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.

Tuesday, August 14, 2007

An Easy Way To Save Fax Confirmations

My COLA lab inspector suggested--actually demanded--that I keep a permanent record of all fax confirmations, which I have not been doing. It is actually a good idea, and with the system that I have, not so hard to do. I have started to do it for every fax message that I send, whether it be the referral letter, or semen analysis results, or requested records. Here is how I do it:

  1. Right click-->fax to recipient-->type in name and number comes up automatically
  2. Fax sent
  3. Confirmation is sent via email
  4. double click on message-->save as Text only file into patients e-folder
  5. done-->have coffee

That is it. I actually like it. No more of the shannanigans "We never got the fax."


The IU.

Saturday, August 11, 2007

The 4 Essential Qualities for Success in Private Practice

Remember the 3 A's--ability, availability, and affability--the age-old 3 ingredients for success as a physician. Do they still apply? Yeh, they still apply and can take you a long way, but they are no longer enough. Here are the 4 key elements as I see them:
  1. Focus: You must have a goal for your practice and remained focused to it as the myriad of competing forces try to pull you away. In addition, I'm a big believer in being a focused student of the process of medical practice and small business.
  2. Fortitude: Medicine has always been challenging, but now the challenges come from so many different sources, not just the medical ones, but also regulatory, legal, insurance oversight, etc. You must be made of some pretty tough stuff just to survive with your passion intact. My skin is raw hide!
  3. Fun: If you don't find it fun, or you have lost your passion, it's over unless you can find it. Try to view it as a journey--a road trip--and everyone knows that the road trip is always better than reaching the final destination.
  4. Family: You better keep your family, and especially your wife, happy. Without them, forget about it and just get a job.

Now off to make my wife happy. . .by relieving her of newborn duty. "Alright, I'm coming, I'm coming. . ."

Thanks for listening,

The IU.

Thursday, August 09, 2007

Define and Refine Your Processes

I just had a lab inspection by COLA, the accreditation agency for my in-office andrology lab. The goal of COLA, among several goals, is to educate lab directors, this case me, in how to run a lab and how to develop operational processes that can enable the lab to function efficiently and error free. A laboratory, like a medical office, is really a set of processes designed to achieve a goal, such as the safe delivery of health care. In the case of a clinical lab, the goal is to obtain and report clinical lab results in an accurate and timely manner so that physicians and patients can act accordingly. These processes are all connected and interact and affect all other processes farther down the chain. Thus, an error in one seemingly minor process can result in disastrous outcomes for the lab and the patient. COLA teaches us how to put systems in place that can help to avoid these errors.

As a result of my own lab inspection, I have been able to re-think operational systems for not only my lab, but for my general office as well, and since the inspection, I have been busy defining and refining these systems on paper for the goal of achieving COLA accreditation and also, to make my urology office function better, more efficiently, and with fewer errors. Here are a few processes I have defined that occur daily in my office and lab.
  • Data Entry Procedures
  • Patient Verification Processes
  • Patient Entrance and Exit Processes
  • Specimen Cup Labeling Systems
  • Test Reporting Systems
  • Test Result Tracking Procedures
  • Test Ordering Procedures
  • Specimen Collection Procedures
  • Back-up and Data Recovery Systems
  • Instrument Sterilization Processes
  • Error Reporting Procedures
  • Quality Assurance Processes
  • Quality Control Processes
And many more. In fact, as a requirement for COLA accreditation and for CLIA itself, all of these processes must not only be defined, they must be in book/manual format, in the lab, ready for inspection.

Thanks, the IU.

Tuesday, August 07, 2007

The Box-Method Revisited

Last November, 2006, I wrote about the Box Method, an easy, yet not-oft-recommended way to store important documents easily and without fear of document mis-files. I wish to update you on how my box method is doing.

As I said in the that post, I first learned of the box method at freshman orientation at the University of Maryland, College Park, my Alma mater. In essence, the box method is an easy way to secure important papers in one location and is so easy to do, a disorganized frat boy can do it, and never lose the proof he needs regarding that dropped course.

Here's how it works. Every time you get important mail, like monthly bank statements, bills, credit card statements, etc, just put them in a box. Don't try to organize anything. Just throw them into the box. At the end of the quarter, you can then organize the papers into appropriate sections in an accordion folder so that your accountant can go through them do your quarterly income and cost statement. Read the earlier post in which I explain it in more detail.

When I first started my solo urology and male infertility practice, the box method worked fine. At that time, I was seeing ~20-25 patients per week and operating once per month. I had no call. I went to one hospital, no lithotripsy center or surgi-centers, and had huge gaps in my schedule. When it came time for my quartely accountant meetings back then, I had time to organize the box prior to the meeting. Back then, the box method worked well.

Now I see 40-50 patients per week, and do ~10 surgeries per month at my local hospital in Smithtown. In addition I do another 10 cases per month, such as sperm retrievals, litho's etc, at a variety of places, like the lithotripsy center, the surgi-center, or the IVF centers. My days in the office still have breaks, though not long ones as in November 2006, and when I am not seeing patients, I am transporting my younger girl to and from camp/school, making bank runs, writing, planning, & thinking (yes, I schedule "thinking" time--very important), or helping out with the new born at home. On top of that, I am on call for St Catherine's Medical Center in Smithtown, and have been busy with ER and hospital consults. So now, does the box method work?

You betcha! Works better than ever. You see, the busier you get, the more you need the box method. My accountant meeting is tomorrow, and I organized my box in less than 30 minutes while I watched a promo video for a cool new health website called

Get the box. Don't listen to the nay-sayers. It works great.


The IU.

Saturday, August 04, 2007

Outdone by JiffyLube

"Convenience service and the personalized attention that you deserve."

That is what the radio ad said as I sped off to the office so that I could offer my personalized services at a convenient times to my patients. Only this ad was for JiffyLube. They were offering complete diagnostic work-ups with consultations to discuss the diagnosis and treatment options--for your car.

Interesting. But it leads me to wonder, are we, as physicians, the same as JiffyLube, or are they trying to become more like us. In any case, it makes me re-think my marketing and differentiation strategy.


The IU.

Thursday, August 02, 2007

Six Sigma and Your Medical Practice

Here is the conundrum.

Mistakes are unavoidable.

We, as physicians, can't make mistakes.

How can this be reconciled? Well, while we can't completely eliminate mistakes, we can seek to minimize them. In industry, businesses have turned to a concept known as Six Sigma to reduce error, eliminate waste, and maximize profits.

What is Six Sigma? Read the following link, and then I'll explain it in English, as I understand it.

The objective of Six Sigma Quality is to reduce process output variation so that on a long term basis, which is the customer's aggregate experience with our process over time, this will result in no more than 3.4 defect Parts Per Million (PPM) opportunities (or 3.4 Defects Per Million Opportunities – DPMO).

So, in other words, Six Sigma is a quality goal that allows for only 3.4 mistakes in every million cycles of a process. Here is an example that may make it easier to comprehend.

Honda makes cars by the millions per year. Auto production is a complex endeavor with many, individual processes. In order for people to like Honda Automobiles and to want to buy more of them, the cars must be reliable, ie built without errors. By using the concepts of Six Sigma, designers can create processes of making cars that keeps defects--such as faulty ignitions--to a minimum, such as 3.4 faults per million cars made. Other examples of Six Sigma quality include airline and rail safety procedures, though not timeliness, and pharmaceutical manufacturing safety control, among others.

The concept of Six Sigma has been applied successfully in many high production industries in many different sectors from manufacturing, to the airline industry, even to health care. In fact, Six Sigma is becoming somewhat of a mantra in health care as we move into the pay-for-performance era--an era in which medical mistakes are not tolerated.

Medicals practices, both large and small, have found it necessary to increase production--throughput, as we say--in order to maintain profits in the face of rising costs and decreasing reimbursements. The average urology practice sees >80 patients per week per provider in the office. Some practices see 40-60 patients per day per physician! In fact, many patients and providers alike have called this type of practice "the assembly line." With numbers like these, it is no wonder why medical mistakes are on the rise. As you can see, with regards to throughput, physician practices are not unlike manufacturing plants with high production rates.

Medical practices, like auto manufacturing, has many processes that take place many times a day in the normal course of business. These processes may include patient intake and exit, document management, data entry, billing, test ordering, patient recall, etc, and any one of these processes is prone to error. Like the auto industry, error in one process can effect the others down the chain, thus producing a lemon. For example, a front desk worker may forget to add a middle initial to a chart, which may result in mis-filed labs, which may result in treatment errors, and on and on. The busier the practice, the more errors. The more patients seen, the more likely some aspect of the process will break down, mistakes will be made, and efficiency and patient care will suffer.

As physicians and owners of medical practices, we must design--and refine--our processes with the goal of Six Sigma. And if you are a young physician about to enter a practice, you may wish to evaluate a prospective medical practice based on how they do business--their processes--and how the doctors and administrator THINK about these processes. You see, in a solo practice, you design and control the processes, but in a larger group, often the processes were put in place by someone else before you arrived. Unfortunately, while the processes may be theirs, it is often YOUR ASS when mistakes are made. Ask your prospective employer and the administrator if Six Sigma is their goal.

I have started to re-think my processes--how I do things in the office--in an effort to increase efficiency, to reduce error, and to simply be better at what I do.

My goal is Six Sigma.