The lesson of Officer Krupke
The subject of this blog is how to (1) run a financially successful practice, (2) earn as much money as the anesthesiologist sitting behind the curtain thinking about his dinner plans, (3) not miss your kids’ soccer games and school plays, and (4) work 40 hours a week. All at the same time. I can write about it because I’ve done it. My experience is that (3) and (4) are way more important than (1) and (2). However, in the spirit of cognitive dissonance, my focus is on financial success. The reason is that the Match results are in, and once again family practice residencies attracted fewer American medical students than the year before. The extinction continues. The reason is net income. So I return to the subject of money, the love of which is the root of all evil. While I continue to wait for the angel of charity to slash the unwarranted incomes of less challenging specialties, let’s address collection policies. Every time I go to a medical convention, a management consultant has a couple of sessions in a noisy, curtained venue that will tell you in 45 minutes what I’m going to tell you in six words: You’ve got to dump the deadbeats. Some of you have been brainwashed by social workers (on government payrolls, with defined-benefit retirement plans) into believing that deadbeats should be objects of mercy, not justice. They believe, with the delinquents confronting Officer Krupke (see Stephen Sondheim, West Side Story):
“Dear kindly social worker,
They say go earn a buck.
Like be a soda jerker,
Which means like be a schumck.
It's not I'm anti-social,
I'm only anti-work.
Gloryosky! That's why I'm a jerk!”
The world is full of jerks. The key to a successful practice is to distinguish between the jerks you can work with, and the jerks you can’t. That’s where your collection policy comes in.
Personally, I hate confrontation. I have only tossed a couple of patients out of my practice face-to-face. One of them was a pretty good friend who kept verbally abusing my staff. I’ve never done it for non-payment of debt. But lots have been booted out by a process that I consider both just and merciful.
The key is that I make it clear that no one will ever be dumped for inability to pay. If they ask for their debt to be forgiven, it will probably be forgiven. If they want to pay $5 per month, that will be fine. Here’s the key paragraph from the letter patients get before they are turned over to collections:
“I’ve tried to be human about debts. Anybody who tries to make arrangements to pay, and then follows through without our badgering, will make us happy. I don’t care if your monthly payment will never retire the debt. Just don’t make us keep sending you bills. That’s all we ask.”
And then there's this from our dismissed-from-practice letter:
“Our office policies do not prevent us from forgiving debts. It is only when patients neglect to discuss arrangements with us, or fail to abide by agreements, that we terminate service for financial reasons. It simply wastes too much time to chase patients with past due bills. Our office policies do not allow for dismissal based on the patient’s type of insurance or medical needs.”
Bills must be sent monthly, with “past due” amounts clearly labeled. At some point (you decide) comes the collection letter, then the heave-ho. But it has to be the same for everybody; no “respecting of persons,” in the Biblical sense, is allowed.
The alternative? Wasted time, which is wasted money; confused staff, leading to demoralization; all the tough calls ending up on your desk, making you late for the soccer game; or, worse, one more paper stacked in the inbox.
And ultimately, you'll end up with a practice skewed toward the type of patients who are least satisfying to treat, and whom you encouraged in their dysfunctionality.
Posted at 10:46AM Mar 25, 2009 by Doug Iliff | Comments[10]
Trust me. I'm your doctor.
I’m meandering my way through six questions that will determine your productivity as a family physician, to wit:
1. How fast do you work and think?
2. How many problems can you manage in an hour?
3. How much time do you spend on non-paying medical activities?
4. How much do patients trust you?
5. How efficient is your collection system?
6. How much attention do you pay to coding?
I do this under the (challengeable) conviction that when family physicians have met the enemy, he is us; that we can make specialist-level incomes if we pay attention; that the bio-psycho-social model is a time waster, and caters to the lazy or lackadaisical; and that, as TransforMED discovered (in perhaps its only useful return on an investment of millions), you can’t make a living seeing 15 patients a day – unless you choose the micro practice model, and you’re willing to empty your own trash and serve as an insurance clerk part-time.
Let’s walk into a minefield: Why does it matter how much patients trust you?
When I started in family practice, I was a big believer in patient education and informed patient choice. I’ve already told you how I discovered that most patients need an ounce of willpower more than a pound of knowledge. Since I believe in Original Sin, that wasn’t a big surprise.
The big surprise was that they really wanted me to be God.
I don’t like people who think they’re God. Many CEOs are ordinary people; but when I encounter a godlike CEO, I can’t get rid of them fast enough. (“Yes, you really do need to go to the Mayo Clinic for your $3,000 annual physical.” “No, I won’t see you at 6 in the morning.”) Give me honest, hard-working, unpretentious, blue-collar folks any day.
What I found with experience was that long-winded, derriere-shielding discussions with patients about the risks and benefits of ingrown toenail removal, including death, were promptly met with “What would you do, Doc, in my situation?”
Maybe my practice is eccentric. But that’s what I’ve found. My patients want to know what I would do. That shouldn’t be confused with What Would Jesus Do. But I’ve had to get over the discomfort of answering that question honestly.
It really isn’t the same as wanting me to be God. I was exaggerating. What they are doing is trusting my judgment, which is exactly the same thing I would do in their situation. After all, if I didn’t trust the judgment of my physician, wouldn’t I choose another?
So I got over it. I don’t have a dictatorial personality (at least in person), and learning to simply be grateful for the trust I am granted makes me a lot more productive. I don’t have to listen to myself talk, unless requested. A lot of problems are handled in a lot less time.
Trust has to be earned. It takes time, and exposure. I work with an excellent PA, but I decided early on that I wasn’t going to reroute routine colds and pains to my mid-level; those encounters are trust builders.
It takes honesty, including the humility to say, “I don’t know.” Be well-informed, and shoot straight. Sincerity is important, and eye contact is important. I have seen evidence that tapping on a laptop doesn’t hamper relationships, but I don’t believe it.
Here’s a pearl: Review the chart, including labs and the last visit, before you enter the exam room. Don’t pull it out of a slot on the door; then the patient knows what you’re up to. The point is to make them think you’re smarter than you are, or at least that you care enough to devote full attention from the moment you cross the threshold.
Kathy Saradarian, a family physician with a micro practice in New Jersey, recently wrote, “The PCMH die-hards are not allies. They are so caught up in this high-tech, low-touch, doctor-manager definition that they have forgotten who we are.”
That’s the ticket. There’s the danger. And it may not pay well, either.
Posted at 09:37AM Mar 16, 2009 by Doug Iliff | Comments[0]
Chronicles of wasted time
To review: This blog is about financial productivity. It is directed at medical students (to give them hope regarding a career in family medicine), residents (to give them insight into the business of family medicine) and family physicians of all ages who are still learning and growing.
Age isn’t important. I’ll be 60 this summer, and I’m still learning and growing.
The third of my six factors determining financial productivity is the time spent on non-paying medical activity. By “medical activity” I mean any professional time that is not recreational. If you are a social butterfly and enjoy medical society meetings, that’s recreational. So is serving on a hospital committee, if you’d rather do that than watch a football game, or reading the New England Journal of Medicine, if you prefer that to the Wall Street Journal.
Besides having the misconception that family medicine pays poorly (it often does, but doesn’t have to), students and residents often feel overwhelmed by the knowledge demands of a generalist. Let me see if I can help you get a grip.
From an historical perspective, things were much harder in the good old days. When I started practice, I had a notebook full of “pearls," which were difficult to access, and a whole library of books to help me find the information I couldn’t remember. I rarely consult the library anymore. Between my PDA and laptop search engines, information is amazingly accessible, so that time waster is gone.
That leaves the problems that haven’t disappeared in the information age.
The first is knowing what you don’t know. This is an issue of experience and conscientiousness, for which there are no shortcuts. But specialists have the same problem. That’s why medicine is an apprenticeship trade, and why we all undergo at least seven years of training after college. Knowing what you don’t know enables you to, as the book by Dr. Oscar London is entitled, “kill as few patients as possible.”
The second problem is learning what you don’t know, but need to know. In every field, physicians must have certain knowledge and skill at their fingertips. A surgeon who has to consult an anatomy text halfway through a Whipple’s procedure won’t be a surgeon very long. A family physician who has to review the treatment of impaired glucose tolerance three times a day will contribute to lowering the average salary of the specialty.
An analogy in industry would be “just on time” delivery of component parts, which has markedly raised productivity. Some things you just need to know; the rest you must find very quickly. That’s why I’ve never been a fan of review articles.
The authors of a review, or a textbook chapter, experience a powerful hidden incentive. They absolutely, positively cannot allow themselves to be “bagged” by some smart-aleck who finds an obscure item missed in the differential diagnosis. For them, that is a recipe for academic suicide; for me, information overload. It makes my eyes glaze over. And it wastes my time.
When I read, I’m searching for something I need to know. Medical writers in the lay press have gotten so good that I usually encounter important research results in my daily newspaper. I can scan the NEJM in just a few minutes, looking, always, for something I should do different in my daily practice. As you gain experience, and your practice patterns become second nature, this demands less and less time.
The third problem is developing practice strategies that are based on evidence and common sense, and sticking to them. There are several strategies for managing hyperlipidemia, diabetes and hypertension: the "Big Three" of family medicine. Pick one strategy for each, and be consistent. Don’t fly by the seat of your pants. Every clinical decision shouldn’t be ad hoc.
That wastes your time, and it confuses your staff. A confused staff will waste more of your time. They want to help you; they would like to read your mind. Give them a chance. If you alter from your usual pattern, explain why. Draw them a picture. Diagram your algorithm. When they are confident that they know what you would do, they won’t have to ask.
Productivity isn’t magic, and it isn’t really difficult. But you’ve got to want it. It's the result of intention, not accident.
Posted at 10:09AM Mar 09, 2009 by Doug Iliff | Comments[2]
