- remotely completed medical records
- used a greenlight laser
- performed a TESE in conjunction with ICSI
- roasted a chicken
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Practical Solutions and Positive Encouragement For The Independent Minded Practitioner
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I don't have an I-phone but I may get one soon since I just discovered a new use for it that would fit in well with my practice: e-prescribing. E-prescribing has some advantages over traditional paper prescription writing. To name a few such advantages, e-prescribing decreases Rx dosing errors and insurance formulary and tier-ing issues, not to mention handwriting problems. Though I'm still slow at it, I can see that e-prescribing willmake my practice more efficient.
In NY State at least—which is fast becoming the most physician unfriendly state in the nation—only licensed practitioners such as RNs and MD/Dos can call in prescriptions to a pharmacy on behalf of the doctor. As you might imagine, a busy doctor, especially a generalist, can easily become overwhelmed by prescription management. In comes e-prescribing. With this new high tech tool, my high school educated MA—or anyone else with no medical training for that matter--can queue up all the prescriptions and refills for me that come in throughout the day and then I can review, edit, and approve them with a simple keystrokes from anywhere. My MA does not need any specific training in prescription writing or drug-drug interactions and she really can't make a mistake that can get my patients and me into trouble. Yet she can do the lion's share of the work for me.
Beautiful and just what I need.
Here is where the i-Phone comes into play. I was in the OR today and forgot my Rx pads. I did several cases on patients, all of whom had different pharmacies and I had have to call in some scripts for them. Now with hold times and phone trees and formulary related call backs etc, calling in prescriptions to pharmacies can be a royal pain and not something that I relish. Instead, I asked to borrow my friend Mike's i-Phone. With it, I logged onto my e-RX network, located my patients' profiles, selected the meds and doses from drop down menus, selected their pharmacies, hit approve all and voila', done.
Not bad. I can see other nice uses for the i-Phone as well, but this one is among the best.
Now if I could only use an i-Phone to reach Governor Spitzer to beg him for relief from this ridiculous med-mal environment that Long Island's docs have entered.
As always, join me on legislative day in Albany, March 4th.
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From today's NYTimes: Congress is preparing for the switch, allocating money for 33.5 million $40 coupons to defray the cost of set-top converters, which retail for about $50-$70. Each U.S. household is entitled to request up to two coupons, redeemable at a certified retailer within 90 days.
Do the math: That is 2 billion dollars for health care—Oh I'm sorry, for digital TV.
Yeh, that is what we need in this country.
Am I nuts, or is that just bonkers? Someone, please tell, what am I missing.
Pillitieri Ob-Gyn has been delivering babies in Suffolk County NY for 50 years. The practice was started by Dr Pillitieri senior, and it was ultimately inherited by his sons, Carl and Mark, and his daughter Eileen, a nurse practitioner. I got to know Carl first, and then Mark, Mother's Day 2003, when I was on call for my urology group. Carl called me first and asked that I see his patient who was in pain from a kidney stone while pregnant. I said sure. About 30 minutes later, Mark called to ask where I was because his patient was in pain.
Who are these guys? And why do they torture me thus?
Several months later, when my wife became pregnant with our second child and we needed a new Ob-Gyn, the Pillitieri's were the first and only number that I called. I only knew them from that interaction and one or two more like it, but I could tell that these guys were patient advocates to the n'th degree. Their commitment to my wife and me from beginning to end confirmed my initial belief.
I have come to know Drs Mark and Carl, as they are called, and "Dr" Eileen, pretty well over the years. They send me patient referrals from time to time and in fact kind of supported me in my early years as a solo urologist in start-up. Their patients are nothing short of fanatical about them as doctors; almost cultish in their reverence for the 2 docs and nurse. On several occasions I have treated mother-daughter-baby combos all of whom were patients of Drs Mark and Carl. From an unassuming office, the Pillitieris practice outstanding patient care and safety combined with state of the art medical treatments. They are the real deal.
They are also dying.
Dr Pillitieri senior left practice in the 90's after being on the losing end of a multi-million dollar lawsuit. Dr Carl left practice after 15 flawless and lawsuit free years in practice to relocate to Maine, where his liability insurance premiums dropped by 66%. Dr Mark has remained behind in the Deer Park NY office, along with his sister Eileen. They are committed to the practice and the community that they love. Mark takes call everyday and has not had a single day off since Carl, left 2 years ago. Now that is devotion!
This year, Mark paid the standard rate for Ob-Gyns in Long Island, which happens to be $180,000. Unless legislative action in Albany intervenes, Dr Mark will be forced to pony-up another $56,000 in July 2008, in addition to his $180,000. If he cannot do afford the rate increase—and who really could—he will be forced to close his doors to new obstetrical patients.
There is a real human drama unfolding here on Long Island—a crisis in the making.
You have the ability to avert it. Contact your local state senator and assemblyman. Join me in Albany for legislative day on March 4th.
What affects Dr Mark affects me and affects you.
Medical practice is a business. Like any other business, a medical practice has 4 stages in its life cycle. Stage 1 is the embryonic stage. Like a developing embryo, the new business must develop the basic necessities of life, such as an office, a phone system, a computer system, etc. And like the wonder we feel towards our newborn infant, when we look at our new business, we feel awe and amazement over all that we've accomplished just so that we can open our doors on day 1.
Ultimately, the business will either die in the embryonic phase or will proceed to the next phase, the growth phase. The growth phase is like childhood. It starts out all fun and wonder, but becomes more challenging and stressful as maturity hits. The growth phase will morph imperceptibly into the next and longest phase of the life-cycle, the mature phase. It is during this cycle that the business continues to grow, but it grows at a more predictable level. Cash flow is somewhat stable and daily operations sort of take care of themselves but the stability is often interrupted by head-aches and fires that seem to sprout up out of nowhere. Finally, like life itself, all businesses ultimately die. Businesses end either in bankruptcy, or they get bought out, or they simply disband.
During each of these stages, you'll have outside forces that will push or pull your practice in one direction or another. The chance to make some "quick bucks" with some new equipment, the possibility of hiring a new associate, or perhaps the opportunity for a strategic merger with another group; these, and many more possibilities will avail themselves to you during your career. Since you will not have a crystal ball and will not truly know what to do when faced with these uncertainties, you will need something that can guide you in the right direction. And the only place that you can turn for guidance will be your long range plan.
The long range plan is your vision. It is where you see yourself in 10 years. It is your ultimate dream; the business or practice that you would want if nothing could ever get in your way. Your 10 year vision, or 20 year vision for that matter, is never too large or too ambitious. Nor should it be something that can be reached to soon, for then it would not be big enough.
Recently I have felt a strong pull towards a large group that has formed in my area. The temptation to reach out to them has been great. From all that I've heard, this group will achieve tremendous success and financial glory. They'll have their hands into everything and generate revenue hand over fist. Urologists around me are falling like dominoes and have been lining up—and paying handsomely—just to join. Should I try to get in as well.
My answer: no. To join that group right now would be incompatible with the long range vision that I formed for myself many years ago.
For now, I stay solo and grow on my own terms.
David vs Goliath.
Wish me luck.
Some in Congress believe that the entire health care problem would be solved if doctors would "accept" salaries of $75,000 per year. Let's examine this figure to see if it is reasonable.
First, what do people make in other fields, on average?
Call center analyst: $36,000
Admitting director for a hospital: $80,000
Retail store detective: $35,000
Risk Manager: $120,000
Appraiser, residential: $36,000
Advertising Account Exec: $70,000
So I suppose that the congressman believes that his personal physician's worth lies somewhere between his bricklayer and the admitting director of his local hospital.
Perhaps until he gets chest pain or shortness of breath or renal colic or a fracture or an elevated PSA .
Now what does it cost to become a bricklayer? Nothing. Bricklayers do apprenticeships.
What does it cost to become a hospital admitting director? The price of a college degree at a state school.
How about a doctor? $250,000, and 12 years minimum of training.
I don't know, but I just don't see it. $75,000! Am I nuts or is that unreasonable.
You can hear it the way they say provi-i-i-i-ders. You can sense it in the tone of their rhetoric. You can read it in the policy papers. And you can view it on TV during debates and on c-span. Doctors—I'm sorry providers—have become--in the eyes and minds of the policy wonks--drains on the economy.
I am not sure why this is. I simply don't see it this way.
In my little practice, sparsely 2 years old, I employ 4 people. I provide them with health insurance and a retirement plan. Neither the state nor federal government does this.
I pay payroll taxes for each employee and myself. I pay into unemployment insurance and workers comp insurance funds, as well as into the government mandated disability insurance fund. In fact, these "social" programs are not provided for us by our government but by us, the employers. They are simply mandated by the government and funded by business owners.
For every dollar I earn, 70 cents gets returned into the economy. The revenue that I generate—because I provide services that people want--supports medical equipment vendors, insurance personnel, billers, PHARMA sales reps, hospital employees, home health workers, lab personnel, marketers, lawyers, software vendors, hardware vendors, the cable company, the phone company, and others.
I get none of the tax subsidies that are commonly given to big retail businesses, such as Cabella's Sporting Goods or Walmart.
The income that my employees earn pays for consumer goods, which fuels our US economy. Thirty nine percent of my income gets returned to the federal government, and 7% goes to New York State. Ten percent goes to my retirement savings, and the rest is returned to the economy.
Please tell me, Mr Stark, or any other policy maker, how can you have such disdain for us? I just don't get it.
No, I don't see myself as a drain on the economy in any way. I give back, and I give back quite a bit.
I wish that our political leaders and policy makers would see it this way and stop viewing me as a cost center rather than what I truly am—a business owner and an employer and a valuable member of society.
After our family practice doc completes 4 years of medical school AND passes all 3 USMLE parts AND completes an accredited residency program, only then can he APPLY for permanent state licensure so that he can start to treat patients on his own.
And there is one more hurdle for most of us, including our family practitioner. We MUST become certified by our respective specialty boards. This entails completion of all the above PLUS an application to simply be allowed to take the exam PLUS recommendations from practicing doctors that attest to our competency and character AND THEN you must pass the exam. And these tests ain't easy.
After all this is done, you have to send proof that you compeleted all the above and send it to the credentialing commitees of EVERY hospital you wish to practice in and EVERY insurance company you wish to participate with and EVERY state you in which you wish to be lisensed.
And you must update it every 1-2 years.
For our family practice doc, if he was to hit no road blocks along the way, the process would take him a minimum of 8 years and cost at least $100,000. For me, a specialist, the process began in 1988 when I began to study for the MCAT and it ended in February of 2003, when I passed by final test for certification by The American Board of Urology. Total cost ~$125,000 and only vague memories of my life outside the hospital between age 26 and 32, when I was a resident in urology.
So here's what I said to my friend.
"When can I start work?"