliance

Direct costs: These are costs that are directly involved in patient care. Here's how to minimize these costs.

  • Everyone does everything. MA's do data entry, answer phones, clean rooms etc. The docs answer phones (if they are not seeing patients) when needed, clean rooms, order supplies, schedule patients, e-file labs. Again, an EMR and a VPN helps here as well.
  • Part time employees and on-demand staffing: see above.
  • Creative patient scheduling: Figure out which works best for you; clinic, open access, proportional, or wave scheduling, and then determine minimal staff requirements for your office hours.
  • Ergonomic room design. I have rigged my rooms so that I can do a many procedures without an assistant present. I learned these skills as a surgery resident in central line clinic. In fact, I can prep with my left hand, place the scope with my right hand, and simultameously do a UA with my toes (kidding!). If you have 2 hands, a brain, and a Mayo Stand, you can make it work as well, and in the mean time, you'll free up staff to answer phones and book new patients or enter claims.
  • Training and process management: Training employees well and developing efficient processes of doing business will allow you and your employees to work smarter and with less mistakes and to get the job done right the first time. This simply saves money.

Indirect costs: These costs cover non-patient care activities, such as back-office staff and billers. Here's how to minimize these costs.

  • See direct costs.
  • VPN
  • EMR
  • Embrace technology
  • Multi-task
  • See training and process management

Hope you enjoyed the post and thanks for listening. And Seaspray, thanks for the baby card. Unexpected and appreciated.

The IU.

Tuesday, September 11, 2007

Why I recommend a VPN

I have exactly 5 seconds to publish to the blog, so I am going to be brief. VPN's--virtual privacy networks--are among the best features of the modern computing age. Here are some reasons why you may wish to invest in one for your office.
  • Ability to check labs and study reports from home or away
  • Ability to catch up on charting from home or away
  • Ability to access schedule from home or away
  • Ability to put drug-seekers in their proper place
  • Ability to access charts when not in the office
  • Ability to always seem omniscient
  • Ability to grow faster by "booking" patients that call during "off" hours
  • Ability to submit claims remotely
  • Ability to have multiple offices with one central chart storage system
  • Ability to stay connected yet have a life at the same time

And others. At the risk of stealing from MasterCard's add campaign:

  • 8 port VPN router $200
  • Computer guy to set you up with VPN ~ $500
  • Checking labs while giving your newborn a midnight bottle Priceless!

Get a VPN. You'll like it!

Thanks for listening,

The IU.

Friday, September 07, 2007

A little known side of urine analysis

Urine analysis by dip stick is a CLIA waived lab test. What this means is that as long as you follow the manufacturers directions, exactly, you will be in compliance with CLIA'88 regulations and will not need not anything other than a CLIA Waived Certificate to legally do the tests and bill for them. But here is the rub. You must follow the manufacturers directions exactly, because veering from the package insert directions automatically converts your waived lab into a high complexity lab, and you don't want to go there. Below is a description of the QC (quality control) requirements for urine analysis.

  • The package insert from the test strips recommend that QC (quality control) be performed on every new package of test strips.

  • QC, according to the package insert, involves 2 sets of negative controls, and 2 sets of positive controls

  • If you use an automated test strip reader, the manufacturer recommends that, at the very least, QC be performed daily, as above, on all testing days.

  • Each test costs 33 cents (PSS brand) or 50 cents (Bayer Brand), thus daily QC just for UAs costs netween $1.20 and $2.00, or between $370 and $624 per year.

If you don't, then in essence you are converting a waived test to a high complexity CLIA test. Good luck.

Dr Schoor

Thursday, September 06, 2007

Forms the Easy Way

Scheduling surgeries at the hospital has become somewhat painful due to none other than hand writing issues. I have decent handwriting, and I print so as to make it that much more legible. Still, every 3rd or 4th OR scheduling form ultimately bounces back to us for clarification or re-do based, no doubt, on legibility. I suggested that the hospital make the booking forms available on-line, and they said "great idea", but nothing happened. Here's how I do it now:
  • OmniPage 5.1 ($89.00, Staples)
  • Forms are scanned in and then converted to digitally amendable forms on my computer
  • We configured the forms so that my information is stored and automatically entered into the form without the need for duplication of data entry.
  • My staff enters the patient demographic data and insurance information
  • I enter the diagnosis and code (if I know the code off hand) and the procedures and CPT codes (if I know them off hand).
  • The form is saved in the "OR scheduling directory" and the patients chart
  • We then "print to efax" and the form is faxed directly from desktop to OR scheduling office

We just began doing it and the increase in efficiency is readily apparent. Plus, I enjoy home grown solutions, though hat tip to Sunrise Urology for the OmniPage tip.


The IU.

Monday, September 03, 2007

Cold Busted!

Technology has made it very difficult for drug seekers to fool us physicians. In the past, though, this was not the case. Prior to advent of the CT scan, drug seekers had somewhat of a golden age. During this gilded age, these addicts could go into any ER, or call any urologist on-call, give the doctor a history suggestive of kidney stones and renal colic, state that they were allergic to IV contrast, and that their stones were uric acid, so not visible on regular x-rays, and then they would receive their fix. The more ERs they went to, and the more doctors they called, the more drugs they would receive, and perhaps even sell on the street to other narcotic addicts. I came out of medical school and became an intern on the urology service in 1994, just prior to the era of the ubiquitous ER CT scan, and I learned fast how to differentiate drug seekers from true renal colic patients. I still use those skills today.

Now, life has become difficult for drug seekers because technology is readily available that allows us doctors to catch the drug seekers in their own lies. Yesterday, I achieved what I would characterize as a pinnacle moment in my on-going game of out-wit-the-drug-seeker. A person claiming to be my patient called me Sunday ~9AM, and stated that I saw him 2 weeks previously both at the hospital and in my office and that he was still in pain from a kidney stone that he had not yet passed. I did not recognize his name. This would be somewhat usual for a kidney stone patient in my practice, because I have few of them. Red flag number one, but still possible. He when on to say that he was taking oral toradol--a medication that I have never prescribed because it is ineffective for pain--and that the toradol was not helping him. Red flag number 2, but still possible. I then asked him if he would like me to call in something stronger, and then I asked him what has helped in the past, an old urologist trick to smoke-out the seekers, since they always have their preferred drug and will often tell you not only the name of the drug, but their desired dose, potency, and quantity. He stated he wanted hydrocodone 7.5mg. Boom, red flag number 3. I then asked him for his pharmacy, and he stated that it was closed for the holiday, but that I could try this "24 hour" pharmacy. OK, red flag 4, but still I was giving him the benefit of the doubt. I asked him for his phone number and for him to spell his name out for me, and then I said that I would call in the prescription. And here is where the fun began.

I have an EMR and can access my entire office network, both EMR and PM software, from my house. I logged into my network and searched through the patient names in my PM software, looked through the charts, and even looked for a copy of his drivers license, which we always scan into our system on the patient's first visit. Low and behold, he was not a patient in my practice. I even typed in a variety of permutations for possible spellings of his name, and still, no patient by his name, or anything even close to it. As I was trying to find any evidence that he was in fact my patient, he called back, 5 minutes later, to find out why I had not yet called his pharmacy. I told him that I was having difficulty verifying that he was my patient, at which point he seemed to become annoyed. He swore that I had seen him in my "Smithtown office" 2 weeks ago, and that he had received a letter from my office in the past few days, only that his name was severely misspelled on the letter and "was not even close to my name." I asked him how we spelled it on the letter, and he stated that he forgot and that he "lost" the letter and could not remember what it said. At this point he was really irate and was trying to put me on the defensive--how could I not remember my patients! This is a good technique used my many drug-seekers and often they threaten to "tell" your senior partner, or attending, or boss, or "the medical board" and to have you fired, or worse. Now that I am the boss, this just pissed me off, and I decided to end the conversation. I told him that if his pain was severe, he could go to the ER, but that I would be unable to prescribe the narcotic for him without verifying that he was an established patient of mine, then I hung up on him. This is the first time I so competely, efficiently, and undeniably caught a drug seeker as they tried to defraud me. Un-@#$%-believable!

Drug seekers are really a bain in our collective exhistences. They will lie and cheat--even steal--to get what they need, the drugs, and we the doctors, are the victims. Their behavior puts us doctors in a precarious position, for if we deny them the drugs, we risk negative word of mouth and damage to our reputations and practices. Yet if we acquiesce, we risk providing poor medical care at the least, and being accused of malpractice and possibly criminal offense--diversion--at the worst. Many drug seekers have successfully sued the very physicians to whom they lied when the doctors yielded, gave them their candy, and then damages ensued.

Attempting to obtain a narcotic prescription under false pretenses is a crime, and if the physician facilitates it, then he/she may be committing a crime as well. I always give my patients the benefit of the doubt and err on the side of trying to alleviate their suffering. But when I diagnose them as a drug seeker, I cut them off mercilessly, and if I can prove they lied to me, I'll contact the authorities and report the crime. I did so on this patient.

If you are a drug addict and are reading this blog entry, be forwarned. There is a new sheriff in town. And his name is The Independent Urologist.


The IU.

Friday, August 31, 2007

Beware: A Down-side of Blogging

If the up-side of blogging is the development of a web presence and all the good things that that brings, then the down-side of blogging is the development of a web presence with all the negatives that that brings. There are numerous ways that the web can cause head aches, just ask Flea. But aside from taking grief from what you write, when you become visible on the web, you become a target for all the crack-pots, hackers, and "lonelies" determined to do you harm.

Here's a question: What do Latvia, Microsoft, The Pentagon, Google, and Dr all have in common?

Answer: We've all been cyber-attacked.

Here is what happened to me yesterday. At ~3PM I went to check email and received ~100 mail demon messages, the ones that indicate undeliverable email messages. 3:15PM I checked email again, and ~100 more mail demon messages. 3:30PM, ~100 more. On so on and so on. By 8PM I had received well over one thousand such messages, from all over the world, in all languages. So many messages, in fact, that my server was tied up and sluggish and business was affected negatively. Finally, I called my ISP and learned that I had been "spoofed."

Spoofed! What does that mean? It involves taking over someones email "spf" protocol. Hence the term "spoofing" but in English, I learned, it involves commandeering a person email extension, such as or etc, and, I guess for the fun of it, spamming the world with your email. Undeliverable messages--those without recipients--get bounced back to me with the notation "undeliverable massage" from mail demon or something similar. The spammer can use an automated program to send millions of spammed messages from YOU, and your server gets tied up with the junk mail that returns.

I have no idea what message the spammer sent using

Dr, cyber-attacked. Richard A Schoor MD, victimized. Yes victimized, that is how I feel. I have solved the problem and the messages are slowing down. All that is left to do now is to find the important messages mixed in with the mass of junk, hope that the spammed message was not too offensive, and to file a police report. I hope the authorities catch the perpetrator, though I know they will not.

Beware of the Web. It giveth and it taketh away.

Thanks for listening,

The IU.

Wednesday, August 29, 2007

Professional Tennis Player vs Urologist: Which is Better?

I've been spending time at the US Open this year enjoying the matches and people watching. Only this year, I have begun to look at the players through the prism of a business man and could not help but wondering who has it better; them or me. Here are some things I noticed.

  • Income potential: While it seems limitless in professional tennis, this is a myth. Only the top 100 players in the world make any significant income, and the truly big money, millions per year, goes only to the top 50 in the world. The seemingly limitless corporate money goes only to the top 10, and even to them, only to those whose names transcend the sport, such as Andy Roddick or Roger Federer or in Spain, Rafael Nadal. In contrast, there are ~8000 practicing urologist in the USA, and most do very well, in the >$200,000 income range. Like in professional tennis, the "top" urologists do far better and can earn >$1 million per year in addition to corporate money via "consultant fees" and speaking fees. Over the course of ones career, the average urologist will earn many times what the average professional tennis player will.

  • Threats: Both urologists and professional tennis players have significant threats to the viability of their careers. For urologists, the ever present threats are devastating lawsuits, rising costs, declining reimbursements, and outside regulatory changes. These are all very significant threats that affect all practicing urologists, yet most of us soldier on and do well despite these challenges. Professional tennis players face threats as well, and I think theirs are even worse than ours. In addition to challenges from their competitors, professional tennis face the high probability of having a career ending injury.

  • Overhead: Urologists have high overhead. Ours comes from rent, payroll, insurance, professional dues and CME, equipment, etc. A solo urologist's overhead can easily exceed $150K per year, and a group of 3 can exceed $1 million per year. Now lets look at a tennis player. While it may seem that they travel light, I believe it only seems that way. A tennis player's overhead is high and includes the costs of training facilities, coaches and trainers, equipment, travel, hotels, health insurance (if they are Americans), and others. Coaches take 10% of earnings, or more, before expenses, and this can be more than a practice manager earns in a big group. Yes, professional tennis players have high overhead.

  • Lifestyle: It may appear to be an exciting lifestyle--and I believe it is for the top players, or while a person is still in their young 20's--the extreme travel schedule gets old fast. Family building must be put off until after ones career, for women, and for men the travel is difficult on relationships as well. Either you bring your family with you and live out of suitcases, or you leave them at home and suffer without them. No doubt, urologists have a better lifestyle than the majority of professional tennis players.

So I think my parents were right after all. . .stay in school, play as amateur, and enjoy the Open, no doubt my favorite time of the summer.

Hope you enjoyed the post,

The IU.

Monday, August 27, 2007

Please tell me which P4P guidelines to use for this patient.

Anyone who reads this blog knows I rarely, in fact never, post medical issues on this business related blog. But alas, I feel I must. I have a patient I'd like to share with you who no doubt defies all P4P guidelines.

She is an 80+ year old woman with COPD and chronic bacteriuria. Now please note, I did not say urinary tract infections, which would indicate that the bacteria in her bladder causes her problems. No, she has simply bacteria in the urine, but otherwise does well. Despite her lack of symptoms, other physicians--no doubt well intentioned--had persistently started her on antibiotics for every positive culture, which happened to be on every urine specimen sent, or 6-8 times per year, for several years. By the time she came to me, she had multi-drug resistant bacteria in her bladder. Fortunately, she was not symptomatic, because if she was, we'd have had a problem.

Now she has incontinence, mild incontinence, but incontinence nonetheless. She is not particularly bothered by the problem, but she does wet the bed at night, and this bothers her caregiver, who is her daughter. Having ruled out the other usual causes of incontinence, and having tried medications to treat the problem, I have concluded that her bacteriuria is contributing, or causing, her incontinence. Since she is now symptomatic, she has, by definition, a UTI--or urinary tract infection. The urine cultures, which are catheterized cultures, show an E. coli bacteria that is susceptible to penicillin's and cephalosporins, though not to quinolones, sulfas, nitrofurantoin, or macrolides. I can use aminoglycosides, since the organism shows susceptibility to them. The patient is allergic to penicillin's and cephalosporins.

So what do I do? Well I know what to do because I have a brain and judgement and I cognate and I can have informed consent discussions with the patient and her family, all things that computers and guidelines are incapable of doing. Is the government telling me that P4P guidelines would help me treat this patient? I don't think so.

Oh, and one last thing. If you think that this patent's situation is unique or uncommon, think again. Asymptomatic bacteriuria occurs in 80% of institutionalized octogenarians. Moreover, millions of elderly woman will find themselves in a similar predicament as my patient and effective treatment requires thought and interactive discussions, not guidelines.

Thanks for listening.

The IU.

Finally, a good use for a camera phone.

My cell phone of 4 years finally croaked, so I bought a new phone. I actually did not want anything fancy, just a phone that made and received calls with reliability, which on Long Island, with its shoddy cell phone service, is no small feat. Other features on phones, like MP3 players and cameras etc are not important to me, and are merely toys. And you know what I think of toys, right?

So on call this weekend I had 4 consults, and you know what I did. I used the camera phone to take photos of the patient demographic sheet, or face sheet as we say.

Worked pretty well, though it does not save me any time. But in a pinch, could be a useful tool.


The IU.

Tuesday, August 21, 2007

VONAGE Vindicated!

I have switched from VONAGE to Optimum voice, have purchased a $3000 phone system and calls still drop. Broad band is sufficient to handle the volume, so it is not a VOIP issue and was likely never a VONAGE service issue. After all this, the issue may be in a faulty phone line from the source to the wall jack by the reception area.

Of course everyone blames everyone else, but I am zeroing in on the problem. In the meantime, we just march on and continue to function.

The IU.

Monday, August 20, 2007

The Human Element and Screw-Ups

I have a little lab in my office, as you may know. Nothing fancy, just semen analysis and urine analysis, but to do these tests, I need a CLIA ID, and I must run my lab with an eye on quality control. To that effect, I have taken great pains to prevent specimen mix-ups. Here is how I did it:

  • Pre-label specimen cup with patients name and DOB.
  • Staff gives appropriate patient the cup with their name on it.
  • Patients produces appropriate body fluid into cup, and leaves cup in bathroom, etc.

Here is why I recently changed:

  • Staff gave cup labeled John Smith to patient named Mary Washington
  • And vice-versa
  • The mistake was caught in time

Here is how I do it now:

  • Pre-labeled cup as before
  • Staff gives patient cup
  • Patient signs attestation sheet that verifies that name on cup is their own
  • Attestation sheets are saved

Humans are wonderful. I love them. But you must admit it, we, as a species, can and will find any and all ways to screw-up. Scary stuff. Better re-think your processes and close up the holes.

Thanks for listening,

The IU.

Saturday, August 18, 2007

99% Accurate. Is it Good Enough?

I would like to comment on something I just read on KevinMD. Here is the Title:

Retail clinics: 99.15% proper treatment rate?

And here is Kevin's input: No doctor can match the perfection that retail health clinics offer.

Why don't we examine what 99% means, and then we can decide if Kevin is right in his assessment and more importantly, if the retail clinics' accuracy rate is acceptable.
  • If a surgeon removes 99% of the tumor, the patient dies of cancer
  • If the antibiotic I prescribe is 99% effective against the bacteria, the infection will recur.
  • If my sterilization technique for cystoscopy is 99% effective, I'll infect 2 people per year, and a busy urology group will infect 10-20 per year, potentially, with an infectious disease!
  • If my specimen labeling process is 99% effective, I'll mix-up specimens at least 26 times per year (100 per 2 weeks x 26 bi-weeks per year).
  • If a busy internist is given the correct chart with 99% accuracy, he will make his notation in the wrong chart on 52 patients per year, on average.
  • If a lab filing system is 99% accurate, labs will be misfiled 100 times per year, on average, in a moderately busy doctors' office.
  • If an established medical office has an EMR that uses back-up that is 99% accurate, a crash could cause the permanent loss of 100-200 charts (10,000 to 20,000 patient practices, respectively).
  • If surgeons operated on the correct side/site only 99% of the time, in my little community hospital, we would see 1 wrong side/site surgery per week, and the hospital would be shut down by the state.
  • If you drove with 99% accuracy, you'd have a car accident every 4 to 5 weeks.

You see, 99% sounds great, but in actuality, is only good if you are taking a college final exam. In life, big number enterprises, such as medicine, 99% is not very good at all.

I disagree with Kevin. "Proper treatments" are given by doctors at a far more accurate rate than 99%, or we'd all be out of business. And I'd think twice about going to a retail clinic.


The IU.

Thursday, August 16, 2007

Inspiration for blogs

Someone asked me today how I get my inspiration to write the material on my blog with such frequency. The answer is that life and life-in-practice serves up more than enough material to fill my pages. In fact, as you can see, the question itself became a topic. Here are some some examples of some inspiring blog topics that I'll hopefully find time to publish:
  • Last week a sales rep from a small uropathology lab in NJ came to my office. Despite the 90+ degree heat, he had on a cheap suit--jacket, tie, and all--and his forehead was covered in beads of sweat as he tried to convince me to use his lab. Unfortunately his message was lost on me, as I could not help but find myself thinking about my mom and dad, and thanking them for encouraging me to stay in school as I regrettably viewed him as a somewhat unenviable character in a very undesirable job. Maybe I'll throw him some bones, since I've always liked underdogs.
  • Yesterday, 2 avodart reps came to my office. One was a late 40's woman, and the other a mid-30's man. The woman did all the speaking, so obviously, the man was her boss, ie her territory manager. As she showed me her marketing material, several things went through my mind. The superb quality of the marketing material made me think of how I would like to mimic it, in some way. Then she showed me graph, and as I marveled over the complexity of it, I was reminded of medical school, and then I thought of calling my friend Mike, to catch-up. Finally, I found the dynamic of the woman and her boss interesting, and I found myself thinking that I would not do well in such a situation, and would not like the obvious post-encounter debrief/critique that was sure to ensue.
  • Today I had a case get canceled due to a scheduling mix-up on the part of both the hospital's and my own scheduling processes. The hospital booking agent, who was new, did not know the difference between intra-corporeal lithotripsy and extra-corporeal lithotripsy, and the patient and I were told to report to hospital A, when the correct equipment was at hospital B. It happened to another of my colleagues this AM as well. Fortunately, the mistake was caught before the patient was taken to the OR and sedated, and his case was elective, so no harm was done. But it got me thinking again about process management and six-sigma in my office, practice efficiency, and a whole other host of blog topics.
  • My COLA lab inspection has provided me with tons of material not yet published.
  • My late night baby feedings has inspired a host of posts as well on such topics as: how to type while one hand holds the infant bottle, good late-night bottle feeding movies, how to get a quick post in between calls for help from the wife, and how scheduling early morning cases can become an effective method to avoid late-night feeds.
You see, life is full of topics perfect for a blog, and all that you have to do is live, observe, listen, and write.


The IU.

The IU.

Wednesday, August 15, 2007

EMR: The Essential Features

I'm in the market for an EMR system. I have one, a home-grown system, that actually is pretty good and efficient, but lacks some features that I believe are essential. Here are features that I look for in an EMR:

  • Unalterable: Records must be unalterable once written and the system should not have any "back-doors" that allow alteration of a record. While mine does not do this automatically, it does do it. I just had to develop easy method to make the records final and unalterable, a feature that I consider absolutely essential.

  • Amendable: Entries must be amendable, but the date and time of the correction and the amending person must be noted amd time stamped. In addition, the original entry must be visible for all to see. Mine does this too, but again, I had to come up with my own home-grown solution.

  • Efficient: One time data entry, and seemless transfer of information from the PM program to the EMR to the lab ordering system, letter generation system and result reporting system. If you have to enter the same piece of data more than once, the program is no good. My system fails in this regard.

  • Intuitive: If someone with a no more than a basic knowledge of windows and MS-Office need extensive training to use the system, it is too complex and not worth it. Reconsider. My system scores high in this feature.
  • Affordable: I'm not saying cheap, but if you have to see 1000 extra-patients a year just to support the EMR, it is not worth it. My system socres off the charts on this feature.


The IU.