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.

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.

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.

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.

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.

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.      

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.

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 !!!

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

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.

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.

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.

Keeping Track of Your Patients? Here's a method.

Another re-print of a previous post, with some modifications. Now that I have ~2000 patients, how am I supposed to keep track of them all? Here is part of how I do it.

Have you ever sent a patient for a test or study only to have them not have it done? Have you ever had a patient lost to follow-up? Do you ever lose sleep at night worrying about what positive cytology result is floating around in the ether, unknown to you or your patient, waiting to give the patient--and you--a problem? I used to, but no longer. And that is because when I went solo I was able to really analyze in a comprehensive way how patients get lost to follow-up and why they don't comply with orders and then my staff and I developed a system to counteract this problem. We call it The No Worries Log, and here is how it works.

When I finish seeing a patient and have formulated my plan, I tell my staff to enter my orders into the outbound referral section of my practice management software. This section is really designed for something else; to keep tabs on referrals from a primary care doc to a specialist, but I have customized it easily to fit my own needs as a specialist and a rapidly growing solo practice doc. For example, if I order a CT scan without contrast and a cytology on patient Richard Cockworthy, I tell my staff and they enter it like this: CT I-, cytology. If I send patient John Smith to a surgeon to rule-out a hernia, we log that as hernia ref to Dr J. You can accomplish the same thing with a log book and paper and pencil or with an Excel Spreedsheet, but that results in lots of wasted time and effort due to data entry duplication. Since our patient's data is already in the PM software program, there are no issues regarding repeat data entry, and the date of the log entry is automatically noted by the program. Once a week my staff goes though the list and checks off all the labs that have returned and I have signed. We then contact the non-compliant patients and gently prod them to get the tests that were ordered. Of course, we document these phone calls in the medical record.

The patients think its magic; they think that we are omniscient. We are not! They really think we are on top of things. We are! It's easy. We are simply using our existing software to its fullest extent.

This way I sleep well at night with the knowledge that I have minimized my liability risk by maximizing my power over a patient's non-compliance. It also makes for outstanding patient care and does not cost anything extra. Moreover, I can check the log from my laptop computer, while in bed at home, using a secure VPN connection, and can call the non-compliant patients from my Vonage office line that happens to be plugged in to my router at home. The caller ID that the patients sees says Dr Schoor's office.

Technology. It's wonderful!

After the Open

Corona Park at Sunset.

A good day, made possible bacause I am my own boss.

Think about it.

How to talk on the phone while watching a tennis match and not piss people off!

Solo practitoners face challenges that are unique to our breed. Coverage is always an issue and we must continuously balance self-time with availability.

Yesterday I spent the day at The US Open watching tennis. My office remained open and staffed and the phones, as always, went answered. My staff are non-medical types and will never answer medical questions. They simply take messages, prepare e-scripts for me to finalize, schedule patients, and track down claims. When doctors or patients need to speak with me, my staff knows to contact me immediately. But when I am court side at the US Open, cell phone etiquette often makes doctoring problematic.

Here's how I did it:

• Phone set to silent mode
• Staff sends text messages with pertinent information
• Blue tooth in ear enables talking on the phone in an inconspicuous manner
• Text messages back to staff with instructions on how to respond

Easy stuff. When I become the USTA touring urologist (Billie Jean, if you are reading this post, consider it my application for the job), I'll get an i-phone so I can be even more connected, yet more remote.

Fun.

Why a Professional EMR is better

A very smart urologist makes a good argument for a commercial EMR.

In his words:



I commend you for using the home-grown medical documentation system with Word. Advantages of a fully integrated EMR from a "vendor" are numerous. Here are a few: 1. FULL integration instead of piecemeal programs to do multiple tasks. 2. No need to redundantly enter pt demographics / name when you start a new encounter. 3. Electronic charge capture and being able to document within one program and send the charges to the PM side. 4. ONE page summary of just your A&P automatically generated and faxed to PCPs. 5. FULLY INTEGRATED eRx module, instead of having to use a separate system OUTSIDE of the "EMR". 6. Ability to completely mine your EMR database. For instance, I can find all male pts with LUTS over the age of 65 who have not had in-office microwave who also don't have bladder or prostate cancer and who are not on anticoagulants, as well as post an automatic pop up reminder into every one of those pt's electronic charts. 7. Intra-office messaging and integrated patient messaging. 8. Full document management system built-in to handle all incoming and outbound faxes. 9. Auto-documentation of any/all documents generated out of the EMR, including date, time, who generated the doc, and how it was output, including which printer. Accountability and transparency! 10. Requirement to change password according to HIPAA best-practice policies. Word documents are easily hacked. 11. Ability to standardize training and have a program to teach new employees / new hires. I can go on, but you get the idea. To me the price paid for a commercial EMR is completely worth it.

I agree with the above. I do have several caveats.

• Upfront costs: This is the least of my concerns
  
• Ongoing costs: every 6 months the vendors get you for upgrades, maintanenance, etc. All these are very necessary, but you are a captive audience since changing vendors is almost impossible
  
• Necessity: do you need all the functionality mentioned. Only you can answer that question. I would suspect that if you have a predominantly insurance based practice in a market place where you can use the data to find leverage, than yes. In my case, with a large cash base and no leverage to negotiate, I am not certain it would help.

But thanks for the back and forth.

The DIY EMR: Revisiting an earlier post.

This post was previously published by The IU, but due to recent contacts from readers, I thought I re-post it.

Here are some features of MS Word 2007 that make it so attractive for a homegrown EMR:

• Insert signature line: once inserted, you can sign it with the stylus. The program then locks the document to prevent any changes.
• Built in PDR conversion tool: No need to buy acrobat. PDF is a great format for an EMR for a variety of reasons.
• Insert inbedded files: The user can easily insert inbedded files, like bitmaps, with things such as illustrations, photos, notes, etc.
• Change tracking: This feature is also on older Word versions. Allows the user to make changes with cross-outs, rather than erases. Makes for good transparency, ie spoliation accusation resistant.
• Can easily create templates and record macros.
• Phrase finishing: user can train program to complete phrases and sentences. Useful when documenting encounters quickly.
• User friendly: very little training required.
• Ubiquitous: Is pre-installed on most computers, and is compatatble with google documents and MAC OS.
• Inexpensive.

In other words, it is an excellent tool for the homegrown EMR. AND, from what I've seen from many vendor sold EMR's, the basic platform that they use in their products. Kevin's right: why pay so much more?

Inspirational!

Ball Girl. 2008 US Open

Urologist vs Professional Tennis Player: Revisted

Someone on the way up and someone on the way down

Congratulations to the victor!

Once again, the US Open comes to NY and I love it. I go every year, both to the qualifiers and to the main draw. It is my favorite time to be in NY.

Personally, I think the qualifiers is better than the main draw, at least the first week of the main draw. Aside for the lack of crowds, you get very excellent tennis matches with lots of drama. You see players on the way up, and some on the way down. Most are never-wills. You also get to sit and talk to coaches and parents and player entourages in a way that is simply impossible during the main draw. You can learn some things and see that life is tough all over!

Players in the qualifiers must win 3 matches to make the main draw. Winning only once or twice during this week results in a big fat zero payout. If theplayers win all 3 matches, they make the main draw. Just being in the main draw, even with a first round loss, is worth a couple grand. Most, if not all qualifiers will lose in the first round. So 16 players will work for a solid week--and work very hard--and make only 3 or so grand. Factoring the cost of travel, lodging, coaching, food, clothing, rackets, stringing,etc. . .they don't do so well. The remaining 112 players, those that lost during the Q week, do even worse. They make nothing.

The 2 players in the picture up top are Victor Estrella and Xavier Malisse. Victor, the player on the left, was the victor. He is a young Brazilian on the way up. Xavier, the other player, was a former top 50 player who was considered a real contender at one time. He was a media darling as well, in his younger days, and had long hair and a flamboyant persona. Unfortunately, his career did not turn out as he, and others, had hoped it would, and he has been struggling. I guess his short hair is a symbol of his new-found-focus. Perhaps it is to little to late. I wish him well.

I did peruse the draw and roster of competitors from this years tournament and I did not recognize any players from this year that played last year. Maybe that is good sign and means that all of last years players made the main draw this year.

I doubt it.

I did recognize one name in the Q-tournament draw, Nicholas Massu. He is a former Olympic Tennis Gold Medal winner in 2004 and top men's player. I wonder what happened to him.

In urology, most of my own colleagues are still practicing and most urologists in my area can report higher incomes than last year because of a stregic merger of competing groups. I don't know of a single urologist that has left practice in Long Island due to the competition or external factors such as rising costs of living.

Recently Medicare has not been paying in a timely fashion. I know of one urologist that sees 95% Medicare patients. He has only received $1700 in reimbursements in 2008. For the rest of us urologists who see a mix of patients from a mix of payers, 3 days of work brings in considerably more money than the majority of qualifiers earn in a similar work week.

During Q-week, I watched the qualifiers struggle. I witnesses intense happiness with victory and devastation upon defeat. I saw several players at the end of their careers; no doubt faced with the question that I faced several years ago; "what next."

For me, as I watched the qualifiers compete, I felt comfort in my own situation. I am my own boss and my outlook is positive. I call my own shots. My wins are mine alone, as are my losses.

I think I am better off as urologist than a professional tennis player, aside for the fact that I really not very good at tennis. As a pragmatist, I know my earning potential, even with the current reimbursement landscape, is better than for 99.999% of tennis players.

So for now, I practice urology by day and play tennis by night.

And go to The US Open every August. . .the best show in NY.

What do you do with all those radiology CD-ROMs?

In the past, doctors, especially surgeons, would request radiologic images on films and would review them on light boxes in their offices. However, in the past 5-7 years, actual films have become somewhat of a rarity. Instead, CT scans and other images can be viewed either over a secure internet connection or via a CD-ROM that contains the images and the software necessary to view them. Personally I have found this changed approach to the viewing of radiological studies as a huge plus, with one exception.

What are we supposed to do with all the CD-ROMs that patients hand to us?

When I had paper charts, I used to simply staple the jacket that contained the disk to the patient's file. This worked ok. But now I have electronc charts. So now what?

Here's how I do it now.

1. Place the disk in the drive
2. Go to My Computer and open it up
   
3. Right click on the icon for the image viewer in the DVD-CD reader
4. Click Explore to open the files on the CD-ROM
5. Select ALL, then Copy
6. Create and label a new folder in the pertinent patient's folder
7. Paste the files into the new folder

And now you have the images saved and you can shred the CD-ROM.

Alternatively, you can ignore the CD-ROMs since you are under no obligation to save them in your files. The radiologist is the one responsible for ensuring that the images remain available for the time period specified by state laws.

However, I find that when comparing old studies it is nice to have images saved in a location that allows for rapid and effortless recall.

The "Green" Consent: Consent Foms On-Demand

I have developed a simple method to get written informed consent from patients in way that completely eliminates paper waste and ink usage while simultaneously maximizing efficiency and the "wow" factor.

Here's how it works.
I composed 5 or 6 consent forms for the various procedures that I do in my office. These procedures include cystoscopy, prostate biopsy, testicular biopsies, and penile duplex scans. I developed the consent forms myself and worded them in English rather than legal-ese. Since I am neither crazy nor stupid, I did have them approved by an attorney.

I keep the consent forms in a directory called "CONSENTS." The documents are MS Word 2007 files. Word 2007 has a great feature: it enables documents to have multiple signature lines. In my consent forms, the documents have 2 signature lines. One line is for the patient to sign and the other line is for me to sign.

After the patient and I have our informed consent discussion, I copy and paste the consent form from the "CONSENTS" directory into the patient's folder. I then type in the patient's name and date and then here comes the cool part. I swivel the tablet PC so that I can use it like it's a piece of paper and I slide it across the desk to the patient. He/she then reads the document right on the Tablet PC and if he/she agrees and understands it, they sign it. Then I take the tablet back and sign it as well.
After my signature is completed, the document locks so that no further changes to it are possible.
Done.
5 goals have been thus accomplished:

1. A necessary legal consent form has been obtained.
2. The consent has been placed in the chart forever.
3. The process was done efficiently, inexpensively, and with considerable "cool" factor.
4. It was accomplished with off-the-shelf software.
5. Not a shred of paper was used!
   

I like it. How about you?

Want to negotiate with insurers? You better have these characteristics.

I had a conversation the other day with an expert on negotiating insurance contracts on behalf of doctors, groups, and hospitals. Here is what she told me:

"I am going to be brutally honest doc, because I don't want to just take your money, but you don't have a chance in hell."

Essentially, what anyone needs to successfully negotiate is leverage,which is what doctors in NY-metro just don't have. There are simply too many of us in every specialty. In fact, this woman told me that the panels are over filled already and that she spends most of her time just getting new doctors accepted into the plans under any terms. While it is not impossible to get a better-than-average contract, it is difficult. Essentially, you need to be special to do so. Here are some of the key elements as I interpreted them based on my conversation with the negotiator.

1. Unique: If you are the only one of your specialty in a 20 or so mile radius, you may have some leverage.
   
2. Efficient: If you can save the insurer money by operating at a lower cost to them, such as by doing in-office procedures, or with less errors due to an EMR, you may be able to make a case for the insurer to cut you a piece of the action in return.
3. Desirable: If you are one of few doctors who does something that people want or need and will pay more to the insurance company for it in the form of premiums or plan selection--then the insurer may cut you into the action as well.

Notice that large size is not on the list. Size can work for you if your group becomes so large that it controls the market place. In a larger market place, such as NY, reaching this critical size can be difficult if not impossible. In addition for most large groups, lets say a 50 person group or larger, operating expenses become so high that they can become unable to sacrifice a contract worth 20% of their revenue. They simply could not survive the acute loss of revenue. Well managed groups, ones that know their numbers inside and out, may be able to determine if they can play hardball with an insurer and survive for the year or so that is needed to recoup the lost patients that will follow the lost contract. So know your numbers!

Finally, if you do successfully negotiate, don't brag about it: that could cost you the contract. . .and more. Most plans make their "special" docs sign strict confidentiality agreements with draconian penalties for non-compliance. So the next time you hear a doctor in the lounge bragging about his great negotiating skills know that he is either crazy or full of crap.

Therefore, don't feel like you are the only schmuck on the block that takes whatever contract is offered you. If you live and practice in an over saturated market and don't have one of the big 3 characteristics in my list, you simply must sign on the line and work like a dog.

Good luck.

The IU.

Can't get affordable insurance? Start your own company.

Four years ago, an emergency medicine physician in south Florida was asked to pay liability premiums that represented greater than 1/3rd of his entire revenue and he could simply no longer afford it. Rather than flee the state, grin and bear it, or bitch and moan, this physician studied the issue and came up with a solution. He started his own insurance company. Fours years later EMPAC, the company founded by that physician, has become a very successful and profitable liability insurance company-RRG that underwrites emergency medicine physicians only.

2 years ago, a urologist, Ernie, in Nevada became fed up with double digit increases in his premiums that made it difficult for him to simply remain in business. Rather than flee the state for a more hospitable environment, he drove himself to the offices of the Nevada Department of Insurance and "ranted and raved." He wanted answers. He wanted solutions. A persistent individual, Ernie was not about to give up until he had a solution. Ultimately, an official in Nevada's insurance office gave him a name of someone in Florida who started an RRG for emergency physicians.

Ernie called him. And he called him again. And again. And again.

Over an 8 month period Ernie would not go away and he would not take no for an answer. After 8 months, Ernie had convinced this person in Florida to help him start a new company with him. The new company was to be called SCRUBS. Ernie's Florida contact was the founder of EMPAC; the man who started that company out of his own necessity.

Ernie and the EMPAC founder along with his EMPAC founding partner, personally risked $500,000 to fund the cash reserve requirement needed to obtain an insurance operating liscence in Nevada. They hired outside consultants to administer the plan and they flew around the country to meet with urologists and urology administrators and to promote the new product. In order to operate as an insurance company, SCRUBS would need at least one policy holder. Ernie risked once again and dropped his traditional policy to become SCRUBS first and only policy holder. The entire company, all 3 or them, prayed that Ernie would not get sued.

Both Ernie and SCRUBS survived that first year and looked to grow the company in 2008. The 3 managers of SCRUBS knew that New York's urologists were ripe for the taking and they concentrated promotional efforts on this group. SCRUBS' management obtained a list of practicing urologists in New York and elsewhere and sent a flier.

While the 3 SCRUBS managers worked on their problems, I had problems of my own and was facing the double digit increases in insurance premiums that most of my urology colleagues faced. At these 15% rates of increase--compounding of course--our premiums were to double every 3 years and would have crossed the $100,000 threshold by 2010. At the current rate, many of us had to work without a paycheck for 3 to 4 months just save enough for July's premium, its increase, and any additional surcharges that often accompanied them. By 2010, I'd be done without intervention from Albany or elswhere.

In February and March and I attended medical staff meetings and joined grassroots efforts to effect change at the capitol. I became an activist, I pleaded with Albany and begged "them", to not let us doctors go under.

But there is no "they", and what "they" there is does not care about "you"; well certainly not about me.

In mid-April 2008, I recieved a flier from a company called SCRUBS, an RRG that only underwites urologists. Fed up with "them" and "they" and and a future that in the absence of course-change, would lead to certain demise 4 to 5 years hence, I responded to the letter and sent in an application. Several weeks later my life changed, or at least my outlook changed. SCRUBS had answered me. SCRUBS had agreed to underwrite me at considerable savings now, stable premiums into the future, and the possibility of premium reductions as the company grew.

In July 2008, I joined Ernie and became SCRUBS second policy holder, and the first in New York. As of today, I am one of 45 urologists across the nation who decided to take a chance and change course; to take control of our destinies. Our future is still uncertain, only now it is hopeful.

Wish us look and good fortune.

The IU.

Referral Pads or a Plate Full of Feces?

The following story is true.
It is in no way exaggerated.

I had some referral pads made up recently. I personally like referral pads. I use them in my own office and a good one can influence where I send my patients for referrals, tests, and studies. For me, a good pad fits easily on a corner of my desk, has just the tests that I want in check box format, room for the patients name and my name, and how I want the results reported. Several of the labs and imaging centers that I use have referral pads that fit these criteria and I admit that I send more than a fair share of patients to these centers, rather than other ones, because of the pad. Of course, these centers do quality work as well.

Because of my own use for referral pads, I had some made for Richard A Schoor MD PC. The pads met all my criteria and were professionally designed and printed. They costs me ~$1000, total. My plan was, and still is, to distribute them to referring docs and potential referring docs via a practice rep, ie Janet.

Yesterday, I had some slow time and I learned of a new doctor that recently started practicing in an office next door to mine. She is an OB and joined a doctor that I have excellent relations with and view as a friend. So I stopped by myself to see them both. Now I no longer typically do this because one, I'm too busy,and two, I don't like being mistaken for a Pharma rep. But on this day, why the hell not!

I went to the reception desk, said hello I'm Dr Schoor, is the new doc here, or something to that effect. The staff was very friendly and replied that the new doc was not there but that she would be in the next day.

So I left my calling card and then asked the receptionist if she had any use for a referral pad, as I slowly extended my arm with pad in hand.

The receptionist immediately recoiled. In one motion she rolled her chair back 2-3 inches, put both hands behind her back, turned her face to the left, and said "no we don't use those."

It was like I had handed her a plate of feces. Incredible really.

I had to look back at the pad to make sure nothing was on them, like urine, blood, etc. Of course, the pad was pristine, all white and blue.

I wonder what I did wrong here. . .

Wine as gifts for doctors

I like this piece.

Doc vs World: How to Survive Long Term

The cost of running a medical practice has skyrocketed over the years. In this same time period, the reimbursement for our services has declined tremendously. While many of us may generate the same or more gross revenue than we did years ago, we have done so only by increasing our through-put; ie the number of patient encounters that we see per year. Clearly, this compensatory mechanism is limited, unsustainable and ultimately very costly to us doctors both personally and professionally. In addition, our patients pay a high price as well in terms of their declining satisfaction, decreasing access, and an increase in adverse outcomes. Like being on an desert island with a limited water supply, if you want live for many years to come, you better get off the island. If you are a doctor and want to be around and happy in years to come, get off the island while you still can.

My name is Richard A Schoor MD FACS and I am The Independent Urologist and a solo practice survivalist. I have been in some tough jams over the past few years and have come out stronger and more resilient than ever. Recently, I and many other doctors, survived a 10.6% Medicare pay cut. Of course the actual income loss, factoring in decreased reimbersements from private insurers that were sure to follow Medicare's lead, would have been closer to 20%. For many of us, that would have been death. What does this mean?

It means that the future is clear. It means that you best start building your raft and planning your escape.

How do you do escape? You plan.

You know what the future will bring if you stay the course, so that is not an option. But you probably know others who seem to have your "dream practice" and these doctors' practices can serve as templates for you to emulate. Simply call them and ask them "how'd you do it." More likely than not, they'll tell you, especially if you are not among their direct competitors. Ask them how they built their practice, which marketing vehicles were beneficial and which stunk, if they negotiated with payers or just took the cash-only plunge, how they dealt with referral sources; anything you can think to ask them. In my experience, these people are proud of their accomplishments, as they should be, and are glad to talk to about themselves. If you have a blog, offer them a guest post. If they don't have time to write, you offer to write about them and to provide their website with inbound links and a favorable web-plug.

When you have done your homework, then you must develop your own plan. And you must commit your plan to pen and paper. Once your plan is written down, it will take on a life of its own and become a reality. If nothing else, at least you'll feel like your fighting and not just being swept along, for whatever that is worth.

January 2010: a storm is coming. Will it kill you or will you be prepared?

Make the plan. Be prepared. Live. Thrive.

Thanks.

The IU.

Reunited with an old friend

I was recently reunited with an old friend, a very good old friend in-fact, that I had lost touch with several years ago. I'll call him The Kid, and he was my college roommate. He stood at my wedding and I at his and we shared many terrific memories over many years. He was always a loyal friend and I know we both regret that we lost touch 5 years ago. In any case, water under the bridge.

I think that many people would say that I was good role model for the kid. I think that Kid's parents felt that way. Maybe I was. But I saw things differently. It was kid that was my role model.

Kid was our fraternity's social chairman, and he was the best one we had ever had. he approach the job with passion and zeal and a business plan. Yes that is correct: a business plan.

After graduation he went to work for his dad and then his dad sold the company and the kid found himself without a job. He moved home and into the bedroom of his youth, complete with twin bed and "Marc" on the door. Not a very glorified life for a college grad. But the kid was not phased. He got a separate phone line and he promptly started a business. It was called Marc Photo and Marc was the only employee. Kid would answer the phone that was next to his twin bed "studio." It was hysterical. When I drove with him in his car, he'd be playing audiobooks on business topics. While other friends of ours thought it was pathetic and would joke that Kid couldn't read, I thought it was terrific. I saw Kid as hungry, clever. He'd be on the road so much promoting his business, that he used the time as productively as possible, hence the audiobooks. It was brilliant,really. I never doubted that he'd be a success in business. Within 5 years Kid had transformed his bedroom company into a multimillion dollar commercial photography and design business.
Though far from Kid's multimillion dollar company, I have my own successful urology practice now and I've become very busy in my office and life. On top of work and an old house, I have 3 kids, i.e. children, of my own, and I have very little time or energy to read, whether it is for pleasure or business. What have a done? I have taken The Kid's lead and have turned to the audiobook. Phenomenal! I can download the books from the internet and listen to them on my desktop at work, on a iPod as I lay in bed with Emma and wait for her to fall asleep, and on CD while in my car. It has really been nice and in the past few weeks I have "read" 5 or 6 books and have learned some new things. Sure my wife makes fun of me because I'm not really reading, but I assure you I know how to read just fine.

Kiddo, it was great seeing this weekend and thanks for re-entering my life. I can learn a lot from a guy like you. You've been a huge success in business and many of the things I've done that have worked, I learned them from you.

Let's keep in touch buddy-boy.

Waiting with baited breath.

How will they vote?

Waiting for our leaders to lead. . .we will remember in November!

Doc vs World Episode 4: Risk Avoidance

If you don't parachute, your risk of dying in a sky diving accident is zero.
If you don't let your children swim unattended in a pool, you can minimize the risk of a drowning incident.
If you stay in your home between 11PM and 5AM, your risk of injury from an alcohol related incident can be significantly reduced.
If you perform surgeries that are well within your skill set, you can minimize your risk of an adverse event and resulting legal issues.

My name is Richard A Schoor MD FACS and I am urologist in solo practice in Long Island. As urologist and physician I am well versed in risk and each day that I awake, I face plenty O'it. But I don't take unnessesary risks.

While risk is unavoidable, unnecessary risk is avoidable.

If you are a urologist, for example, you can get into trouble during a surgical misadventure, an informed consent issue, missed diagnosis, or a failure to act on an abnormal lab. If you are a urologist, these problems are not completely avoidable, but they can be minimized. For example, many a urologist has had problems arising from failing to act on a positive lab test, such as a PSA or cytology, namely because they never saw the test. This type of error happens for several reasons:

• the patient fails to go for test
• the test result is never sent to the doctor
• the test result is sent to the doctor and filed without the doctor's knowledge
• the doctor sees the test and chooses to not act upon it for some reason, though never documents the rationale for that action
• the doctor and patient have a discussion about the lab test, and that discussion is not documented

In a significant portion of the above instances, it is the patients themselves that fail to go for the test. The easiest way to eliminate this risk is simply to do the test in your office or to obtain the specimen in your office. If you want the patient to have a PSA, draw it yourself.

Risk minimized.

In today's environment of zero tolerance for medical errors and high liability rates for doctors, it is simply imperative that doctors avoid taking on any extra-risks. You can examine your own processes and identify areas in which you are assuming extra-risk that is simply unnecessary.

Get rid of it.

The IU.

A butcher without an advantage

My son is turning 1 and my wife and I are having party. Not anything fancy, mind you, just a barbecue by the pool with family. This weekend while driving on 25A in St James we noticed a new butcher that had opened next to our favorite pizza place. Looking for something unique for the party, we decided to stop in see what the butcher had.

He had what every local supermarket had to offer, hamburgers, hot dogs, steaks, chicken breast, ribs. Nothing different. Nothing unique.

How is this place supposed to survive?

What is his competitive advantage?

Perhaps if he had very high end cuts of meat that I could not get at the Stop & Shop. But he didn't.

Perhaps if he had unusual meats, like impala or a TurDucken, but he did not.

Perhaps if he specialized in free range, organic, or local only animals. But he does not.

How does he plan to compete? Beats me.

Maybe he should get a competitive edge.

Location, Location, Location

A perfect night for fireworks.

A terrific view.

Blocked by the 59th Street Bridge. When it comes to real-estate, BPH, and now fireworks. . .it is all about location.

The Medicare Cuts

Now everyone calm down. The sky is not falling in and the world is not ending. What has happened is that the Republicans, led by our fearless leader, has screwed us. But all is not bad. You know why?

Because if you can survive without Medicare then maybe you can become independent of Medicare. And then just maybe you can drop them on your own terms.

Just maybe this whole thing is a blessing in desguise.

Think about it. Plan for the next time. Transition your practice to be independent. You may not be able to fix the system, but perhaps you can fix your own lot.

Just thoughts.

Even a solo guy can take some time off

A tail gate party and salza dancing at Sunken Meadow Park, Kings Park NY.

Fisnhing on the pier, Sunken Meadow Park

BobBob and The Beeshee boy. . .my little boy. It is good to get out, see the community, and gain some persective.

Doc vs World: Episode 3

My name is Richard A Schoor MD FACS, and I am a urologist in solo practice in Long Island. In this day and age, the solo practictioner is the medical equivalent of the eco-survival specialist: without the proper skills, knowledge, and a bit of luck, you can die out here. Like my true survival specialist-alter-ego, Bear Grylls, I have amassed quite a bit of experience in survival, only in the harsh medical landscape rather than the jungle, the desert, or the tundra. While I have not had to eat bugs, snakes, or carrion to survive, I have had to eat a lot a crap!

Today, I will be trying to survive the double digit increases in malpractice insurance liabilty premiums that are facing New York's physicians. Of course New York is not the only state in crisis. Just ask any doctor in Florida, New Jersey, Massachusets, or Pennsylvania and they can tell you that thriving is no longer the goal. Economic survival is the name of the game.

Here's how to survive dramatic rises in liabilty rates.

One, you must budget, budget budget. And not just your office finances, but your personal ones too. You may need to float your business with a personal loan in the case of cash flow disruptions in the office and vice versa. In the office this means being an absolute miser. Negotiate for rock bottom fees with vendors, turn off your lights, disallow overtime, hire part-time employees, hold on to bills as long as long as possible; essentially do more with less. Put off that vacation untill things get better.

Two, you must plan for the future. The rates will go up this July. They will go up more next July, and still more the following one. When it comes to liablity insurance rates in NY, the direction is and has always been one way--up. Knowing this, one can plan an escape. In the time frame of a year, any physician can relocate to another state, join a practice, and start again. You may take a loss on your house, but ultimately you'll come out ahead. Even in states with long lines for licenses, the whole process can be completed in 18 months, tops. You should know financially if your practice can survive this July's increase and even next July's, so realistically you have 24 months to get out of Dodge. When faced with certain demise 3, 4, or 5 years hence, or survival with a calculated risk, take the risk.

Three, look for alternative insurance vehicles. In the last few years, deus-ex-machina has come in the form of RRGs. RRG's, or risk retention groups, are insurance mechanisms that cover businesses of similar risk characteristics when tradional insurance has become too expensive. Congress passed the federal law that allows for these RRGs inthe 1980s and since then many have formed in a variety of industries, including medicine. Anesthesiologists have had successful RRGs for many years and while the rates for anesthesiologist with traditional insurance companies have risen , anesthesiolgy rates have actually dropped for those covered with the RRG. There is an RRG for emergency physicians and even one for orthopedics. A new one, called SCRUBBS, is being formed for urologists. RRGs are under ferderal jurisdiction, rather than state control. As a result, insureds can move about the nation and retain their policies. On the downside, since RRGs are not under state insurance rules, insureds have no protection--zero--when these companies go bankrupt. In other words, switching to an RRG is risky, but survival and calculated risk go hand in hand.

Lastly, do not ask for devine intervention, providence, or the good will of others to protect you. In the wild, it is survival of the fittest. Same thing here. Many people I know have said the following: "they can't let doctors in NY go bankrupt." I say bull. This type of logic has led many people, cultures, even civilzations to their downfalls.

Eight years ago I stood among a bunch of obstetricians before grandrounds and listened to them gripe about their malpractice premiums. At the time, they were asked to pay $90,000. "How could it get any worse?" said one. "Albany will intervene" said another. Now these same docs are paying over 200K per year and Albany has done squat.

Albany can let doctors go bankrupt and they will. No help is coming. You're on your own.

But you have the tools to survive. Stay calm and use them.

Good luck.

The IU.

Why is a manager worth their incomes?

I recently posed that question to a bunch of practice managers on a listserve and got some great feedback. A good practice manager is worth their weight in gold, as long as they exhibit excellence in the followings areas:

• Human resource management
• Billing and coding
• Payroll
• Business development and strategy
• Information technology management
• Risk management
• Financial management
• Contract negotiation and insurance company management

I could not agree more. A good practice manager is truly worth their weight in gold and can help you generate income, run a business, and be a doctor.

Thanks.

How can an established medical practice go under? It is easy.

The used to be a saying that went something like this: there are no starving doctors. When I decided to become a physician, in 1987, that was certainly true. Now, established practices that have served communities for 40 or more years are going bankrupt. The question is how can this be happening?

It is actually quite easy. Here's how:

1. Take a practice full of established patients that are older and sicker.
2. Combine that with rock bottom reimbursements especially for that exact patient demographic
3. Add to this brew soaring medical liability premiums and rising payroll costs

. . .and you have a ship on the verge of foundering.

Then throw onto the already struggling business disruptions in cash flow, the inability to get additional financing, ie loans, and rising energy costs and voila, the ship goes down like a rock.
Very easy indeed and it can all happen in the span of 3-4 months.

Here's how to defend your practice from this demise.

1. Have 3 months of operating expenses for the business, minus your salary.
2. Have at least 3 months of savings to cover your personal costs.
3. Develop a 5 year plan for your practice and strive to achieve it.
4. Know your numbers amd metrics inside-out, backwards and forwards.
5. Be lucky!

Good luck.

Doc vs World: Episode 2

Imagine this:

• You're an orthopedic surgeon and part of a group. You have 3 partners, 2 of whom have been in the practice for 15 or more years. You are a partner, but not a managing one. What that means is that you come to work, do your thing, and get "partner's pay." One day, the managing partners call a meeting. In the meeting, they ask that all employees go 2 weeks without a paycheck because the practice is out of money. The partners, they say, will go without pay "until further notice." What do you do?

You don't believe this scenario? Believe it. This exact thing is happening in an orthopedic group with which I am familiar. So, again what do you do?

Well first, as a partner you must make it your business to know about the financial health of your business. You are a partner and it is your right. In this case, however, your options will depend on your answers to several questions.

1. Do you have savings?
2. Do you have another source of income?
3. Do have good credit and can you get a loan?
   
4. Are you willing to relocate?
5. Have you planned for this contingency?

If you have savings or a source of income that can last 1 year, you can go off on your own. Otherwise, I don't believe that this is a viable option, unless you have an established practice, a loyal patient and referral base, and an unenforced no-compete clause. In that instance, you may be able to become cash positive in 2-4 months. Here's how to start.

1. Get phone.
2. Get a box.
3. Get an address, even if it is a PO Box.
   
4. Get all your provider ID information and credentialing information gathered and organized.
5. Put all of the above information into the box.
   
6. Set-up a new PC or LLC.
7. Get a biller, even if you need to out-source it.
   
8. Change your provider IDs to your new location and your NPI to your new address.
9. Find office space or sublease on a per diem basis if need be.
10. Collect all copays.
11. Do not submit ANY claims until all provider IDs and your NPIs have been confirmed as switched, unless of course you want your old employer to get all the money.
12. Answer your phone 24/7.
13. Tell your kids they ain't going to camp.

Good luck. But there is a lesson here. Whether you are a partner or not, as a doctor you are a small business man. You must know the details of your business and you must have an exit plan. This disaster plan must be in place even during the good times. When the bad times come, they'll come plenty fast and your plan could save you. This plan should include savings, alternative income sources, your own insurance policies, knowledge of the competitive landscape and possible employment opportunities and even a license to practice in another state.

I hope this never happens to you, but if you're reading this intently, I suspect it did. Contact me if you'd like.

Again, good luck.

Doc vs World

Imagine being safe in group practice then walking into work one day only to find yourself out of a job. Happens everyday. This is the economic equivalent to being in a shipwreck and stranded on a desert island. What would you do?

Your first priority is to not panic. Panic will prevent you from calling up all your survival skills learned in school, training, and life. Time is of the essence since cash reserves will quickly dwindle away and if you don't start generating cash flow, you'll die. Panic just gets in the way and prevents you from developing a survival strategy.

Your first step is to make a business plan, set-up shelter, ie an office, and start foraging for food, that is customers. All this must happen simultaneously and in a timely manner. The survivor's business plan is a simple and rough one. You can revise it later. Just jot down your long term goals, your short term goals and needs and strategies to achieve them; should take about an hour. Your office can be virtual rather than physical and foraging for food really means to do what it takes to get customers. On a desert island, make a fishing pole or net. In start-up, get on the web and start answering your phones. I can't tell you how to make fishing gear out of bamboo, but I can tell you how to set up an effective and inexpensive web presence in under 1 hour.

I was inspired last night when watching Man vs Wild, on the Discovery
Channel. Aside from having to eat carrion, opening up on you own has
many elements of pure survival. I hope you enjoyed the first
installment of my new series, Doc vs World: Surviving Your Start-up.

Good luck.


The IU.

A hidden cost of an EMR

EMRs are energy suckers. If you have and manage your own server, the energy requirements can be enormous. I have 5 work stations, all networked, and they all remain on 24/7. I can turn them off, but I often need to access them remotely. I don't have a server and am thankful for that. Servers require large amounts of energy to run, cool, and maintain.

If you use windows based workstations, you may wish to adjust the power schemes to save money.
Here's how:

1. Start
2. Control Panel
   
3. Power Options
4. Power Schemes
5. Select the one you want

I tend to put the lesser used computers into hibernation mode after 20 minutes of idleness. Hibernation allows the computer to stay on, but at lower power-usage. The computer does not need to be re-booted and it will save projects between hibernation cycles.

In this era of rapidly increasing energy expense, little things will go a long way.

The IU.

SIZE. IT DOES MATTER.

When it comes time to pick an office, size matters. An office that is too large can be problematic for obvious reasons, namely that you will be paying for square footage and utilities that you don't need. Conversely, when the office is too small, the working environment can become cramped and unpleasant, and, even worse, you may not be able to maximize revenue producing business because you simply lack the room. However, all things considered, when it comes to office space I feel that smaller is better.

Here are some advantages that small offices have over large ones.

• No need for expensive intercom systems
• No need for dumb-waiters or tube transport systems
• Easier inventory control
  
• Lower rent
  
• Lower maintenance costs
• Lower utility bills

Let me explain some more. I can overhear every conversation in the office when my office door is open. This comes in handy when situations arise between staff and staff and staff and patients. If I need something from my MA, I can intercom her, but I typically revert to a more vocal paging method.
During a patient encounter in an exam room, everything that I could possibly need is within my arm's reach. Last year, my electric costs were ~$50 per month. Now, thanks to our current energy predicament, I pay $150 per month. If I had a 3000 square foot office, I'd probably pay double or triple. I don't have storage room for much, so I order supplies "on-demand." Whether that saves money or not, who knows. But it works for DELL. My office can be cleaned by my staff in 20-30 minutes. This is important for 2 reasons: costs me less and makes my office more secure.

See, small is better, at least for office space and now automobiles. Prerequisite: EMR.

Good luck.

The IU.

Doctors have it better than fisherman. . .for now.

I went fishing this weekend in Montauk--Long Island's eastern-most tip. I went on a charter full of amateurs and pleasure seekers. The boat was staffed by pros; fisherman that had done everything from "swording" on the grand banks to crabbing off the Aleutians. I am a terrible fisherman and have not ever caught a fish, but I love talking to people and learning about what they do and how they earn a living.

The man in the picture is a professional fisherman. He has fished on commercial boats all over the Atlantic. From talking to him, I learned that I have it pretty good as a doctor, even when I was a resident. Fishing boats are generally under corporate ownership yet the crews that staff them are independent contractors; that is they are 1099-ers. Like independent contractors anywhere else in the US, fisherman must fund 100% of their health insurance benefits, retirement accounts, and business expenses, yet have very little in the way of the tax advantages afforded to other corporate structures. On top of that, in a quirk unique to maritime law, the owners of the fishing outfit do not risk the financial losses that can occur in the event of a poor fishing season. The crew takes that risk.

For example, as I was told, if the ship brings only $15,000 worth of fish, but the expenses for the expedition were $20,000 , the crew owes the company $5000. The employers don't lose the money, the employees do. In the case of a good haul, the owners can keep up to 60% of the profits, and the crew splits the remaining 40%.

The employees risk not just life, but money, on every outing. The employers risk nothing.

Contrast that to my life. I have 3 employees and I'm the employer-owner. My overhead is in the $16,000 range per month, often up to $20,000. On good months, when I exceed the overhead, I take it all the money. On months that I fall short, I eat it all of the loss. My employees get paid regardless of the profits or losses in any given period. When times are great, perhaps they are envious of me. When times are bad, they make more than I do. With the exceptions of maritime law and CEO pay, this type of arrangement is true for all businesses in the USA.

So what I took away from the fishing trip--other than some fluke--was that doctor-employees typically have it better than doctor owners at present. Fisherman employees have it far worse than doctors or boat owners. Doctor-owners and fisherman face similar challenges; namely an environment that is largely outside their own control and one that is only getting less bountiful.

Again, just my observation.

The IU.

A great use of technology

Congrats to the Axiom Law Firm for using technology to lower costs and expand reach. They don''t have an expensive, high rent corporate office. Instead their attorneys' offices are virtual; in their laptop computers. All computers are networked to a central server and attorneys can meet with clients anywhere.

A great model.

Can it work in medicine? Already does. I know generalists that don't have an office and do all work while on the road or by electronic forms of communication. Aside from the insurance implications of this type of practice, from a logistical perspective, the virtual physician office can work quite well.

Can it work for a urologist? I have thought about this long and hard and have yet to come up with a good solution. I simply need an office to do my work. I don't need a big office, thanks to computer technology, but I need an office. While an attorney can talk with a client at a coffee shop with some degree of privacy, I simply have not figured out how to do a prostate exam at Starbucks.

Still, the standard operating procedures for physicians are changing. Large offices and large staffs have now become liabilities. Physicians can share offices, yet have completely separate practices; practice management, EMR, and phone systems, all at low cost, can be set up easily so that they are not shared amongst the doctors. I can see a situation where a urologist has the office Mondays, Tuesdays, and Saturdays, and an ENT takes it the other days. The 2 doctors share physical space only. Staff can be shared, or can be individual. With VOIP and internet telephony, even phones can be completely separate. The urologist can have his EMR/PM software housed on an external server and access it from anywhere; same with the ENT. If the urologist needs to see a patient on one of the off days, he can do so either virtually, in the ER, or by house-call. Financial arrangements can be made in these unique circumstances with enough foresight and planning. Using this technology, the urologist can still be operational and productive when out of the office.

I think this is an exciting time to be young, in start-up, and ignorant of "how thing are done." This way, you may just develop a system that works well in the 21st century.

Again, congrats to the success of the Axiom Firm.

The IU.

25A: The Route of Broken Dreams

I drive home along Long Island's route 25A, a historic road that meanders along the fabled North Shore of Long Island. On my 7.6 mile drive home I pass nice homes, busy restaurants and bars, and thriving businesses. I also pass failing businesses. Route 25A has served as a good reminder of how lucky I am just to be in business 2 years after opening my doors. Here's the list of failures of my kindred spirit businesses: those that started around the time I did but have since closed.

• A bagel place closed after 3 months.

• A seafood restaurant has closed, after having been open for only 8 weeks.

• A Mexican restaurant across from my sushi place closed after several weeks.

• A "Hooka Lounge" bar just opened, though I've never seen a single car in the lot and I think it'll no doubt close soon enough.

• A coffee shop in Kings Park went under after 6 months.
  

• A cellphone storefront lasted 1 month before going under.
• A printer cartridge retail store in Smithtown lasted 1 year.
• A law office closed and an alarm store took its place. The alarm store closed 2 months later and has been replaced by a real estate agent, all in under 1 year.

That makes 9 failed start-ups in less than 8 miles. . .in an affluent area. Yes the economy is not well and in these times having a job or a business that is simply surviving might have to suffice.

Depressing, yet true.

Good luck out there.

The IU.