How to sack someone in academia.

Academic medicine, like private practice medicine, is not immune from market forces that force change. Occasionally, those market forces dictate that a physician move on to another job. Unlike private practice, however, termination--firing--of academic appointments is not so straightforward, and often involves a team of lawyers and human resource personnel to ensure that the person is sacked legally, and without recourse. Here are some ways to get rid of your academic partner:

• Termination: Easier said than done, and throw gender, ethnicity, and age into the mix, and it can become next to impossible. To do so requires either 1 egregious act on the part of the target, or a paper trail of poor performance examples. The paper trail can cut both ways, as the target can use it in their behalf as proof that they were, in fact, targeted. There are better ways.
• The Squeeze: Cruel, but effective, especially with a younger employee who has other options at their disposal and can take the "hint" and act. The squeeze involves slowly and surely removing or altering privileges, such as OR block time, office hours, or physical office space. It may seem petty, but the message should be loud and clear. When your office is relocated to a trailer at the far end of a parking lot, it may be time to find a recruiter and bolt. Of course, since you were not actually fired, legal action is more challenging, though doable.
• The Demotion: Similar to the squeeze, but usually involving pay and rank. When the head of the section of oncology is made vice-head upon arrival of the "superstar", that is a demotion. For some people with poor ego resources and even less financial resources, the demotion may not be enough of an incentive to leave, though remaining behind is, well, unpleasant to say the least.
• The Promotion: This is the best way to get rid of an ineffective employee, and while it may seem like a joke, it is not. When the OR scheduling clerk at the VA, where I worked, went "nuts", he was promoted to "concierge." Usually the promotion is to a position with a nice title, an office, no staff, and no responsibility. In effect, you've been made inconsequential. From a legal perspective, these promotions are iron clad. How are you going to complain, you ingrate, you were promoted. Beautiful.

So the next time someone tells you that they were "promoted", you can raise your eyebrows, in knowing recognition of the truth.

Thanks for listening,

The IU.

The agonal rythyms of a medical community.

Have you ever watched a hospitalized patient die? I have, on several occasions, as medical student and as a resident. If you could detach yourself from the human element, the suffering, the tearful families at the patient's bedside, the horror of modern, tube-filled death, the physiologic aspects of impending death can be quite interesting.
As a medical student, on an SICU rotation, I witnessed a tragic case involving 16 year old girl--a passenger in a high speed MVA--who suffered severe traumatic brain injury, and no other damage. She was not brain dead, as she had some brain stem activity only. All that the family could do was to make the agonizing decision to terminate supportive measures. After the family left the bedside and said their final goodbyes, I sat in the room with my senior resident who wanted to teach me about agonal rhythms.
As a patient's death becomes imminent, respiratory rhythms change from deep, regular breaths that sustain life, to short, erratic, and non-functional breaths that hasten death. These are called agonal rhythms, and they mean the end of life for the unfortunate sole.
Yesterday I spent my day in the Hospital where I had 7 surgeries for male infertility. Between cases I had the good fortune--or not--to speak with my colleagues in other specialities such as orthopedics and OB and general surgery. To say there was griping is an understatement. I have spent the last 10 years in physician lounges hearing griping, and what I heard yesterday was something different. This was desperation and fear. This was solemn resignation to a simple fact--it's over. We've lost. We're dying.
Agonal respiration.
Some said they were going to try this, and some said they were going to try that and others simply shrugged, accepting of certain demise.
Agonal.
If I could somehow detach myself from the human aspect of professionals at the heights of their careers with busy practices and happy patients who are going out of business, I might be able to find it interesting. How will the market correct itself? What will they do? What will break first? From a business, case study perspective, yes, it is interesting.
But it is not interesting! It is horrifying and scary and sad.
Agonal rhythms.

A good reason to blog.

If you are a physician, or any other public person, there exists a great deal of information about you that is readily available to anyone with access to a computer and some google skills. Physicians, it seems, are among the most public of figures, and with a couple of key strokes, potential patients--or anyone for that matter--can learn the entire work history, training history, and any disciplinary history for any physician, any where in the USA, 24 hours a day. And most of this information is supplied not by the physicians themselves, but by third party data entry personnel, some who work for the state, and some who are employed by for-profit companies. In other words, there is dialogue that goes on about you, and you have no part in what is being said.

Here is a simple, low or no cost way to combat this dialogue.

Take part in it.

Engage it. Add to it. Reply to it. Embrace it, and eventually, control it. How?

Blog.

By blogging actively and transparently--in your own name--you can influence the dialogue that already exists and turn it in your own favor. Your blog should be compelling, honest, and well written, and if it meets those criteria, people will find it and link to it. The more posts, the more links, and the higher the google organic ranking. Plus, it's fun, and you'll make friends.

All of your posts should be linked to your own website, if you have one, and--this is key--you must blog in your own name and be proud of what you write.

This way, you can influence the conversation that takes place in cyberspace that is about you.

Thanks for listening,

The IU, aka Richard A Schoor MD, urologist, Long Island, NY

The PC: Am I a professional or a corporation?

This morning I noticed my incorporation kit sitting in my book case and decided to have a look. I find it very interesting. I am professional corporation. My corporation was incorporated in New York State in February 2006. I have a corporate seal and by-laws, and I take minutes. The first meeting of the share holders took place on February 21, 2006. I signed the minutes as the secretary , the director, and chairman. Well that certainly sums up the role of the solo practitioner. According to the article of incorporation--the documents--I'm supposed to have periodic shareholder meetings, which I do, with myself, daily.

My corporation has 200 shares. I own all of them. When they were issued, they had no value. Zero. I don't know what they would be valued at currently, probably somewhere between the $0.00 and Google's stock price. In case you have never seen an actual common share document, they are quite impressive looking, even pretty, and of course, are the color green.

As a corporation, my fiduciary responsibility and my legal obligation are to make a profit and moreover, to maximize it. That is the law.

As a professional, my ethical and fiduciary responsibilities are to provide the patient with the best medical care at the lowest price possible, given their medical situation.

How can I reconcile these 2 seemingly adverse goals, the corporate one and the professional one?

I believe it can be done. Maximizing profits at the expense of good patient care is ultimately counterproductive and bad from a business perspective. Any practice's long term problem is 20-30 years of continued growth, or at the very least, survival. Unethical medicine, while it may be profitable in the short run, is in essence a short term solution for what is a long term problem. I prefer to do the right thing by way of the patient and to provide them with the best care that I, and my staff, can give them, and then encourage them to tell others about how great we are. So far, this has been a successful business model for the corporation, Richard A Schoor MD PC, and the professional, Richard A Schoor MD FACS.

Thanks for listening.

The IU Inc.

A bankrupt bagel place

The bagel place near my office has gone out of business. They opened their shop right around the time I opened my urology office. They were on Terry Rd in Smithtown, a busy, well traveled road in the heart of Smithtown's professional office complex district. The nearest bagel place was 1/2 mile away in a shopping center. That bagel place, which seems to do well, was much more expensive than the Terry Rd store, had long lines, and often a rude staff. Why did one place close, while another has thrived. Here's my take.

• Inconsistent service: The Terry Rd store delivered, sometimes in 5 minutes and other times after 1 1/2 hours. The thriving bagel place only delivers for large orders, but they deliver on time, as promised. Sometimes the failed store would answer the phone promptly, while at other times, they would not answer. Sometimes, faxed orders would be filled, but not on a consistent basis.



• Inconsistent results: The Terry Rd store had a great Turkey BLT. The first time I got it, it had mayo--the perfect amount--crisp bacon, and smoked turkey. It really hit the spot. The next time I got it, they forgot to put mayo on it. The next time, they forgot the bacon! I called them, and they delivered the bacon and an apology. I ordered the sandwich several times, but it was never as good as the first, and consistently inconsistent in it's quality. My staff had the same experience with their sandwiches. I actually began calling the bagel place the "The Chance Bagelry." Eventually we stopped ordering. At the thriving store, The "Smithtown Special" is the same day in, day out, as is the "Main Street", and the "John Smith."



• The Experience: Being that delivery was inconsistent, I used to stop in from time to time to pick up food. The never seemed to know me, never a "hey Doc." And I was a loyal customer. The thriving store seemed to know who I was, even though I stopped there less frequently. Even the mean front desk worker, a 19 yo girl, was mean to me in the same, personal way that made me feel, in some odd way special. Actually, she had the same relationship with many patrons, sort of like at Ed Debevec's in Chicago. I do not like her, but I enjoy going to the store to see what kind of pissy mood she'll be in, and how she'll take it out on me. Weired!

There are lessons to be learned here. Physicians may not sell bagels, but we are in the customer service business. In order to thrive, inconsistency in service and results must be minimized as much as can be, and the customer's experience must be as positive and personal as possible.

Just my opinion.

Thanks,

The IU.

PS: The baby and mom are doing well and are coming home today.

The IU has a new partner!

I am proud to announce that I have hired a new, young gun hotshot to join me. Born yesterday, 7-16-07, he is 6lbs, 8oz, and does not yet have a name.
I call him dude.
The IU.

Myth #6

Almost a year ago I wrote a post that dealt with some of solo vs group practice myths. That post had 5 myths regarding call issues, economies of scale, etc. Here is a sixth myth.

Myth #6: A specialist depends on professional referrals to grow.

If that was true, I'd be out of business. Professional referrals, while important, are no longer an essential for practice growth. Patients come from a variety of sources, and only one is the referring doctor. I recently analyzed from where my patients were coming. Here it is, not necessarily in order.

• Internet insurance lists--this is the modern age equivalent of the insurance book, only it is on the internet. It accounts for ~35% in my practice. Recently patients have found me on Cigna's site, Aetna's site, and even Medicare's. I did not know Medicare's site even had a physician search feature. Live and learn.
  
• Internet Search Engines--this has been a growing segment of my patient population, with the overwhelming majority coming from Google. Prospective patients type in any number of search terms, but "urologist smithtown" or "vasectomy doctor smithown" predominate. Male infertility patients will often find one of my other blogs, then hyperlink to Dr Schoor.com. I always ask people what keywords they used and which search engine. ~15%, but growing. And I have not even really started to web-market!
  
• Word of mouth: this is my one of my best sources of new patient business. And the best things about it is, one, it's free, and 2, WOM self-perpetuates. As the practice grows, more mouths talk, and more patients come to see me. Off course, so long as I remain a good urologist with good outcomes. About 30%, and growing.
  
• Professional referrals: when I first opened in April 2006, I concentrated most of my efforts on the cultivation of a cadre' of doctors who would refer to me often. While I have done well in this regard and now have several docs that send repeat referral business, the truth is that referrals even from these docs come infrequently and sporadically at best, and if I had no other sources of new patients, I'd be up the creek sans paddle. I'd say that professional referrals account for about 15%. Interestingly, WOM is the best way to cultivate professional referrals. When your happy patient tells their primary about you, that has more positive impact than a brochure and a box of coffee for the staff. In addition, doctors talk also and a "I use Schoor for infertility" said to a colleague is worth thousands of dollars to me, not to mention the personal satisfaction of peer recognition.
  
• Yellow Book and Yellow Pages: Less than 5%. Not even worth mentioning. Just get the free or cheapest listing, or better yet, none at all.
• Print ads: 1 patient, and his check bounced, twice. Money spent on ads into the thousands. Worse than worthless.
  
• In office free seminars: I held 2 on ED. 10 people came overall. I got one patient out of it, and he turned out to have a bogus Medicare card.

I have found enormous satisfaction from my success in the absence of a large professional referral base. It means that I am truly independent and beholden to no one for my next meal. It also portends well for me, since the professional referrals will come with time, and then imagine how busy I'll get. Until then, I'll focus my efforts on internet marketing and WOM referrals.

Thanks for listening, and send me some patients.

The IU.

WOW! That's some bad WOM.

This is an example of some terrible, negative word of mouth marketing. In case you don't read the link, a stewardess for Continental Express Airlines kicked a mother and her chatty toddler off of a flight because the toddler was being annoying. The stewardess asked the mom to give the toddler a sedative, apparently.
Unbelievable. In fact, I'm not sure I believe it. But it is bad word of mouth for this airline.

The IU.

. . .and continues

I had the phone techs here for 2 hours yesterday re-routing lines and checking connections. When they left, my 2 Optimum voice lines worked, only the call hunt feature was not working. I called optimum voice support, who remotely accessed the modem, made some changes, and then it worked. For the rest of the day everything went smoothly. And we booked 4 new patients.
My credit card processor was on a dead line. The techs were able to re-connect the line, though the credit card processor was unable to connect to the carecredit site. We tried a number of maneuvers, such as powering up and down, connecting the processor to the router itself, and connecting the processor to the modem itself. The processor only worked if connected directly to the source jack, which was in the closet, close to the ceiling. No problem. I'd just have to make my staff climb a ladder in the closet 20 times a day.
That works for me. Yeh right!
Finally I sent home the install techs and decided to call Vonage, since the credit card processor was on one of the remaining Vonage lines. As I was on hold with Vonage tech support, which is actually pretty good support, "firewall" popped into my head. Yes, the firewall, you knucklehead. All routers have built in firewalls that are distinct from the firewall that are installed in your computers, you know the ones you buy from Semantec, etc. These router firewalls need to be set and adjusted to allow for 2-way traffic. When the credit card processor transmits to the processing company, it also receives signals. The firewall was preventing that incoming signal from reaching the unit. The Vonage guy fixed it in several seconds. Now it works.
So everything is now good, right?
No.
This morning I came into work, un-did the forwarding feature so that calls would come into the office phone. Call one worked fine. Call two came while I was on with call one, and . . dropped. WHAT THE F---!!!!!!!!!!!!!!!!!!!
Optimum voice, my local, Long Island, VOIP provider is having difficulties and call hunt on their end is temporarily disabled. Calls that come into a busy line 1 go immediately to voice mail. "We're sorry for the inconvenience," said the tech. INCONVENIENCE! An inconvenience is getting a BLT when you ordered tuna. I'm losing money, lots o'it.
I really just want this fixed.
On a good note, I got 3 new patients this morning.
Thanks, the IU.

The phone saga continues. . .

Seaspray asked me why I felt loyal to VONAGE. The answer is that I don't. But I do know that fixing one problem will create 5 others that need to be fixed before things begin to run smoothly again. This is exactly what has happened to me since last Friday, when I changed phone service providers.

• My dedicated fax line is no longer working.


• My credit card processor is no longer able to connect and we can't use it.


• The data line in my office is on the fritz--it intermittently goes out--making it impossible for me to connect to my server from my workstation.


• Today, lines one and two on my Optimum voice phone are dead.


• My remaining VONAGE lines, 326-6035 and the other in the hunt sequence, are the only working phone lines, though calls still drop.
• My cell phone, thankfully, still works.

As I have said before, phone systems are like urethras. If they cause you pain, you got a problem.

Thanks for listening.

The IU.

An alternative way to book an appointment

My dad sees a urologist in NJ. This urologist, who happens to be a good friend of mine from medical school, is in one of these mega-urology groups--30-40 urologists. My mom says that she is never able to get through by phone without at least 10 minutes of hold time. No doubt that this is a sign of a thriving practice--or really bad phones--but it is somewhat of a pain for patients, new and follow-up alike. I'm sure this group already employes these techniques, but here are some things I do to give patients access to schedule appointments without tying up phone lines.

• Fax an appointment request
• Email the practice administrator that you wish to make an appointment and that you are an established patient of the group.
• Voicemail--just make sure you check. I have not yet employed voice mail.
• Text-message--I had one patient contact me this way. In general, I am not very good at the MMS lingo, but I got him in the door. "OMG, I g hsv. n2cu." Translation: Oh my God, I have herpes. I need to see you.

The moral of the story is that the phone is but one avenue to reach the scheduler in the office. Personally, I think fax is the best. We check the fax on our free time and contact the patient when our phones are not ringing off the hook.

Thanks,

The IU.

On credit card processors

We take credit cards. I know that seems trivial, but for a while, over a year, I did not take plastic. I did have a good rationale for not accepting credit cards, namely because of the transaction fees. But then something started to happen that pushed me over the edge. Patients at an increasing number were not carrying around cash and could not pay the co-pays. They would ultimately pay upon receiving the mailed statement, but they were not paying at the time of service. So I evolved.

In order to accept credit cards in your practice, you must have a credit card processing unit and a merchant account with one of the processing companies. I happen to use care credit, but many people I know and trust, use ACCPC. Setting up an account is easy. All you do is call their toll free numbers, purchase a processor (typically in the $300 to $500 range, and negotiable), fill out the application, send them a voided bank check for direct deposit, and voila, you're up and running. You will need a separate phone line dedicated just for the processor, despite what others may tell you. Processors don't function well over a splitter.

The processing companies take transaction fees, which is how they make their money. Transaction fees range from 1.5% to 3% and vary for a number of reasons. Some companies are just more expensive than others, but some credit cards exact higher transaction fees than others. Have you ever wondered from where the money comes to fund rewards for purchases or for college 529 plan cards? The merchants--me, you, the pizza guy--we fund those rewards programs via higher tranaction fees. VISA and Mastercard have variable rate fees. AMEX always charges a flat 3%. Sounds like a scam, right.

Well, yes and no. When I have to send my biller to collect on un-paid co-pays via repeated mail and phone call attempts, I pay much more than 3% of the value of the co-pay. I pay $18 per hour, not including taxes, plus postage and envelopes. In addition, un-collected co-pays adds to accounts receivable, and negatively impacts cash-flow.

Since I have started using credit cards, my cash flow has improved and my ability to collect co-pays, some of which are in the $50 range, has improved. Live and learn, but I wish I took the cards from the beginning. Who knew?

Thanks for listening.

The IU.

An overheard converstion.

During lunch today, I overheard a conversation from some people seated near me. The Chinese Buffet, in Smithtown NY, was nearly empty at 3PM, when I finally had a break for lunch and a bank-run. 3 college students, seated 2 tables from me, were involved in what seemed like a nice discussion. As I gazed in their direction and stared intently at their moving lips, I really could not help but listen in on their conversation.

One of the students, I'll call him Alex P Keaten, was telling the others of his career plans. He wanted to be a doctor and he seemed to have a pretty good business sense. His plan was to do something in the primary care field, but with a complementary and alternative medicine bent. In addition, he wanted to incorporate chiropractic into his practice as well. His business plan was to start patient treatments using an alternative medicine and/or chiropractic model, but then switch to an allopathic approach should the patient not respond as desired. He would then prescribe medication, which he would sell from his office, via his staff pharmacist.

Really not a bad plan. I was impressed. But let's dissect it a bit, for fun, to see if we can find some wholes in it. First, in NY at least, physicians can't sell drugs, only pharmacists can. Alex gets around this by employing a pharmacist. While I can see a conflict of interest that I find bothersome, it may be legal, depending on how he structures it from a corporate perspective. Perhaps he'll make his practice a PC, with him and the pharmacists as employees of the corporation. I think this may work, legally. I know of some big groups that do this, though certainly no smaller groups do it. I suppose that having to stock such high volumes of drugs requires a huge capital outlay and could impact cash flow negatively. In addition, unsold drugs that expire would become financial losses. Plus, pharmacies have very low profit margins and rely on volume. Thus smaller groups can't support the pharmacy. I don't know if Alex has considered these problems.

Now lets discuss drug stocking issues as they relate to the insurers. Most insurers have 3 tiers of drug coverage; generics, formulary, and non-formulary. What this means is that some plans will pay for, let's say Nexium, though others will only authorize prevacid. Of course, like many things in medicine, patients, if given a reasonable alternative, only choose the least costly option. I guess Alex's pharmacy will just have to stock all the drugs, but that would be very expensive. In addition, is he going to stock herbal remedies that are so popular in eastern medicine. These are expensive for Alex as well as for his patients and they are never covered by insurance. This is good for Alex, unless he has a predominantly insurance-only allopathic clientele, because this population doesn't go out-of network. I'd be surprised if Alex considered these problems as he slurped on his chicken corn soup.

Finally, Alex planned to incorporate western medicine with alternative medicine and even chiropractic. I think this is a great idea, as do many other practitioners. In theory at least, the allopathic practice can complement and build the eastern medicine and chiropractic practice, and vice versa. But here's the rub. Insurance does not really pay for eastern medicine and people don't really pay for allopathic medicine, other than via there insurance policies. So does Alex plan to participate with insurance or not? Participation is the fastest way to build a practice, but you pay the price of filling your practice with patients that only value YOU if you accept their insurance. Moreover, these types of patients don't do anything that insurance does not cover. I mean they don't do anything not covered. These types of patients don't pay out of pocket for alternative medicine. This is certainly how it is in Suffolk County Long Island, where I practice.

In addition, I think the allopathic pharmacy business will suffer in an eastern medicine practice. Eastern medicine devotees don't want big pharma drugs and western medicine types don't trust herbal remedies, unless they are covered by insurance plans, which they never are. So I guess Alex will have to stock both types. But that gets back to expense, not to mention conflict of interest, credentialing, and licensing problems. Oh, brother!

Perhaps Alex will not accept insurance. Excellent! I commend him on his bravery and I hope he can pay his bills in the early years. He will ultimately grow via his alternative medicine practice, but patients who want alternative medicine are often suspicious and un-wanting of western medicine and this aspect of his practice may flail. So how is he going to reconcile this dichotomy? I don't have a clue, but I know there are practices that successfully do it. I recommend that he put down the egg roll and visit one of these successful practices.

I certainly don't mean to pick on Alex and belittle him. To the contrary! I was extremely impressed by his savvy. When I was his age, I wanted to be doctor. Why? To help people. How was I going to make money as a doctor? I was going to get paid. Naivety. Or schmuck. You decide.

I think medical school does a great disservice to its students--you know, the ones that pay the school's tuition--by not teaching some of the business side of medicine. Actually, I think in today's environment, medical practice management ought to be required teaching and students should select schools that offer these types of courses. Maybe times are changing in this regard. But I don't think so.

Alex, I hope you apply to med school, and if you do, pick one that offers curriculum in business. And if you want a letter of recommendation, come find me at the Chinese Buffet. I'll be the guy eavesdropping.

Thanks, the IU.