Beware: A Down-side of Blogging

If the up-side of blogging is the development of a web presence and all the good things that that brings, then the down-side of blogging is the development of a web presence with all the negatives that that brings. There are numerous ways that the web can cause head aches, just ask Flea. But aside from taking grief from what you write, when you become visible on the web, you become a target for all the crack-pots, hackers, and "lonelies" determined to do you harm.

Here's a question: What do Latvia, Microsoft, The Pentagon, Google, and Dr Schoor.com all have in common?

Answer: We've all been cyber-attacked.

Here is what happened to me yesterday. At ~3PM I went to check email and received ~100 mail demon messages, the ones that indicate undeliverable email messages. 3:15PM I checked email again, and ~100 more mail demon messages. 3:30PM, ~100 more. On so on and so on. By 8PM I had received well over one thousand such messages, from all over the world, in all languages. So many messages, in fact, that my server was tied up and sluggish and business was affected negatively. Finally, I called my ISP and learned that I had been "spoofed."

Spoofed! What does that mean? It involves taking over someones email "spf" protocol. Hence the term "spoofing" but in English, I learned, it involves commandeering a person email extension, such as @drschoor.com or @gmail.com etc, and, I guess for the fun of it, spamming the world with your email. Undeliverable messages--those without recipients--get bounced back to me with the notation "undeliverable massage" from mail demon or something similar. The spammer can use an automated program to send millions of spammed messages from YOU, and your server gets tied up with the junk mail that returns.

I have no idea what message the spammer sent using @drschoor.com.

Dr Schoor.com, cyber-attacked. Richard A Schoor MD, victimized. Yes victimized, that is how I feel. I have solved the problem and the messages are slowing down. All that is left to do now is to find the important messages mixed in with the mass of junk, hope that the spammed @drschoor.com message was not too offensive, and to file a police report. I hope the authorities catch the perpetrator, though I know they will not.

Beware of the Web. It giveth and it taketh away.

Thanks for listening,

The IU.

Professional Tennis Player vs Urologist: Which is Better?

I've been spending time at the US Open this year enjoying the matches and people watching. Only this year, I have begun to look at the players through the prism of a business man and could not help but wondering who has it better; them or me. Here are some things I noticed.

• Income potential: While it seems limitless in professional tennis, this is a myth. Only the top 100 players in the world make any significant income, and the truly big money, millions per year, goes only to the top 50 in the world. The seemingly limitless corporate money goes only to the top 10, and even to them, only to those whose names transcend the sport, such as Andy Roddick or Roger Federer or in Spain, Rafael Nadal. In contrast, there are ~8000 practicing urologist in the USA, and most do very well, in the >$200,000 income range. Like in professional tennis, the "top" urologists do far better and can earn >$1 million per year in addition to corporate money via "consultant fees" and speaking fees. Over the course of ones career, the average urologist will earn many times what the average professional tennis player will.


• Threats: Both urologists and professional tennis players have significant threats to the viability of their careers. For urologists, the ever present threats are devastating lawsuits, rising costs, declining reimbursements, and outside regulatory changes. These are all very significant threats that affect all practicing urologists, yet most of us soldier on and do well despite these challenges. Professional tennis players face threats as well, and I think theirs are even worse than ours. In addition to challenges from their competitors, professional tennis face the high probability of having a career ending injury.


• Overhead: Urologists have high overhead. Ours comes from rent, payroll, insurance, professional dues and CME, equipment, etc. A solo urologist's overhead can easily exceed $150K per year, and a group of 3 can exceed $1 million per year. Now lets look at a tennis player. While it may seem that they travel light, I believe it only seems that way. A tennis player's overhead is high and includes the costs of training facilities, coaches and trainers, equipment, travel, hotels, health insurance (if they are Americans), and others. Coaches take 10% of earnings, or more, before expenses, and this can be more than a practice manager earns in a big group. Yes, professional tennis players have high overhead.


• Lifestyle: It may appear to be an exciting lifestyle--and I believe it is for the top players, or while a person is still in their young 20's--the extreme travel schedule gets old fast. Family building must be put off until after ones career, for women, and for men the travel is difficult on relationships as well. Either you bring your family with you and live out of suitcases, or you leave them at home and suffer without them. No doubt, urologists have a better lifestyle than the majority of professional tennis players.

So I think my parents were right after all. . .stay in school, play as amateur, and enjoy the Open, no doubt my favorite time of the summer.

Hope you enjoyed the post,

The IU.

Please tell me which P4P guidelines to use for this patient.

Anyone who reads this blog knows I rarely, in fact never, post medical issues on this business related blog. But alas, I feel I must. I have a patient I'd like to share with you who no doubt defies all P4P guidelines.

She is an 80+ year old woman with COPD and chronic bacteriuria. Now please note, I did not say urinary tract infections, which would indicate that the bacteria in her bladder causes her problems. No, she has simply bacteria in the urine, but otherwise does well. Despite her lack of symptoms, other physicians--no doubt well intentioned--had persistently started her on antibiotics for every positive culture, which happened to be on every urine specimen sent, or 6-8 times per year, for several years. By the time she came to me, she had multi-drug resistant bacteria in her bladder. Fortunately, she was not symptomatic, because if she was, we'd have had a problem.

Now she has incontinence, mild incontinence, but incontinence nonetheless. She is not particularly bothered by the problem, but she does wet the bed at night, and this bothers her caregiver, who is her daughter. Having ruled out the other usual causes of incontinence, and having tried medications to treat the problem, I have concluded that her bacteriuria is contributing, or causing, her incontinence. Since she is now symptomatic, she has, by definition, a UTI--or urinary tract infection. The urine cultures, which are catheterized cultures, show an E. coli bacteria that is susceptible to penicillin's and cephalosporins, though not to quinolones, sulfas, nitrofurantoin, or macrolides. I can use aminoglycosides, since the organism shows susceptibility to them. The patient is allergic to penicillin's and cephalosporins.

So what do I do? Well I know what to do because I have a brain and judgement and I cognate and I can have informed consent discussions with the patient and her family, all things that computers and guidelines are incapable of doing. Is the government telling me that P4P guidelines would help me treat this patient? I don't think so.

Oh, and one last thing. If you think that this patent's situation is unique or uncommon, think again. Asymptomatic bacteriuria occurs in 80% of institutionalized octogenarians. Moreover, millions of elderly woman will find themselves in a similar predicament as my patient and effective treatment requires thought and interactive discussions, not guidelines.

Thanks for listening.

The IU.

Finally, a good use for a camera phone.

My cell phone of 4 years finally croaked, so I bought a new phone. I actually did not want anything fancy, just a phone that made and received calls with reliability, which on Long Island, with its shoddy cell phone service, is no small feat. Other features on phones, like MP3 players and cameras etc are not important to me, and are merely toys. And you know what I think of toys, right?

So on call this weekend I had 4 consults, and you know what I did. I used the camera phone to take photos of the patient demographic sheet, or face sheet as we say.

Worked pretty well, though it does not save me any time. But in a pinch, could be a useful tool.

Thanks,

The IU.

VONAGE Vindicated!

I have switched from VONAGE to Optimum voice, have purchased a $3000 phone system and calls still drop. Broad band is sufficient to handle the volume, so it is not a VOIP issue and was likely never a VONAGE service issue. After all this, the issue may be in a faulty phone line from the source to the wall jack by the reception area.

Of course everyone blames everyone else, but I am zeroing in on the problem. In the meantime, we just march on and continue to function.

The IU.

The Human Element and Screw-Ups

I have a little lab in my office, as you may know. Nothing fancy, just semen analysis and urine analysis, but to do these tests, I need a CLIA ID, and I must run my lab with an eye on quality control. To that effect, I have taken great pains to prevent specimen mix-ups. Here is how I did it:

• Pre-label specimen cup with patients name and DOB.
• Staff gives appropriate patient the cup with their name on it.
• Patients produces appropriate body fluid into cup, and leaves cup in bathroom, etc.

Here is why I recently changed:

• Staff gave cup labeled John Smith to patient named Mary Washington
• And vice-versa
• The mistake was caught in time

Here is how I do it now:

• Pre-labeled cup as before
• Staff gives patient cup
• Patient signs attestation sheet that verifies that name on cup is their own
• Attestation sheets are saved

Humans are wonderful. I love them. But you must admit it, we, as a species, can and will find any and all ways to screw-up. Scary stuff. Better re-think your processes and close up the holes.

Thanks for listening,

The IU.

99% Accurate. Is it Good Enough?

I would like to comment on something I just read on KevinMD. Here is the Title:

Retail clinics: 99.15% proper treatment rate?

And here is Kevin's input: No doctor can match the perfection that retail health clinics offer.

Why don't we examine what 99% means, and then we can decide if Kevin is right in his assessment and more importantly, if the retail clinics' accuracy rate is acceptable.

• If a surgeon removes 99% of the tumor, the patient dies of cancer
• If the antibiotic I prescribe is 99% effective against the bacteria, the infection will recur.
• If my sterilization technique for cystoscopy is 99% effective, I'll infect 2 people per year, and a busy urology group will infect 10-20 per year, potentially, with an infectious disease!
• If my specimen labeling process is 99% effective, I'll mix-up specimens at least 26 times per year (100 per 2 weeks x 26 bi-weeks per year).
• If a busy internist is given the correct chart with 99% accuracy, he will make his notation in the wrong chart on 52 patients per year, on average.
• If a lab filing system is 99% accurate, labs will be misfiled 100 times per year, on average, in a moderately busy doctors' office.
• If an established medical office has an EMR that uses back-up that is 99% accurate, a crash could cause the permanent loss of 100-200 charts (10,000 to 20,000 patient practices, respectively).
• If surgeons operated on the correct side/site only 99% of the time, in my little community hospital, we would see 1 wrong side/site surgery per week, and the hospital would be shut down by the state.
• If you drove with 99% accuracy, you'd have a car accident every 4 to 5 weeks.

You see, 99% sounds great, but in actuality, is only good if you are taking a college final exam. In life, big number enterprises, such as medicine, 99% is not very good at all.

I disagree with Kevin. "Proper treatments" are given by doctors at a far more accurate rate than 99%, or we'd all be out of business. And I'd think twice about going to a retail clinic.

Thanks,

The IU.

Inspiration for blogs

Someone asked me today how I get my inspiration to write the material on my blog with such frequency. The answer is that life and life-in-practice serves up more than enough material to fill my pages. In fact, as you can see, the question itself became a topic. Here are some some examples of some inspiring blog topics that I'll hopefully find time to publish:

• Last week a sales rep from a small uropathology lab in NJ came to my office. Despite the 90+ degree heat, he had on a cheap suit--jacket, tie, and all--and his forehead was covered in beads of sweat as he tried to convince me to use his lab. Unfortunately his message was lost on me, as I could not help but find myself thinking about my mom and dad, and thanking them for encouraging me to stay in school as I regrettably viewed him as a somewhat unenviable character in a very undesirable job. Maybe I'll throw him some bones, since I've always liked underdogs.
• Yesterday, 2 avodart reps came to my office. One was a late 40's woman, and the other a mid-30's man. The woman did all the speaking, so obviously, the man was her boss, ie her territory manager. As she showed me her marketing material, several things went through my mind. The superb quality of the marketing material made me think of how I would like to mimic it, in some way. Then she showed me graph, and as I marveled over the complexity of it, I was reminded of medical school, and then I thought of calling my friend Mike, to catch-up. Finally, I found the dynamic of the woman and her boss interesting, and I found myself thinking that I would not do well in such a situation, and would not like the obvious post-encounter debrief/critique that was sure to ensue.
• Today I had a case get canceled due to a scheduling mix-up on the part of both the hospital's and my own scheduling processes. The hospital booking agent, who was new, did not know the difference between intra-corporeal lithotripsy and extra-corporeal lithotripsy, and the patient and I were told to report to hospital A, when the correct equipment was at hospital B. It happened to another of my colleagues this AM as well. Fortunately, the mistake was caught before the patient was taken to the OR and sedated, and his case was elective, so no harm was done. But it got me thinking again about process management and six-sigma in my office, practice efficiency, and a whole other host of blog topics.
• My COLA lab inspection has provided me with tons of material not yet published.
• My late night baby feedings has inspired a host of posts as well on such topics as: how to type while one hand holds the infant bottle, good late-night bottle feeding movies, how to get a quick post in between calls for help from the wife, and how scheduling early morning cases can become an effective method to avoid late-night feeds.

You see, life is full of topics perfect for a blog, and all that you have to do is live, observe, listen, and write.

Thanks,

The IU.

The IU.

EMR: The Essential Features

I'm in the market for an EMR system. I have one, a home-grown system, that actually is pretty good and efficient, but lacks some features that I believe are essential. Here are features that I look for in an EMR:

• Unalterable: Records must be unalterable once written and the system should not have any "back-doors" that allow alteration of a record. While mine does not do this automatically, it does do it. I just had to develop easy method to make the records final and unalterable, a feature that I consider absolutely essential.


• Amendable: Entries must be amendable, but the date and time of the correction and the amending person must be noted amd time stamped. In addition, the original entry must be visible for all to see. Mine does this too, but again, I had to come up with my own home-grown solution.


• Efficient: One time data entry, and seemless transfer of information from the PM program to the EMR to the lab ordering system, letter generation system and result reporting system. If you have to enter the same piece of data more than once, the program is no good. My system fails in this regard.


• Intuitive: If someone with a no more than a basic knowledge of windows and MS-Office need extensive training to use the system, it is too complex and not worth it. Reconsider. My system scores high in this feature.

• Affordable: I'm not saying cheap, but if you have to see 1000 extra-patients a year just to support the EMR, it is not worth it. My system socres off the charts on this feature.

Thanks,

The IU.

An Easy Way To Save Fax Confirmations

My COLA lab inspector suggested--actually demanded--that I keep a permanent record of all fax confirmations, which I have not been doing. It is actually a good idea, and with the system that I have, not so hard to do. I have started to do it for every fax message that I send, whether it be the referral letter, or semen analysis results, or requested records. Here is how I do it:

1. Right click-->fax to recipient-->type in name and number comes up automatically
2. Fax sent
3. Confirmation is sent via email
4. double click on message-->save as Text only file into patients e-folder
5. done-->have coffee

That is it. I actually like it. No more of the shannanigans "We never got the fax."

Thanks,

The IU.

The 4 Essential Qualities for Success in Private Practice

Remember the 3 A's--ability, availability, and affability--the age-old 3 ingredients for success as a physician. Do they still apply? Yeh, they still apply and can take you a long way, but they are no longer enough. Here are the 4 key elements as I see them:

1. Focus: You must have a goal for your practice and remained focused to it as the myriad of competing forces try to pull you away. In addition, I'm a big believer in being a focused student of the process of medical practice and small business.
2. Fortitude: Medicine has always been challenging, but now the challenges come from so many different sources, not just the medical ones, but also regulatory, legal, insurance oversight, etc. You must be made of some pretty tough stuff just to survive with your passion intact. My skin is raw hide!
3. Fun: If you don't find it fun, or you have lost your passion, it's over unless you can find it. Try to view it as a journey--a road trip--and everyone knows that the road trip is always better than reaching the final destination.
4. Family: You better keep your family, and especially your wife, happy. Without them, forget about it and just get a job.

Now off to make my wife happy. . .by relieving her of newborn duty. "Alright, I'm coming, I'm coming. . ."

Thanks for listening,

The IU.

Define and Refine Your Processes

I just had a lab inspection by COLA, the accreditation agency for my in-office andrology lab. The goal of COLA, among several goals, is to educate lab directors, this case me, in how to run a lab and how to develop operational processes that can enable the lab to function efficiently and error free. A laboratory, like a medical office, is really a set of processes designed to achieve a goal, such as the safe delivery of health care. In the case of a clinical lab, the goal is to obtain and report clinical lab results in an accurate and timely manner so that physicians and patients can act accordingly. These processes are all connected and interact and affect all other processes farther down the chain. Thus, an error in one seemingly minor process can result in disastrous outcomes for the lab and the patient. COLA teaches us how to put systems in place that can help to avoid these errors.

As a result of my own lab inspection, I have been able to re-think operational systems for not only my lab, but for my general office as well, and since the inspection, I have been busy defining and refining these systems on paper for the goal of achieving COLA accreditation and also, to make my urology office function better, more efficiently, and with fewer errors. Here are a few processes I have defined that occur daily in my office and lab.

• Data Entry Procedures
• Patient Verification Processes
• Patient Entrance and Exit Processes
  
• Specimen Cup Labeling Systems
  
• Test Reporting Systems
• Test Result Tracking Procedures
• Test Ordering Procedures
• Specimen Collection Procedures
• Back-up and Data Recovery Systems
• Instrument Sterilization Processes
  
• Error Reporting Procedures
• Quality Assurance Processes
• Quality Control Processes

And many more. In fact, as a requirement for COLA accreditation and for CLIA itself, all of these processes must not only be defined, they must be in book/manual format, in the lab, ready for inspection.

Thanks, the IU.

The Box-Method Revisited

Last November, 2006, I wrote about the Box Method, an easy, yet not-oft-recommended way to store important documents easily and without fear of document mis-files. I wish to update you on how my box method is doing.

As I said in the that post, I first learned of the box method at freshman orientation at the University of Maryland, College Park, my Alma mater. In essence, the box method is an easy way to secure important papers in one location and is so easy to do, a disorganized frat boy can do it, and never lose the proof he needs regarding that dropped course.

Here's how it works. Every time you get important mail, like monthly bank statements, bills, credit card statements, etc, just put them in a box. Don't try to organize anything. Just throw them into the box. At the end of the quarter, you can then organize the papers into appropriate sections in an accordion folder so that your accountant can go through them do your quarterly income and cost statement. Read the earlier post in which I explain it in more detail.

When I first started my solo urology and male infertility practice, the box method worked fine. At that time, I was seeing ~20-25 patients per week and operating once per month. I had no call. I went to one hospital, no lithotripsy center or surgi-centers, and had huge gaps in my schedule. When it came time for my quartely accountant meetings back then, I had time to organize the box prior to the meeting. Back then, the box method worked well.

Now I see 40-50 patients per week, and do ~10 surgeries per month at my local hospital in Smithtown. In addition I do another 10 cases per month, such as sperm retrievals, litho's etc, at a variety of places, like the lithotripsy center, the surgi-center, or the IVF centers. My days in the office still have breaks, though not long ones as in November 2006, and when I am not seeing patients, I am transporting my younger girl to and from camp/school, making bank runs, writing, planning, & thinking (yes, I schedule "thinking" time--very important), or helping out with the new born at home. On top of that, I am on call for St Catherine's Medical Center in Smithtown, and have been busy with ER and hospital consults. So now, does the box method work?

You betcha! Works better than ever. You see, the busier you get, the more you need the box method. My accountant meeting is tomorrow, and I organized my box in less than 30 minutes while I watched a promo video for a cool new health website called http://www.organizedwisdom.com/.

Get the box. Don't listen to the nay-sayers. It works great.

Thanks,

The IU.

Outdone by JiffyLube

"Convenience service and the personalized attention that you deserve."

That is what the radio ad said as I sped off to the office so that I could offer my personalized services at a convenient times to my patients. Only this ad was for JiffyLube. They were offering complete diagnostic work-ups with consultations to discuss the diagnosis and treatment options--for your car.

Interesting. But it leads me to wonder, are we, as physicians, the same as JiffyLube, or are they trying to become more like us. In any case, it makes me re-think my marketing and differentiation strategy.

Thanks,

The IU.

Six Sigma and Your Medical Practice

Here is the conundrum.

Mistakes are unavoidable.

We, as physicians, can't make mistakes.

How can this be reconciled? Well, while we can't completely eliminate mistakes, we can seek to minimize them. In industry, businesses have turned to a concept known as Six Sigma to reduce error, eliminate waste, and maximize profits.

What is Six Sigma? Read the following link, and then I'll explain it in English, as I understand it.

The objective of Six Sigma Quality is to reduce process output variation so that on a long term basis, which is the customer's aggregate experience with our process over time, this will result in no more than 3.4 defect Parts Per Million (PPM) opportunities (or 3.4 Defects Per Million Opportunities – DPMO).

So, in other words, Six Sigma is a quality goal that allows for only 3.4 mistakes in every million cycles of a process. Here is an example that may make it easier to comprehend.

Honda makes cars by the millions per year. Auto production is a complex endeavor with many, individual processes. In order for people to like Honda Automobiles and to want to buy more of them, the cars must be reliable, ie built without errors. By using the concepts of Six Sigma, designers can create processes of making cars that keeps defects--such as faulty ignitions--to a minimum, such as 3.4 faults per million cars made. Other examples of Six Sigma quality include airline and rail safety procedures, though not timeliness, and pharmaceutical manufacturing safety control, among others.

The concept of Six Sigma has been applied successfully in many high production industries in many different sectors from manufacturing, to the airline industry, even to health care. In fact, Six Sigma is becoming somewhat of a mantra in health care as we move into the pay-for-performance era--an era in which medical mistakes are not tolerated.

Medicals practices, both large and small, have found it necessary to increase production--throughput, as we say--in order to maintain profits in the face of rising costs and decreasing reimbursements. The average urology practice sees >80 patients per week per provider in the office. Some practices see 40-60 patients per day per physician! In fact, many patients and providers alike have called this type of practice "the assembly line." With numbers like these, it is no wonder why medical mistakes are on the rise. As you can see, with regards to throughput, physician practices are not unlike manufacturing plants with high production rates.

Medical practices, like auto manufacturing, has many processes that take place many times a day in the normal course of business. These processes may include patient intake and exit, document management, data entry, billing, test ordering, patient recall, etc, and any one of these processes is prone to error. Like the auto industry, error in one process can effect the others down the chain, thus producing a lemon. For example, a front desk worker may forget to add a middle initial to a chart, which may result in mis-filed labs, which may result in treatment errors, and on and on. The busier the practice, the more errors. The more patients seen, the more likely some aspect of the process will break down, mistakes will be made, and efficiency and patient care will suffer.

As physicians and owners of medical practices, we must design--and refine--our processes with the goal of Six Sigma. And if you are a young physician about to enter a practice, you may wish to evaluate a prospective medical practice based on how they do business--their processes--and how the doctors and administrator THINK about these processes. You see, in a solo practice, you design and control the processes, but in a larger group, often the processes were put in place by someone else before you arrived. Unfortunately, while the processes may be theirs, it is often YOUR ASS when mistakes are made. Ask your prospective employer and the administrator if Six Sigma is their goal.

I have started to re-think my processes--how I do things in the office--in an effort to increase efficiency, to reduce error, and to simply be better at what I do.

My goal is Six Sigma.

How to sack someone in academia.

Academic medicine, like private practice medicine, is not immune from market forces that force change. Occasionally, those market forces dictate that a physician move on to another job. Unlike private practice, however, termination--firing--of academic appointments is not so straightforward, and often involves a team of lawyers and human resource personnel to ensure that the person is sacked legally, and without recourse. Here are some ways to get rid of your academic partner:

• Termination: Easier said than done, and throw gender, ethnicity, and age into the mix, and it can become next to impossible. To do so requires either 1 egregious act on the part of the target, or a paper trail of poor performance examples. The paper trail can cut both ways, as the target can use it in their behalf as proof that they were, in fact, targeted. There are better ways.
• The Squeeze: Cruel, but effective, especially with a younger employee who has other options at their disposal and can take the "hint" and act. The squeeze involves slowly and surely removing or altering privileges, such as OR block time, office hours, or physical office space. It may seem petty, but the message should be loud and clear. When your office is relocated to a trailer at the far end of a parking lot, it may be time to find a recruiter and bolt. Of course, since you were not actually fired, legal action is more challenging, though doable.
• The Demotion: Similar to the squeeze, but usually involving pay and rank. When the head of the section of oncology is made vice-head upon arrival of the "superstar", that is a demotion. For some people with poor ego resources and even less financial resources, the demotion may not be enough of an incentive to leave, though remaining behind is, well, unpleasant to say the least.
• The Promotion: This is the best way to get rid of an ineffective employee, and while it may seem like a joke, it is not. When the OR scheduling clerk at the VA, where I worked, went "nuts", he was promoted to "concierge." Usually the promotion is to a position with a nice title, an office, no staff, and no responsibility. In effect, you've been made inconsequential. From a legal perspective, these promotions are iron clad. How are you going to complain, you ingrate, you were promoted. Beautiful.

So the next time someone tells you that they were "promoted", you can raise your eyebrows, in knowing recognition of the truth.

Thanks for listening,

The IU.

The agonal rythyms of a medical community.

Have you ever watched a hospitalized patient die? I have, on several occasions, as medical student and as a resident. If you could detach yourself from the human element, the suffering, the tearful families at the patient's bedside, the horror of modern, tube-filled death, the physiologic aspects of impending death can be quite interesting.
As a medical student, on an SICU rotation, I witnessed a tragic case involving 16 year old girl--a passenger in a high speed MVA--who suffered severe traumatic brain injury, and no other damage. She was not brain dead, as she had some brain stem activity only. All that the family could do was to make the agonizing decision to terminate supportive measures. After the family left the bedside and said their final goodbyes, I sat in the room with my senior resident who wanted to teach me about agonal rhythms.
As a patient's death becomes imminent, respiratory rhythms change from deep, regular breaths that sustain life, to short, erratic, and non-functional breaths that hasten death. These are called agonal rhythms, and they mean the end of life for the unfortunate sole.
Yesterday I spent my day in the Hospital where I had 7 surgeries for male infertility. Between cases I had the good fortune--or not--to speak with my colleagues in other specialities such as orthopedics and OB and general surgery. To say there was griping is an understatement. I have spent the last 10 years in physician lounges hearing griping, and what I heard yesterday was something different. This was desperation and fear. This was solemn resignation to a simple fact--it's over. We've lost. We're dying.
Agonal respiration.
Some said they were going to try this, and some said they were going to try that and others simply shrugged, accepting of certain demise.
Agonal.
If I could somehow detach myself from the human aspect of professionals at the heights of their careers with busy practices and happy patients who are going out of business, I might be able to find it interesting. How will the market correct itself? What will they do? What will break first? From a business, case study perspective, yes, it is interesting.
But it is not interesting! It is horrifying and scary and sad.
Agonal rhythms.

A good reason to blog.

If you are a physician, or any other public person, there exists a great deal of information about you that is readily available to anyone with access to a computer and some google skills. Physicians, it seems, are among the most public of figures, and with a couple of key strokes, potential patients--or anyone for that matter--can learn the entire work history, training history, and any disciplinary history for any physician, any where in the USA, 24 hours a day. And most of this information is supplied not by the physicians themselves, but by third party data entry personnel, some who work for the state, and some who are employed by for-profit companies. In other words, there is dialogue that goes on about you, and you have no part in what is being said.

Here is a simple, low or no cost way to combat this dialogue.

Take part in it.

Engage it. Add to it. Reply to it. Embrace it, and eventually, control it. How?

Blog.

By blogging actively and transparently--in your own name--you can influence the dialogue that already exists and turn it in your own favor. Your blog should be compelling, honest, and well written, and if it meets those criteria, people will find it and link to it. The more posts, the more links, and the higher the google organic ranking. Plus, it's fun, and you'll make friends.

All of your posts should be linked to your own website, if you have one, and--this is key--you must blog in your own name and be proud of what you write.

This way, you can influence the conversation that takes place in cyberspace that is about you.

Thanks for listening,

The IU, aka Richard A Schoor MD, urologist, Long Island, NY

The PC: Am I a professional or a corporation?

This morning I noticed my incorporation kit sitting in my book case and decided to have a look. I find it very interesting. I am professional corporation. My corporation was incorporated in New York State in February 2006. I have a corporate seal and by-laws, and I take minutes. The first meeting of the share holders took place on February 21, 2006. I signed the minutes as the secretary , the director, and chairman. Well that certainly sums up the role of the solo practitioner. According to the article of incorporation--the documents--I'm supposed to have periodic shareholder meetings, which I do, with myself, daily.

My corporation has 200 shares. I own all of them. When they were issued, they had no value. Zero. I don't know what they would be valued at currently, probably somewhere between the $0.00 and Google's stock price. In case you have never seen an actual common share document, they are quite impressive looking, even pretty, and of course, are the color green.

As a corporation, my fiduciary responsibility and my legal obligation are to make a profit and moreover, to maximize it. That is the law.

As a professional, my ethical and fiduciary responsibilities are to provide the patient with the best medical care at the lowest price possible, given their medical situation.

How can I reconcile these 2 seemingly adverse goals, the corporate one and the professional one?

I believe it can be done. Maximizing profits at the expense of good patient care is ultimately counterproductive and bad from a business perspective. Any practice's long term problem is 20-30 years of continued growth, or at the very least, survival. Unethical medicine, while it may be profitable in the short run, is in essence a short term solution for what is a long term problem. I prefer to do the right thing by way of the patient and to provide them with the best care that I, and my staff, can give them, and then encourage them to tell others about how great we are. So far, this has been a successful business model for the corporation, Richard A Schoor MD PC, and the professional, Richard A Schoor MD FACS.

Thanks for listening.

The IU Inc.

A bankrupt bagel place

The bagel place near my office has gone out of business. They opened their shop right around the time I opened my urology office. They were on Terry Rd in Smithtown, a busy, well traveled road in the heart of Smithtown's professional office complex district. The nearest bagel place was 1/2 mile away in a shopping center. That bagel place, which seems to do well, was much more expensive than the Terry Rd store, had long lines, and often a rude staff. Why did one place close, while another has thrived. Here's my take.

• Inconsistent service: The Terry Rd store delivered, sometimes in 5 minutes and other times after 1 1/2 hours. The thriving bagel place only delivers for large orders, but they deliver on time, as promised. Sometimes the failed store would answer the phone promptly, while at other times, they would not answer. Sometimes, faxed orders would be filled, but not on a consistent basis.



• Inconsistent results: The Terry Rd store had a great Turkey BLT. The first time I got it, it had mayo--the perfect amount--crisp bacon, and smoked turkey. It really hit the spot. The next time I got it, they forgot to put mayo on it. The next time, they forgot the bacon! I called them, and they delivered the bacon and an apology. I ordered the sandwich several times, but it was never as good as the first, and consistently inconsistent in it's quality. My staff had the same experience with their sandwiches. I actually began calling the bagel place the "The Chance Bagelry." Eventually we stopped ordering. At the thriving store, The "Smithtown Special" is the same day in, day out, as is the "Main Street", and the "John Smith."



• The Experience: Being that delivery was inconsistent, I used to stop in from time to time to pick up food. The never seemed to know me, never a "hey Doc." And I was a loyal customer. The thriving store seemed to know who I was, even though I stopped there less frequently. Even the mean front desk worker, a 19 yo girl, was mean to me in the same, personal way that made me feel, in some odd way special. Actually, she had the same relationship with many patrons, sort of like at Ed Debevec's in Chicago. I do not like her, but I enjoy going to the store to see what kind of pissy mood she'll be in, and how she'll take it out on me. Weired!

There are lessons to be learned here. Physicians may not sell bagels, but we are in the customer service business. In order to thrive, inconsistency in service and results must be minimized as much as can be, and the customer's experience must be as positive and personal as possible.

Just my opinion.

Thanks,

The IU.

PS: The baby and mom are doing well and are coming home today.