Tuesday, September 30, 2008

I stand corrected

Minyan is a quorum. Minion is "a servile follower." Thanks to Kishkes for the correction.

Monday, September 29, 2008

October is upon us and it is time for some Q4 planning.

Tomorrow is the last day of the 3rd quarter of 2008.  Wednesday marks the first day of the last quarter in 2008.  I never really understood the significance of quarters until I went into solo practice, but now I do.  For business owners, the 4th quarter means planning and preparation because Uncle Sam wants his money and $10,000 on December 31 is worth only ~$6000 on January one.  Unfortunately, the $10,000 insurance bill remains $10,000 and the $2500 rent remains $2500, and even goes up due to tax increases.  So I recommend planning and preparing.
  • Pay January bills in December
  • Hold check-posting reimbursements in the last few December week's until January
  • Max the 401K
  • If no 401K, you have several weeks to start a Simple IRA and the rest of the year to max it out
  • Pay off high interest debt with profit
  • Invest in new equipment now
  • Invest in that marketing project you have been considering before years end
  • Pay down some of your business line of credit
  • Of course pay off credit card debt
  • Make any office capital improvements that are needed between now and December 31
And the rest, take in profit and pay Uncle Sam-->Wall Street.

The IU

Sunday, September 28, 2008


Looking forward to the change of seasons and the final quarter.

Saturday, September 27, 2008

Not bad!

15 people responded to the quiz and 11 of the respondents had a similar understanding of regulated waste as my own.

Essentially most items belong in regular trash. The only exceptions are gauze or gowns that drip with blood, body tissue, and sharps. While this may vary by state and locale, the results of my quiz suggest there are some national standards.

Of course with an n of 15, my study lacks any power and we must accept the results with caution.

I will place the pole on the side bar and see if we can get some more responses.

Thanks for the help.

Thursday, September 25, 2008

Still waiting for a "minion."

I am still waiting for a sufficient number of people to respond to my queary to provide the results. In the meantime, check out a new post and pole at http://schoor-urology.blogspot.com/.

Wednesday, September 24, 2008

What is regulated medical waste?

If you ask 5 people "what is regulated medical waste?" you'll likely get 5 answers. Everyone knows that sharps are regulated and they belong in a sharps box. But how about the following?

Let me know, so that I may know. After I have "a minion" of responses, I'll post my understanding based on discussions that I've had of late with experts in medical waste management.

Knowledge of where waste rightfully belongs is important for 3 reasons:
  • Safety of the environment
  • Safety of the public
  • Cost to you, the business.
So please, give me a hand.

Tuesday, September 23, 2008

Considering an EMR? Look Into VISTA.

I spent much of my urology training at Chicago's Lakeside VA Medical Center.  This was in the 1990s and EMRs were in their infancy.  At that time, the VA had it's own proprietary system, called VISTA.  And VISTA was amazing: simply the best EMR ever made.

And it still is.

VISTA is free.  You can get it from the VA Medical Center's Website.  It requires a MUMPS platform to run, and this requires a license, or it can run for free on a LINUX system.

So basically, to have the best EMR is the world you can rent space on a VPS (Virtual Privacy Server) that runs LINUX, get a techie to configure it for you, and then you have the best EMR in  the world


Monday, September 22, 2008

Text Messaging Consultants: I'd Like It.

Last week I had a patient in the hospital who had to stay 24 hours longer than I thought she needed to stay because it was difficult for nursing staff to contact all the doctors that were providing her care and clear the discharge home order. Essentially, I came in to make rounds and the patient wanted to go home. She was eating, having BMs, and was in no pain, and she felt that she would get better rest at home. I reviewed her chart and agreed with the patient that she could go home. However, I wanted to coordinate her care with all the other consultants who had helped on her case, such as pulmonary, ID, hospitalist, and general surgery. Aside for writing an order "d/c home if OK by pulm, hospitalists, ID, and general surgery services" I had no efficient way to convert the order to action.

To make a long story short, it took 18 hours to contact all the consultants and to finally get an OK for the discharge and then another 6 hours to make arrangements to actually get the patient home.

I have a better way. Doctors or their services ought to use SMS. I could then send one text message to all 5 consultants-or their services--and then the doctor could simply reply "yes" "no" or "?" to me and then I'd give the order, or not. I think it would save time and simultaneosly improve care to patients and communication amongst consultants and primaries.

Ain't gonna happen, but it would be nice.

Sunday, September 21, 2008

5 Ways That Unfaithful Men Get Caught

Men in high profile positions, such as governors, presidents, and senators, get discovered cheating on their wives in very dramatic ways. These men get outed by the media or during a special prosecutor's investigation. Most men, however, get caught by much more mundane reasons. Most men get caught because they contract a disease. If you cheat, here is how you will get caught.
  1. Herpes: condoms don't always protect against herpes. As one can imagine, this might be difficult to explain to your wife. A herpes infection is forever.
  2. Warts: see herpes, but in honesty it is possible, though not probable, that an HPV infection can remain dormant for 20 years. So tell her you must have contracted it from the last woman you dated, 20 years ago.
  3. Gonorrhea/Chlamydia: men have an encounter, then develop symptoms of pain and discharge and come in for evaluation. The problem is that in the interim between the sexual encounter and the medical treatment, the man had sex with his wife.
  4. Abnormal pap smear: of course men don't get pap smears, but our wives do. Typically a wife with 20 years of normal pap smears will have an "abnormal one" and the man will come into my office, look very sheepish, close my door, then spill the beans.
  5. Fractured penis: yes, that right,fractured penis. Usually the man is on a business trip, has vigorous sex with a woman and oops, the penis pops out of the vagina, then gets thrust upon her pubic bone. It then bends when it is erect and snaps. This is a medical emergency and I suppose it could be difficult to explain the penile bandage to your wife when you return home.
So be forewarned and keep your pants zipped.

Wednesday, September 17, 2008

Going Solo? 10 Pearls For Success

Now that I have been solo for 2 1/2 years and feel that I have traversed the valley of death successfully, I can look back with some perspective and understand some of the important decisions I made that enabled me to get to where I am today.

In no particular order:
  1. Start small: preserving capital is critical. Most businesses fail because they run out of money before cash flow starts to take over.
  2. Develop a business plan: this will serve as your road map and guiding vision and will help you make important decisions when the future is uncertain.
  3. Go EMR: whether you purchase one or make your own, these systems have major advantages for small sized practices.
  4. Build up a nest egg: For most of people, the decision to go solo is made over years, not days. This should give you enough time to build up a cash reserve that can get you through the first 6 to 8 months. If you can't save it, then getting adequate loans in important. best of all, save it yourself, then take out a loan and use the bank's money.
  5. Surround yourself with good employees: staff turnover is lethal. When you find good people, reward them and retain them.
  6. Invest into the practice: as money starts coming in, rather than take a vacation, invest some of it back into the practice, say, for new billing software, new equipment, advertising, etc.
  7. Network: This is not only important as a good source of referral business, but you can learn from others who have "done it" and have overcome challenges that you now face.
  8. Study: read business books and do your homework. It will pay off dividends.
  9. Get on the web. Web presence is critical.
  10. Have fun: if you don't enjoy the process, you will certainly fail.
Good luck.

Tuesday, September 16, 2008

The Key To e is C

Though I went electronic a few years ago, I finally figured out the key to e.  It is simple: just go with the flow.

Most EMR or e-Rx modules have a certain "flow" of their own.  The programs seem to force users to adopt to how they are written rather than to how the doctor herself might do things with pen and paper.  Many of these electronic flows, or e-flows, seem to follow a different logic, a different algorithm, than we as doctors are used to, say, from being human or from having been practicing for many years prior to the software's development. 

While many vendors try to engineer the software to be intuitive and analogous to a typical doctor's doctoring "process", the software really can't be everything to everyone.  Most of us will have to change in order to use an EMR to its maximal efficiently.  And that is a good thing.   Just because an EMR forces a user to adapt, does not make it a bad product.  In fact, if the change improves accuracy and completeneness of data collection, promotes mistake proof ordering and prescribing, and allows for efficient data review, then I am all for it.  If adaptation promotes survival, it is a good thing.

E-prescribing for me has been difficult to adopt because writing a prescription on a traditional pad is quick and easy.  Traditional prescribing works like this: I see patient-->discuss treatement options-->recommend medication-->discuss side-effects-->write prescrion-->hand it to patient.  The whole process takes minutes.  E-prescribing requires significantly up front more time and effort for me and I simply cannot do it while the patient sits in front of me in my office.

However, I have found that e-prescribing results in so much less aggravation on the back-end that it is really worth the time and effort to do it.  I just had to change my methods to fit the new technology.  Now that my metomorphosis is complete, I find that I am more efficient overall than I was before the change.  I can see more patients, more easily, and with less aggravation.  Things like, "Oh doctor, can you do 90 pills instead of 30" just don't happen to me any more.  I have successfully found a method to e-prescribe that works for me and now I like it.  Like my grandfather said when he got an answering machine as he turned 89, "Vichie, how did I ever live without one."

So if there are any managers out there frustrated because docs are resistnant to change, maybe try to convince them that once they adapt, they'll be amazed that they ever survived without the technology.  Tell them that the key to e is C(hange).

Good luck.

Monday, September 15, 2008

Protect Your Online Reputation: 10 Steps

One of my employees has a doctor that she worships, so one day I Googled the doctor's name.  He had several listings, but all were from sites such as Ucompare, Healthgrades and some other local doctor rating sites.  I pulled up one of the free reports and found two ratings; one glowed while the other seethed with anger and hate.  And that was all that this outstanding doctor had to represent him to the online world.   

In these days, doctors must be proactive in managing their online reputations.  Any person with an ax to grind and access to a computer and internet can really damage your hard earned reputation.

Here are some things that I do and I recommend you do to manage your online reputation:
  1. Blog and blog often.
  2. Have your own website, even if you are part of a group.
  3. Link your blog and website.
  4. Publish articles, such as review articles, in medical journals and periodicals.
  5. Post comments on other peoples blogs and allow them to post on yours..
  6. Get your name in the media via interviews (see blogging and blogging often).
  7. Google yourself on a regular basis.
  8. Contact content providers that allow subscribers to post malicious writings about you and request that that they remove the comments.
  9. Have a lawyer contact the content services or the offenders themselves with threats of litigation.
  10. Seek help from online reputation management experts (yes they exist).
So protect your online reputation and remember that no one has a right to malign you unjustly and falsibly.  The first Amendmant does not protect people who do this from civil damages.  Do not be afraid to enforce your rights and fight for your reputation.  Your very livelihood could depend upon it.

Good luck.

Tau Epsiilon Phi 1990

My fraternity brothers 1990.
Life, uncomplicated.
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Friday, September 12, 2008

A Weekend With The Boys

I'm taking the weekend off and I'm going to my Alma Mater, The University of Maryland College Park. The weekend plan seemed to come out of nowhere, but actual was made possible by Facebook.
Beginning in August, someone from my college mentioned this weekend as the TERP reunion weekend on Facebook and due to speed of information dispersal over the net, over 100 guys that I went to school replied, excitement grew and the party is going to be tremendous. It's going to be a great time.

As a solo urologist, I have some challenges to overcome so that I can go. One, I had to get coverage. This was easy and I arranged it with a local urologist whom I cover on a prn basis.

The next challenge is how to balance being in touch with being away. I plan to use voicemail and email as my predominate means of communicating; text message as well.

The next challenge is family. This was more difficult than office coverage and well, costly.

See ya next week.

Thursday, September 11, 2008

How to do an Operational Manual for a Practitioner's Office

You really ought to do a "how to" type guide for things you and your staff "do" in your business.  Basically, what you ought to have is an operational manual.    An operational manual is very important for a business to have as it can enable the business to continue to function after you or any particular staff member has left the business.  A good one essentially makes the business larger than any one particular individual, including you.  But you don't have to do it all in one day, or even one week, month, year, or decade.

The concept of "Operational Manual" can be intimidating.  When I think of one, I see a huge binder with thousands of pages of documents that makes for the most boring reading material ever.  Of course, after you've worked on your manual for several years, it'll hopefully look just like the boring one I just described.

You could and should do your manual piecemeal: a little at a time.  And you may wish to include the staff in the process.  Since they are the ones that do most of the actual work that is detailed in the manual, the staff are probably the people most qualified to write it.  I had my technician write down for me the exact steps that she takes when she does a semen analysis.  I then reviewed the steps with her and found ways that could make her more efficient and accurate.  Conversely I discovered--through her--methods to improve the process of semen analysis; the same with urine analysis.  Writing the operational manual with my MA/tech has been an educational process for both of us. 

In my offices, we have documented the processes for digital back-up & recovery, disaster plans, instrument prep and sterilization, specimen collection and handling, phone triage and etiquette, scheduling procedures, copay collection and even how to use the credit card processor.

My operational manual has been a work in progress that started one day in February 2006 as I sat in the The Smithtown Library and planned my new practice.  Over the past 2 1/2 years, I have added to it, subtracted from it, revised parts of it, and learned from it.  The manual has a paper form, but really it has been converted to more of a digital format.  The original document still resides on the shared drive on my office computer but now I keep copies of all the documents and all the newer documents on my Google documents site.  This way, I can revise them from anywhere, at any time.  In addition, with Google documents, you can give staff "collaborator" priveledges and you can adjust settings on the documents site so that it will notify you whenever a change was made by the collaborator.  I don't do this, but you could and I can see the benefits of it.

Also, you can also buy an operational manual from a commercial site, such as the MGMA.  But I don't recommend this because the process of writing the manual is what makes you, your staff, and your practice better.

So start today and after several years, you'll have created something pretty impressive.
Let me know how it goes.      

Wednesday, September 10, 2008

Solo vs Group: The Pros and Cons

For me, solo practice has been just the cure for what ailed me in my professional life. Several years ago, I suffered from low morale, poor outcomes, and desperation. I felt that I had had made a drastic mistake in my career choice and was in a mental prison. I was part of a group, an excellent group, in fact, and I had nice and competent partners. I was making some money and was living comfortably. Yet I was miserable. Perhaps I did not truly know how unhappy I was then, because I had no basis of comparison and know template for what how a good fit was supposed to feel. For me, solo practice is simply more compatible with my core values.

Solo practice has some advantages over group practice. . .for the right person. As a solo practitioner, you run the show. You must have knowledge in some basic business principles, such as accounting, marketing, human resource management, information technology, quality control, and business strategy. Or you better acquire this skill set quickly. Oh, yeh, and you have to be a good doctor as well. . .and be home for your family. . .and make time for your one outside interest, such as tennis. So as you can see, solo practice can be very demanding.

Personally, I enjoy all the business and medical aspects of solo practice,but here is the best part of it. Only solo practice really allows you to pursue ALL of your entrepreneurial dreams and goals. Only solo practice allows you to have hope in a future for you that is brighter than today. And that is truly the best reason for going solo.

Group practice is good too. As part of group you will simply make more money than as a solo doctor,at least at the beginning of your career. You'll have partners for emotional and professional support, and you'll more easily be able to leave the job behind you when not on call. In fact, you'll view it as just a job; not bad! You can focus simply on doctoring and pursue outside interests more easily. Perhaps you have a passion for wine and reading about military history and you play tennis. In group practice, you'll have time for it all.

So the bottom line is that there are many trade offs in the solo-group dichotomy. By defining your core values you can then get a better insight into what will be a better long term fit for you.

Goos luck,

The IU.

Monday, September 08, 2008

No ID, No I See: Some good reasons to require photo IDs from your patients

I have a strict policy in my urology office:

No ID, No I See!

I have developed the policy over the years because,well, I've been screwed on several occasions. Here are some good reasons why you may wish to adopt the No ID No I See Policy.
  1. Fraudulent Health Insurance Cards: In this case, the best situation will be that you only deliver free care. However, I have had instances where insurers have paid me only to demand refunds. Then I have to go after the patient. Good luck tracking them down!
  2. False Names: Drug seekers can use a fake name to get narcotics from you and dead beats can elude collection attempts with a fake name.
  3. Bad Checks: See above, and yes I have had patients give me bogus checks.
  4. Wrong address: This makes collections difficult if you have no proof of address.
  5. The Photo: I find the photos helpful in jogging my memory of the patient and their story.
So in my office, NO ID, NO I SEE!

The Independent Urologist Blog To The Rescue

I just had a patient call. He claimed to be a patient of mine when I was employed by another group. He told my staff that he just left the hospital and has a kidney stone. He said he was a self-pay, did not ask for the fee, and said he'd be right over. He did give his name.

When my staff told me about it, my own mental alarms began to sound. First of all, the name he gave me was a name I remembered from my past and it was the name of one of my old, arch-enemy drug seekers. Four or 5 years ago, this guy got me good with several 2 and 3AM phone calls for refills or new narcotics prescriptions and a feeling as if I had been victimized.

As per our usual custom with ER patients, we called the hospital, the one in which this man reported having spent the prior evening, and the hospital in turn reported having no record of his visit.

Now my alarm bell was sounding in full force.

Several minutes later he showed up. . .and my staff recognized his face. They called me and I recognized him as well. I had seen him within the past year or so. While I have trouble with names, I rarely forget a face. I remembered this man as someone whose behavior prompted me to write a blog post about drug seekers. But I could not recall his name now.

My staff began to rifle through our new patient records, but we have way too many new patients to locate one by shear memory. We needed a time reference as to when he was here as a patient.

So I used to blog search feature on Google blogger, typed in "drug seeker", found the post and the date posted, went to that date in the book and voila, I recognized the name. Moments later I had his medical record opened and found that the drug seeker in March was the very same person as the man who was standing now in my waiting room.

Everything was crystal clear.

Needless to say, I sent him away empty handed.

GALL !!!

Sunday, September 07, 2008

How to use email to imrove your bottom line.

While using email for medical type communication may be risky, email should be used in your office as it is a very powerful form of communication between your office and your patients. On top of that, you can use it to improve your bottom line.

Email is a cheap, actually free method to communicate with people. All that you need, lest you be considered a spammer, is to get the patient's permission, and that is easy to obtain. Just ask for it.

I have an email sign up form mixed in with the new patient demographic form, the ABN form, and the HIPAA form. Basically the email form explains what for and why I like to use email, and what types of information is not email appropriate, ie for protected health information. The majority of my patients sign it readily. In the past year or so I've added about 700 names to the list.

I use email to keep my patients informed about my practice. I think it works well for things such as:
  • Out-of-the-office alerts, eg vacations
  • Changes to office hours, such as Saturday or Evening hours
  • Events, such as the opening of another office or a prosate cancer walk, etc.
  • New additions to the office,such as doctors, staff members, etc
  • New procedures or diagnostic tests that are offered, such as urodynamics
  • Newsletter distribution
  • Warnings; for example to keep hydrated during a heat wave to avoid kidney stones, etc
  • When I have updates to the website that I'd like to share with patients
  • New policies/procedures in the office, such as e-prescribing, changes in insurance pars, online booking, online contact forms, etc
And others.

So how does this add to the profits I see. Easy. Every time I send an email to my patient base, I get a spike in new and follow-up patient business. Think about the psychology of people. You may have done a vasectomy on someone 2 years ago. He has since forgotten your name and even that he had a vasectomy and he probably does not know what a urologist does, aside for vasectomies. When his wife mentions to him that she has been suffering from incontinence, unless you are fresh in his mind and he has been informed about what you do in addition to vasectomies, he will be unlikely to refer his wife to you. For another example, let's say our vasectomy patient sees blood in his urine and gets flank pain and decides that he needs a urologist. Would it not be nice if he remembered you and called you instead of someone else? It may make the difference of who he calles if he had just received a recent email about a new doctor you hired or on an update to the website via his email.

And again, email communication costs nothing.

So try it out and just remember to BCC your patients instead of CC'ing them, for privacy reasons and unsubscribe people who request it.

Good luck and have fun.

The IU

Thursday, September 04, 2008

A cool trick for getting someone a copy of an insurance card

Here's the scenario: you are tryingto book a patient for a procedure at a hospital or surgery center and they request a copy of the patient's insurance card. With a paper chart, you'd have to locate the chart, xerox a xerox of the original, and then fax the xerox of the xerox. Well, you can imagine that the card is basically worthless when it arrives at its destination.

Here's a better way. All you need is a business card scanner and associated software.
  1. someone asks for the insurance card, ie hospital
  2. pull up the card image in card scan
  3. alt print screen to take a picture of the computer screen
  4. open ms word blank document
  5. paste
  6. save as
  7. efax
  8. drink coffee
Total time: 2 minutes.

Wednesday, September 03, 2008

Want a web presence? It's easy.

A urologist friend called me the other day. He's from Jersey and he wanted some advice. Comcast, his ISP, wants to sell him on a package that involves website design, website maintenance, and SEO (though my friend did not actually know what SEO stood for). Comcast wanted $200 per month for the Website and SEO + $50 per month for website "maintenance". Actually the price could and would vary based on the number of clicks and hits, etc, to is site. Total cost per year: ~$2700.

Now here is The IU DIY way:

  1. Go to www.godaddy.com or 1and1.com and register domain name, ~ $2 to $7 per year
  2. Google.com-->blogger-->create blog
  3. Point domain name to blog (easy to do)
  4. Write post #1: Something like this, "Hi I'm here and I do x,y,z."
  5. Go to page layout, then add gadget, then add stuff to the sidebar like phone number, contact information, bio, even a form (available on Google documents)
  6. Write something else, like "Hello,still here and I still do x, y,z" as post #2
  7. Get a google adwords account-->start an ad campaign-->pick some key words, for example x,y,z--->bid on the cost per click (CPC--google can help determine how much the key word phrases cost)-->set daily or monthly max budget-->give AMEX card
  8. Write something more provocative for post #3, like "insurance companies suck" or "working in the ER is cool. . .and bloody" or "The lawyer who deposed me was H-O-T hot!", & have the post picked up on KevinMD then see your readership start to flourish.
  9. Have fun-->feel pride in the new skill set that you have acquired, and make money.
Total cost: ~$5 per year + whatever your adword campaign costs, not to exceed your own pre-determined max budget.

Or just hire some 13 year old kid to do it for you!

Have fun.

The IU.

Tuesday, September 02, 2008

The case against an answering service.

Have you ever called a doctor, perhaps for yourself or your child, and experienced the following:

Ring ring ring. . .ring ring ring...ring ring ring. . ."please hold". . .hold hold hold. . .hold hold hold. . .hold hold hold. . .hold hold hold.

"Hello, doctors' service."

"Yes I need to talk to the doctor, my child has 107 fever."

"What is your number, he'll call you back."

First of all, what is this "Doctors' service"? Dr Who? Can it be any more impersonal? And second of all I find the whole thing so annoying as a patient.

I have learned over the years that doctor's answering services are no longer an essential element to practice. I am going to make the case, a balanced case, against answering services for doctors.
  1. Barriers: Services place barriers between you and established as well as new patients, neither of which is good for the practice. In addition, answering services place barriers between you and referring doctors; never a good thing.
  2. Control: Unless you own the service, you have no control over the voice at the end of the line.
  3. Impersonal: Services tend to be bland, rather than unique. You are looking for unique.
  4. Obsolete: With current technological alternatives, there simply is no longer a need.
  5. Annoying: I find them annoying, since they only take messages. This gets me to my next critique:
  6. Purposeless: Most of them only take messages and either contact the doctor immediately or send a message to the office next business day, but they don't actually do anything. (some top-end services do function as extensions of your business)
  7. A Waste of Time: How many times have you called a service and it has taken 5, 10, or even 20 minutes just to get through. No thanks.
  8. Expensive: Price varies per package, but it can really add up. Plus, you still need all your other communication tools.
Here are some of the positive elements of a service:
  1. Professional: Many people, especially baby boomers and older, equate doctors with answering services and find it "unprofessional" for a doctor not to have one.
  2. Barriers: Sometimes I think it would be nice to have a barrier placed between me and, for example, an irate patient or one who simply decides at midnight to cancel an appointment.
  3. Reliable: You will never miss a phone call with a service.
  4. Human: Sometimes it is nice to have a human element or to give the appearance that you have a big staff.
  5. Cost effective: Some of the better services can function as an extension of your own staff and behave in a seamless manner that gives the impression that you are larger than you are in reality at a price that is affordable, though not cheap.
So, as in anything, there are pros and cons to having an answering service. But for us small guys who are tech savvy, I don't see the utility of an answering service.

At least not a standard one and at least not yet.

The IU.