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It's been a month since I wrote my last post - really more than that, since my last post was a little thank you note to my patients.  While my silence was not premeditated, I have decided that it's more important to do the walk than the talk.  Really, I've just been too busy working.

How's my practice doing?  It's working too.  

I am now up to nearly 400 patients, and while Jamie and I have talked about hiring a new staff person, we seem to be hitting our stride in this different practice model and have not yet been overwhelmed.  New patients are coming with regularity, some still coming from my old practice and many others through word-of-mouth from satisfied patients.  Yes, people still seem very satisfied with the care they are getting from me.  If they have medical problems that need immediate attention, they can come in and be seen.  I frequently hear from patients in the office how happy they are that I am doing this kind of practice.

I've also stepped up my effort to coordinate care by calling specialists or sending them detailed letters explaining why I need them to see the patient.  The specialists I've contacted are delighted with my efforts to make their jobs easier and to give better care.  While it is still difficult to get them to adopt secure communication tools, I am getting a small number who I can throw curbside consults to, and who can give me updates on the patients from their computers or phones.  

I've been working on adding new services as well.  One of the first things I did when I opened the office was to negotiate a very inexpensive fee schedule from a lab who would bill me for the tests.  Most docs mark up the tests and make a profit off of it, but I do very little mark-up of the tests, instead offering things like a CBC for $4.50 and a TSH for $8.00.  I am now working on doing the same thing with an x-ray facility, giving them the opportunity to get guaranteed cash up-front (reducing their overhead) while avoiding the many traps of compliance with Medicare billing (which forbids providers from giving discounts to other patients that they don't give to Medicare patients).  I can attest: get into the cash-pay world and life becomes simpler and overhead is much, much lower.  You can afford much cheaper rates.  In the end, I hope to negotiate this kind of rate for other procedures, like echocardiograms, colonoscopies, and perhaps even minor surgeries.  As my patient population grows, my credibility in negotiation grows as well.

What's the thing that patients appreciate the most about my practice?  Accessibility.  If they need me, they can reach me.  In fact, I just answered a question for a patient right before I wrote this sentence.  One person had a child with flu-like symptoms on New Year's day and was contemplating taking them to the ER.  I told them to meet me at the office and I ran a flu test and took a quick look at them.  No big deal; it took me about 10 minutes and I saved an ER visit.  This kind of thing happens with regularity (not usually after hours, thankfully), and having an office that at most has one patient present, it's easy to handle them quickly and efficiently.  My only challenge thus-far has ben to convince people to call me before they go to the ER or urgent care.  Many of them still imagine their phone calls or secure messages are "bothering me," despite my reassurance that this is exactly why I charge a monthly fee.

The past week has produced a couple of promising opportunities, one with a self-insured local business of 200 and one with a labor union of nearly 1000 people, inquiring about my services.  While both of these may not work out, the fact that I am getting these contacts encourages me that there are many such entities out there looking for an alternative to the agonizingly irritating and inconvenient world of American Medicine.  My job is to work with these groups to give them what they need without compromising the quality of care I have been able to give.  I need to grow, but grow in a way that lets me add new services, expand my staff to broaden the scope of my care, and allow for more investment into making a business and clinical infrastructure that will scale up without overwhelming me or my staff.

That's probably the best thing that has happened: I've become much more patient with the process.  I won't dive at opportunities that offer revenue without taking the time to work out a plan.  I am in no big hurry.  My original goal was to grow this to about 1000 patients, but the fact that I can handle 400 patients with one (beloved and highly capable) nurse and not feel at all overwhelmed, makes me think that it could go significantly higher than that.  But it can only go there if I am careful to build it well, with much planning and care in implementation.

A Rob blog post would not be complete without a mention of (of course!) computers.  My home-baked (and half-baked) EMR system is working reasonably well, and I've been able to pour much of my creative time and energy into building a much more stable "2.0" version of it.  Since I had no good record system when I made the first one, it was put to use well before bugs were worked out (and before I really knew what I was doing).  This new system is much more efficient, stable, and reflects some of the radical changes to my clinical thinking this new practice has allowed me to embrace.  More on that later.

At the beginning of 2013 I stared into the great unknown of this new practice.  I had no idea which plans would succeed and which were foolish dreams.  The road was much more difficult than I expected, but also much more satisfying.  I spent much of my time learning what doesn't work, but in the end learned that most good ideas grow out of the remains of a hundred bad ones that didn't survive.  

Now, as I face 2014 I see great opportunity.  My dreams are still big; I am more convinced than ever that this model of practice could be a game-changer for American health care.  But my ambitions have grown smaller.  I now enjoy the practice of medicine more than I have in many years, and am delighted by the same expression on the faces of my patients.  It doesn't suck to be a doctor any more, and it doesn't suck for my patients to go to the doctor!  My ambition is to keep that reality alive for me while making it available for more patients.  I want them to be happy, and I want to be happy.

It's nice to think it actually could be a happy new year.

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