Monday, April 28, 2008

Exxon: You Have Been Targeted For Termination

I sent this letter to 1000 of my patients. Please pass it along to everyone you know.

Dear friends,

Gas prices are at an all time high and only going higher. The high gas prices affect everything that we do and buy and are making economic survival difficult for millions of Americans. The current administration and the oil companies are to blame, period. We can beat them. Here’s how.

I call for the week of June 1st to be “Pick on Exxon Week”. Our goal is simple: cripple Exxon and send a message to other oil companies. Why Exxon? Why not Exxon. Shell Oil, you’re next.

Please pass this email to others in your contact list and let’s make a difference together.

Richard A Schoor MD FACS

Smithtown NY

Saturday, April 26, 2008

Car trouble, eh?

Car trouble is popular excuse for tardiness. I've noticed, for many
employees that I've had the experience of working with over the years, car trouble happens with surprising frequency. I drive a car with 106,000 miles on it, twice that of any of my employee's cars, yet it gets me there just fine. My medical assistant was an ~hour late this morning. She told my office manager that she had car trouble. What am I to say, she does drive an old car, and who knows?

The funny thing about car trouble is that it seems to only happen on the way to work. Never once, in the 8 years since I have been in practice, or in the 18 years that I have been in the work force, has any employee ever had car trouble after work. Never once has an employee of mine been stuck in the parking lot after work. Nope; after work their cars seem to start right up, no matter the temperature, barometric pressure, humidity or aridness. When the whistle bell rings, the ignition works just fine. When the alarm clock goes off, well, that is another story.

Is there is something peculiar about cars in that they only break down unidirectionally; that is on the way to work?

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Wednesday, April 23, 2008

So you we think we have it bad.

The following was sent to me from a colleague. I find it disturbing and puts suffering into perspective. I've included the entire email:

Thought I would share with you all.

This is an Email from my cousin to his mom back in NYC.

He is a peds resident at Columbia U. He was on a medical mission trip in Uganda.

some of the profanities, but I believe it adds to the overall feel of
the Email and what he is trying to express. I am sure he would die if
he knew I was forwarding this on, but it shocked me back awake today
and I thought I should pass it along.


Subject: thoughts on lilian

hi pretty girl. its 5pm
here - sitting at the computer lab in the mulago hospital library.
feedback was good on the first update, so i added some more people to
the shout out list.

feeling pretty broken down...

on rounds, we met lilian, a 10 year old girl whose dad brought her in
the day before w/ severe belly pain, fever and an inability to pass
urine. at that time, a short discussion was had about renal failure,
blood pressure control and how she needed dialysis but wouldn't get it.
her father helped her to the floor and placed her over a plastic tub. i
heard a whimper and a small splash - dad turns to us and reveals what
looks like milk inside. i realize that she is peeing frank pus and ask
whats being done to control her infection. after a bit about the
utility of urine studies, i was reassured that she was receiving the
proper antibiotic therapy.

per routine, the attending dictates her 'findings' and 'impression' to
the resident, and we move on. the 'plan' is also transcribed but
remains nebulous "continue antihypertensives, monitor urine output". i
remain stunned and fall behind in rounds.

morning she looked awful. her face was swollen such that her eyes were
2 black creases. she was foaming at the mouth; unresponsive. apparently
her potassium was in the 6's and the serum urea was through the roof.
Dad was instructed to go to the pharmacy and buy lactulose (to induce
diarrhea so she stools out some of the potassium she is unable to
excrete by urinating). Dad says in a soft voice that he is afraid he
will get lost. He is reassured that he will not, and rounds continue on.

figiting with my camera when i notice the nurse pushing a clear liquid
through a syringe into the IV in lilian's hand. i ask what it is and
she replies 'adrenaline'. i grab lilian's wrist and feel for a
pulse...none. i grab the medical student who had been examining lilian
- "what the hell is going on?" He looks at me wide-eyed and stutters:
"we were listening to her chest and she just stopped breathing. I asked
for help and they brought this adrenaline."

group, which had moved on to the next patient, was slowly and without
any hesitancy making its way back to lilian's bed. i raise and place my
hands on lilian's chest (as in "news flash people i think we need to DO
SOMETHING" here) but before i even apply pressure, i realize that i'm
the only one moving. the attending reassures me, "there's no point in
resuscitating her. even if we did, we have no ventilator". she then
chastised the resident for ordering the adrenaline and moved on with

believe doctors care for patients to the best of their ability given
the availablity of resources. but i'm like "F you lady, you could have
at least tried!"

know i don't know jack about their world. i'm a american white guy,
raised in the suburbs who has no concept of the reality of life for
doctors and patients in
uganda. and who am i supposed to hate for the fact that they have no ventillator?

father never left for the pharmacy and saw the whole thing go down. i
tried putting my hand over his shoulder and muttering "i'm so sorry",
but i never saw one break in his face. the man just lost his daughter
and he was completely flat. not shocked, just flat. he told me in a
quiet voice that he was going out to make a call. two sisters
(nurse-nun types) dressed all in white came and wrapped lilian up in
her bed sheet. i remember them tying a piece of gauze around her head
and chin to keep her mouth closed. they folded the mattress and carried
her out of the ward, the other parents following with their gazes.

is so different for different people. you can never, ever judge or even
claim to really understand. the only truth i consistently come back to
is this: life is fucked up sometimes. it is not our fault - situations
may be made worse by generations of damage and corruption, but to
expend energy on assigning blame is wasteful and non-constructive. and
it is most certainly not God's will, for the sun shines on both the
righteous and the wicked.

i have faith in the perseverance of the human spirit. we should strive
for a world where basic needs are met and where people can share their
thoughts and feelings freely. i'm probably just on some
africa shit right now, but i believe that we can achieve this goal in our lifetime.

weird but even though the context has changed, it hurts the same way -
i feel awful for lilian's father. no parent should ever have to bury
their child. not in
new york city, not in uganda.

you've made it this far, thanks for sticking with. i miss you tons and
will be in touch. as emily would put it, expect more politicking. hit
me back w/ thoughts (like dude you talk to much..!)


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Tuesday, April 15, 2008

A Guiding Vision

I'd never heard it described quite like that, but guiding vision perfectly describes the concept that I have been trying to convey in several The Independent Urologist posts of recent and past.

A guiding vision.

I like the sound of it. I like its imagery.

A guiding vision, as described to me today by a remarkable coach, Philippa Kennealy MD, represents your long range vision or ultimate goal. This vision guides you and helps you make decisions in the face of uncertainty. It can help you decide where to spend valuable resources or when to join a group or when to leave one.

I have understood the concept for the past 2 years--and it has served me well.
But the words, Guiding Vision; tremendous.

Thanks, Philippa.

The IU.

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The 5 A's of error free medical practice

Errors cost money. Errors result in bad outcomes, unhappy people, and stress. Many errors, if not all, are preventable. Here are 5 things that you can start doing today to become an error free medical practice.
  • Automate: Any process that can be parred down and automated ought to be.
  • Assure: Quality assurance plans will help you nip problems in the bud and to avoid them altogether.
  • Audit: Inspect your work randomly before someone else does it for you.
  • Ask: Ask your patients open ended questions and let them answer in their own words.
  • Aspire: Aspire to become better at what you do, and how you do it.
You'll find that you perform better, more effortlessly and efficiently, and with less cost.

Good Luck,

The IU

Thursday, April 10, 2008

The 10 immutable laws of start-up medical practice

  1. Formulate a vision statement
  2. Compose a mission statement
  3. Write a business plan
  4. Secure financing
  5. Start small, but not too small
  6. Determine your core strengths & weaknesses
  7. Know the marketplace
  8. Develop a competitive strategy
  9. Market, market, market
  10. Answer your phone
Only 10 laws critical to your success. Sure, easier said than done, but not too hard either.
Good luck,
The IU

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Wednesday, April 09, 2008

Going solo? Develop a QA plan.

Quality assurance--QA--represents everything that you do, or do not do, that makes your practice run better: less mistakes, less re-do's, less call-backs, less adverse outcomes, less mistakes, and ultimately less cost.

Quality assurance is process, rather than a one time event. I actually have a written plan that I purchased, then I customized it for my own usage. Here's how the QA plan works:
  1. Divide the year into 12 months
  2. Each month = a QA activity
  3. Document the activities and corrective actions in a book or e-book
  4. Follow-up on corrective actions
Here is an example of a QA plan that you may wish to implement:
  • January: Chart audit for appropriateness of coding levels
  • February: Chart audit for labs and studies filed, signed off, and acted upon
  • March: Assure that employee documentation is in order
  • April: Make sure that all insurances are in-force and up to date
  • May: Financial audit
  • June: Repeat chart audit for appropriateness of coding levels
  • July: Repeat chart audit for labs and studies filed, signed off, and acted upon
  • August: Review marketing plan and ROI; adjust accordingly
  • September: Check in-office lab reagents for expiration dates
  • October: Perform and document equipment maintenance and calibration
  • November: Financial audit
  • December: Chart audit for labs and studies filed, signed off, and acted upon
When you have this QA plan and document the activity, you'll find that "things" just seem to go better and more smoothly. You'll be doing work once, correctly, rather than re-doing over and over again. You'll also find that your operating costs will decrease and your profits will increase. Finally, you'll just be a better doctor.

Let me know how it goes,

Dr S

Tuesday, April 08, 2008

A reader question: How long to positive cash flow in start-up?

One of my readers (not my mom) asked me a question that deserves an answer. Hopefully, she will read this post.
The question was:

When does the
cash-flow usually come in after starting a practice?

Answer: Depends

Medical practice is a business and start-up is start-up. Most start-ups will fail in the first year for one simple reason; they run out of money before cash flow can cover expenses. When these businesses will run out of money depends on a variety of factors. The most important factors are access to capital, type of business, competition, and payer mix. Business that start-out with less than $5000 cash will usually fail in the first year, while those that have access to $100,000 or greater, will most likely live beyond their one year anniversary. If you want to survive, I recommend raising money, and lot's-o-it.

The type of practice you have makes a difference as well. Some practice's have inherently high start-up costs while others can be started with significantly less money. For example, I started my urology practice with $40,000 down and access to $150,000 in case the unowhat hit the fan. An internist may be able to start-up for even less, while an OB-Gyn in NY will need in excess of $200,000 to start-up. But the start-up costs only tell part of the story. A urologist may have high costs compared to an internist, but we also have higher revenue potential. A plastic surgeon or dermatologist in start-up can have very low up-front costs yet have a high earning potential and could thus become cash positive in a very short time. Contrast that to a primary care physician: they'll have relatively low initial costs but very little real income generation potential in today's climate. Plus, as they get busier, their costs escalate much faster than their revenue.

The third factor is competition. If you are the only urologist in town, you'll do well. If you are like me, one of 100s, you'll have to struggle a bit more to make money. A plastic surgeon in start-up on Long Island may have lower costs than, say, I did, but he/she has much fiercer competition than I faced. As for primary care; out here they are dime-a-dozen.

The fourth factor is payer mix. If your patients are insured, and you have enough of them, you'll start to make money. If you practice in a very well-off area and can go "out of network" you'll make the same money with less work and in less time. If you deal with predominantly Medicaid, you'll probably have to move because you'll never get there.

As for me,
my cash flow turned positive after 9 months of hemorrhage.

I started in April 06 with a $40,000 initial investment and was prepared to pour another $150,000 of my own money into the practice to "float it" in a worse case scenario. Initially I estimated a loss of $30-50K in year one and a break even point by end of year 2. I felt that by end of year three I'd start to make in excess of $100K per year. In actuality, I broke even by end of year one and made a modest, yet respectable, profit by end of year 2. This year I have been doing quite well. While I had to dip into my savings, I repaid those loans quickly.


While I have already recovered my initial investment and have been making some money, I am still greater than $200,000 in the hole if you factor in loss of income during my first 2+ years of start-up compared to what I'd have earned had I stayed an employee. So be forewarned: the freedom to be your own boss comes at great cost.

So good luck Rose and please feel free to contact me.

The IU.

Tuesday, April 01, 2008

Where NY State chooses to spend its money

I just finished having a nice conversation with a friend. His son is a criminal attorney fresh in private practice. His clients typically pay cash. What I found interesting was the following:

While this attorney is not a public defender, NY State will send him clients that need defense and pay him $200 per hour.

$200 per hour!

Now let's see how that compares to NY State's Medicaid reimbursement for physicians. I just treated a man with suspected Fournier's Gangrene, a life-threatening infection that requires many hours of intervention by multiple highly skilled and trained medical personnel. I spent 4 hours yesterday—in-total—working on this patient. I will be lucky if I get $100 in reimbursement from Medicaid.

So that is where NY State's priorities are.

The IU

Now they've gone too far!

Insurance companies control much of what we do in medical practice; where we send patients for labs; pre-certs for radiology tests; referrals for visits. Crazy. But this takes the cake.

One major carrier just sent me a letter that dictates how my semen analysis patients can procure their specimens.
  • PPO patients can use DVDs
  • POS patients can only get magazines
  • HMO patients get National Geographic
  • Out-of-network patients can use an escort
This has just gone too far. We must make a stand!!
Have a nice April 1st.
The IU.

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