Thursday, February 28, 2008

More uses for technology in medicine

Today I:
  • e-prescribed
  • remotely completed medical records
  • used a greenlight laser
  • performed a TESE in conjunction with ICSI
  • roasted a chicken
Good day

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Saturday, February 23, 2008

My automated semen analyzer

I recently invested in a new and somewhat expensive technology to automate my semen analysis process. The instrument, called the Sperm Class Analyzer or SCA System is a very sophisticated software program that links by computer and camera set-up to my microscope in my in-office, COLA accredited andrology lab. The SCA System adapts to my methodology of semen analysis and quality assurance and is really a very useful adjunct to my lab. Aside for basic features such as concentration and motility analysis, the software can also analyze sperm velocity, progressive motility, morphology by Kruger and WHO criteria, and sperm DNA integrity. In fact, these cumbersome and complex analyses have become so easy that I have been able to train my MA to do them.

From a technology perspective, the system fits in well with my general electronic office design. I can access the system remotely and review the saved analyses from home, generate a report, and digitally sign it, all from the comfort of my home. I can even do it from the road via my lap top. If I have a doubts as to the accuracy of any particular report, I can even re-run the analyses, since the digital images and motion analysis data are archived.
I can then convert my reports to PDF files with a keystroke and fax them electronically to referring doctors.

Automated semen analysis has some advantages over manual analysis. Perhaps the biggest advantage is reproducibility of results and decreased inter-observer variability. Accuracy is not compromised in anyway, since the instrument is calibrated daily and verified manually for accuracy by a trained andrologist, a guy by the name of Dr Richard Schoor MD.

Apparently, I am the only lab in NY to have the system, though several of the largest IVF groups in the nation have recently adopted the technology for their own usage.

If you need a semen analyses, please contact me:


The IU.

Friday, February 22, 2008

My high tech snow day

Despite global warming, the weather brought snow today to Suffolk County Long Island, where I have my urology practice. Fortunately I had a slow day in the office and was not really disrupted much by the snow. My biller however, was unable to get into the office. No biggy. Here's what we did:
  • Encounter forms were delivered to my biller by my MA, who lives in the same town as my biller. We could have faxed the biller the encounters or emailed them as well, though delivery was just as easy, and HIPAA compliant.
  • My biller VPN'd into the network, entered the charges, and submitted the claims electronically, just as if she was at her post in the office.
  • I left early as well and had phone calls forwarded to my cell phone.
  • From my cell phone and blue tooth wireless, I called in a prescription for antibiotics while I drove and deposited checks in the Commerce Bank drive-through..
  • When I arrived at home, I e-prescribed for another patient and electronically signed off on some labs via the VPN connection to the work station in my own office.
  • At one point, I was on the phone with my biller, who was remotely accessing her workstation from her home while I was remotely on my work station from my own home.
  • While I was at home, where I get little cell phone reception, I received a call from a local doctor's office. They called my office main line which forwarded to a VONAGE line in my home office. Had I been on the road, the VONAGE line would have simul-ringed on the cell phone. Since I was home, I simply picked up a cordless phone,and took down information on a new patient.
  • I did miss one call, but the number was logged on VONAGE, and I easily returned the call.
Maybe mundane to you, but I think it is pretty cool.
The IU.

E-Rx: A Good Use for An i-Phone

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.

The IU

Monday, February 18, 2008

Going Solo? Develop A Competitive Edge.

What makes you so special? Why would patients go to you over someone else? While it may be difficult to compete with an established group or a large group, you can try to level the playing field--or perhaps tilt it a bit in your own favor--by developing a competitive advantage the amplifies your strengths and exploits your competitors weaknesses. Having Saturday hours when others do not may represent one such competitive advantage. Here are some others:
  • Have office hours others do not
  • Offer a service others do not
  • Learn a new procedure that others are not yet doing
  • Treat diagnoses that others find undesirable or less profitable
  • Answer your own phones, and do it 24/7
As you grow, you can adjust your practice's competitive advantages accordingly. That is the fun part of solo practice.
Good luck.

The IU.

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Friday, February 15, 2008

Tell me this is a joke, please.

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.

The IU.

Where is Dr Carl?

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.

Act Now!

The IU.

Thursday, February 14, 2008

An Activist is Born

Liability rates in NY are rising dramatically. Many obstetricians in my own community, have already either given up OB or have left the state entirely. Who will deliver our children?

MLMIC, one of only 2 liability carriers in NY, paid $500 million dollars over a ten year period to defend claims that never resulted in a single payout to a plaintiff. The trial lawyers say that the defense bar is winning the war, but the cost of that war has been so high that the vitality of the entire health care system in NY State is in jeopardy. For the OB that delivered my Emma, legislative action that occurs in the next 6 months will determine whether or not he stays in business--and he is one of the good guys.

The trial lawyer lobby is strong, but ultimately they in are in-the-wrong. The citizens of NY need professionals that can provide obstetrical care, emergency cardiac and surgical care, and preventive medicine. I know personally several family practitioners in my community that subsidize their own practices with personal savings and debt just so that they may keep their doors open.

There is a misperception, perpetuated by the trial lawyer lobby, that there is no crisis looming; that the problem is the result of bad doctors, and that doctors and insurance companies are just greedy. This is simply not true. The overwhelming majority of doctors consistently do the right thing by way of their patients, and the days of the "country club life" for doctors has long since passed. From a financial perspective, most of us are simply trying to stay in business, provide for our families, and practice the professions that are our passions.

Help avert the impending crisis that WILL come in JULY 2008 unless legislative change happens immediately. Join us in Albany on March 4th for Legislative Day. Contact your local assemblyman and state Senator. Contact me, and I'll assist you in contacting your local reps.

Believe-you-me; when you or your child or your husband or wife or dad or mom is sick and in need of medical attention, you will turn first to your doctor and hospital, not to your trial attorney. You have the power to make sure that we are there for you.

Act now!

Thank you.

The IU.

Tuesday, February 12, 2008

Develop your long range plan

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.

The IU.

Sunday, February 10, 2008

Business Acumen or Dumb Luck?

I am reading a terrific book now called, The Illusions of Entrepreneurship, by Scott Shane. I started it, and it has already inspired me to write this post. Rather than give advice that is based on anecdotal information, the author uses data to illustrate the differences that lead to success vs failure for a start-up. Here are some:

  1. Stay in school: college grads do better that high-school grads. Education I have-a-plenty.
  2. Don't start to soon: people who work for others, and learn on their employer's dimes, do better when they ultimately do go on their own and start-up. I did that.
  3. Money matters: Having access to capital early on makes a huge difference. I had significant savings which I used a collateral to get loans.
  4. Have a business plan. I did that, only I did not realize that I had.
  5. Choose the right industry: urology is pretty good, infertility is even better. For me, pure dumb luck! In New York, a start-up OB would be almost doomed to fail. Derm is good!
  6. Have the right motivation: are you doing it to make money or to have autonomy to "do what you want." If you goal is to generate revenue, you'll do what it takes--like answer the phones 24/7 or have evening and Saturday hours. I did those things because they seemed obvious to me. If your goal is to be able to take a vacation whenever you want, re-think your plan.
  7. Buy someone else's business: I did not do this, but I guess you can't argue with the logic.
  8. Focus on your strengths. I did this. Dumb luck.
  9. Marketing: Successful entrepreneurs market their products or businesses early on. Caveat, do it smartly. I wasted a lot of money in my initial attempts.
  10. Find unreached customers: I suppose that had I stayed in the same area as my former employers and tried to compete with them, I'd have lost. Dumb luck and restrictive covenant to thank here. If you are starting your own practice, try to identify patients that others are not seeing, such as patients who need weekend or evening hours or patients of certain ethnicities, disease states, insurance types, etc.
I'll keep you posted about others.


The IU.

Wednesday, February 06, 2008

What happens when physicians leave?

The Governor of Mississippi understands this simple fact: doctors are good for the economy. In his state, according to a KevinMD link, each doctor brings in about 20 jobs to a local economy. I don't know if that is or is not accurate, but in my community in Suffolk County Long Island, I believe that there'd be a ripple effect that would look like this after a physician exodus.

  • Tough times for accountants
  • Loss of revenue for restaurants
  • Decrease big-screen TV sales, among other consumer items
  • The demise of the local tennis industry
  • A fall in house values
  • Decline in school funding
  • Displacement of at least 4 workers for every doctor who leaves
  • Hospital closures
  • Layoffs in law firms, both plaintiff and defense
  • Layoffs in all medically related sales forces
On the economic scale, we are below the the high end technology sector and are above retail. We add jobs to a local economy and give people economic opportunities that would be otherwise unattainable.

Our political leaders must wake up and see it for how it is. It really is that simple.
You can't kill the goose that lays the golden egg.

The IU.

Are doctors worth $75,000 per year in income?

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

    Bricklayer: $70,000

    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.


The IU.




Tuesday, February 05, 2008

Doctors ARE valuable members of society!

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.


The IU

Monday, February 04, 2008

How to become a stock broker

I spent last night at a superbowl party at a friend's house. He does very well and owns a brokerage house. We got to talking and I asked him, only half jokingly, how can one become a stockbroker?

"It's easy" he said, "you just have to take the series 7 test."

"How do you get to take that test," I asked.

"Simple" he said. "Just read some of the study material, go to a local testing center, pay 300 bucks, and take it. When you pass, you get a liscense."

"And then I could trade stocks?" I asked, incredulous.

"Yep, it is that easy."

"So theoretically, I could get study material from Amazon, read it this week, and by next week I could be a licensed stockbroker, work for you, and start making money?"

"Yes, only you don't even have to purchase the study material. I'll give it to ya."

Now that is un-@#$%-believable!

A family practice doc, who makes about as much as a mildly successful broker has to go through at a minimum the following difficult gates before he can earn a only a modest living:
  • The MCAT (trust me, this test is very challenging). Your score--ie how well you do--determines if you can go to med school and where you can go.
  • Step 1 USMLE-the first of 3 parts to our lisensure exam. We can take it only after 2 years of medical school have been completed--the most challenging years. I studied about as much as most students do, which was 15 hours a day 7 days per week for 6 weeks. Like the MCAT, the score means even more than pass/fail and can affect the economic outlook for the rest of your life! This is a very high pressure test.
  • Step 2 USMLE-the second part of our lisensure exam. We take this one after we've completed at least 3 years of medical school. By the time you get here, you're pretty much home free.
  • Step 3 USMLE-the final test for licensure. You take this test during your first or second year of residency training. Actually it is a difficult test, but for the most part one's score is irrelevant.

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?"

Good luck.

The IU.