It feels dangerous to write this, but…my practice seems to be working.
I am now running and hiding from lightning bolts, meteors, or stray arrows shot in the air by a Scottish soldier.  I am also expecting a raid on my office by the IRS, CDC, and BBC tomorrow morning.  I don\’t know why I wrote that.

But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving.  We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from uncle bouncy.  While we\’ve started to discuss when we will hire another staff person (probably a nurse), neither me nor my nurse Jamie (may her name be ever blessed) feel overwhelmed at this point.  We can handle this volume, which speaks well for the future when we actually have a fully-working system.

The past few weeks have been totally consumed by my need to have an underlying system of organization.  After fighting valiantly against the idea for the first two months, I succumbed to the necessity of building my own IT system and have been seeing the many benefits of that decision.  Despite being totally obsessed with how data tables connect and whether I\’ve left a parenthesis off of a script I\’ve written, I now have a place to put data, have a pretty decent task management system, have an integrated address book, and have discussed integration with my phone system vendor, my secure messaging developer, and a lab order/result integration vendor.  I\’ve also found some strong local tech talent who gets what I am doing and yet doesn\’t simply see the market potential for my software.

The reality is, my whole focus is on the practice model, and that model seems to work.  As my business and medical care management systems click into place and become more functional, growing the practice should not be a problem.  We continue to get several new patients signing up every day, and now the reluctant spouses of establish patients are joining (which is a very good sign – for both my practice and for their marriages).

Let me appease the gods and state clearly that this is by no means a sure thing.  There are many, many things that could go wrong.  A successful start-up requires not only a good idea and hard work; it also needs requires luck (or at least to avoid bad luck).  I could get cancer, my building could burn down, or our city could be overrun by a mob of psychotic llamas.  We all know the llama apocalypse is happening; it\’s just a question of when, not if.   So I accept the fact that I am, to a great extent, in the hands of the fates (and llamas).



This is what scientists believe the llama apocalypse will look like. 


That being said, it is encouraging to see the first stage of the practice running reasonably well.  The key will be to keep doing what I am doing: working, working, and working.  In some ways, the satisfaction of my patients should not surprise me, as the care the got from the health care system sets the bar very low.  I am frustrated because I am not yet building care plans for patients or calling to check up on people as much as I would like, but that\’s not care that any of my patients are used to getting.  They are used to being ignored unless they are sick.  They still wonder if they can make an appointment, when I would gladly talk about their problem on the phone.  They are simply happy that we still have an average waiting time of about 30 seconds.

Having been under high pressure over the past few months, my recent success makes it very tempting to take a deep breath and slow down a bit.  Am I simply setting goals of care higher than they need to be?  I think about these things while in the shower.  I\’m not sure why the pelting of my head with water makes me think better, but it does.

While wetly contemplating my obsession (and whether this was a sign of strength or stupidity), I remembered a physician worked under during my residency at Indiana University: Dr. Larry Einhorn.   Dr. Einhorn is credited for the use of Cis-Platinum therapy in testicular cancer, a treatment which made a lethal disease in young men largely curable, even at very advanced stages.  He was one of the group who cured Lance Armstrong of his advanced cancer, and was already quite famous when I was there nearly 20 years ago.  This group of docs was not only amazing in their clinical and research skills, they were very good teachers and treated us residents with kindness and respect.   It was truly an honor and a pleasure to train under them, and I strongly considered oncology as a career because of them.


One of the attendings told me that what made Dr. E so great was that he didn\’t stop at the first breakthrough.  He didn\’t say, \”hey, this cures 75% of advanced testicular cancer!  I am going to name this the Einhorn treatment protocol and be real famous!\”  Instead, he focused on refining and improving the treatment to where, while I was there, the cure rate was well over 90%.

That\’s not a character flaw, that\’s the definition of character.  While I am nowhere near in accomplishment to that of Dr. Einhorn, I am tempted to listen to the happy patients, the complements from colleagues, and the band of groupies that gather on the handicap ramp each morning for my autograph.  I am tempted to think I\’ve accomplished something before the job is done.  I am encouraged by the fact that I can handle 300 patients with just a nurse to help.  I am encouraged by the fact that I am recovering from nearly having my practice impaled by \”meaningful use certified\” EMR products and may actually have a system that really improves care.

But I am a long way from where I initially planned to go, and there will always be more I can do.  The foundation is laid, but foundations are generally unacceptable (and uncomfortable) places to live.  So, I take a deep breath and dive back into all the work I have ahead of me.  I hope things continue to improve, but I won\’t count on it.  People have told me \”you\’ll do it.  I am confident you can make it work.\”  But their assurances don\’t include the footnote that says: \”as long as you continue to work most of your waking hours, and avoid doing something really dumb.\”  That\’s no slam dunk.

And don\’t forget about the llama apocalypse.

10 thoughts on “Working”

  1. When I forget to login first, it throws away my comments when I do login. Not a good design, I think.

  2. So at 300 patients….if they are paying you 30 bucks per month you are taking in 9000/month. Your motivation to make the most money you can and do the least would be to see no one and talk to a few people on the phone.
    Your goal would also be to sign up 300 healthy patients with very little medical problems so your work is easy

    and they do not bother you.

    What happens when you accpt patients with pre-existing conditions or brittle diabetics- the people that have 2 or 3 office visits per month and possibly 2 or 3 ER visits per month???

    What I see in your practice would be a motivation to only sign up healthy patients trying to avoid the “high problem” patients and you are motivated more NOT to see the patient in an appointment.

    What do you think???

  3. I think you don’t realize that the 300 I have so far were not hand-picked well people. I have not filtered out anyone. I have 5 patients on insulin pumps, one child with type 1 diabetes, and new onset type 2 diabetic, people with COPD, on oxygen, CHF, and other severe chronic problems. There’s also a whole lot of folks with anxiety and depression seeking my help, and they’ve required a good amount of communication.

    I will say that all patients are motivated to stay away from the doctor’s office in that I believe that (nearly) all patients want to be well. What I do, however is to let them call me or message me before they get sick enough to go to the ER or even to need an office visit. This makes their problems not become catastrophic, instead keeping it small. It’s just better management of disease to give people access to care.

    Please understand that I am motivated to keep people healthy, while the rest of the system is motivated to keep them sick. Do you really think I have a worse system?

    By the way, even in my old practice with 4000 patients, I’ve seldom had patients who go to the ER 2-3 times per month. If they are doing that, there usually is a non-medical issue.

  4. I’m not surprised that it’s working. It’s well planned/earned.
    Let me share a story one other Direct Primary Care doctor told me about why he shifted from the 7-minute “productivity” driven, volume-based, referral-generating model to a model where he could practice medicine the way he was trained rather than our distorted reimbursement model has created. I asked him why he made what some perceive as a risky move. I’ll paraphrase his words below…

    “I couldn’t sleep well at night when I was in the hamster wheel model answering more to productivity goals and billing/coding than my patients. I felt the medicine I was practicing was bordering on unethical as I was only using 40% of my medical training. Why? When I was meeting with a patient, my medical knowledge and intuition would generate a set of questions I wanted to ask the patient to get at the root cause of the condition. However, there would be a battle in my head knowing that if I asked this or that question, it would initiate a series of conversations and questions that would be very productive from a problem-solving perspective. However, that “productive” discussion would blow my so-called productivity goals out the window.”

    I’ve had the privilege over the last few years to spend time with the leaders of many of the most acclaimed new delivery models that I call the “Triple Aim Champs” as they are light years ahead in improving outcomes, reducing costs and improving the patient experience. There are a couple of common threads:

    1. They are pre-paid allowing them to spend time with patients. Pre-payment has many forms — direct primary care, Medicare Advantage, Indian Health Service, etc. As one said “pre-payment is freedom – not risk” These doctors know how to doctor so they don’t see it as risky and their results bear that out.

    2. They have had to develop much of their own information technology. Naturally, the mainstream establish vendor solutions are optimized for the old, volume-driven model where the “patient” (from a technology perspective) is a vessel for billing codes and not a valued member of the care team.

    My apologies for the long comment. This stuff makes me passionate.

  5. This practice still relies on your brain. Are you using any “decision support” tools (E.g. “Watson” or Isabel programs)?

  6. Great to “meet” you, Dr. Rob! Appreciate your “musings”…and the direct pay model described above and on your About page sounds intriguing — both for you and for your patients/clients. The example of Dr. Einhorn’s continued pursuit of improvement & excellence above is inspiring — reminds me of the “CANI” – constant and never-ending improvement taught by Tony Robbins. Thanks for posting!

  7. Hello Dr. Rob! Thank you for writing about your experiences in your new adventure. I’m a first year medical student with a dream to open a direct primary care clinic, and I was wondering if you could comment on how helpful an MBA might be for what you are doing. I am strongly considering a dual MD/MBA degree (which would add one year and make my fourth year of med school quite a bit more hectic), since I’m afraid that most of the continuing education classes geared towards private practice physicians and office management might be along the lines of the traditional style of doing business rather than what you are trying to do. Do you feel like you have been able to get all the business education you need from continuing education courses, or would an MBA be a better choice for someone just starting out?

  8. I think it would help, but am not sure if it is truly worth the time investment. It may be, but you can also hire someone with an MBA to help your business. I certainly think I’d have avoided lots of pain if I had an MBA. I do agree that CME are largely oriented toward the standard business of medicine, where a general MBA would let you move toward good business principles. I learned business by doing it for 18 years, and doing some CME (mostly early in practice from the American College of Physician Executives). MD/MBA would certainly open lots of options in the big picture as well. On the flip side, most small business owners (which is essentially what my practice is) do not have an MBA. It’s perhaps a bit of over-education, but I can’t say it’s a bad idea.

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