Going Gets Tough

Sorry for the long gap between blog posts. I have been distracted by the volume of work that I have had to do.  Is that a good thing? Yes. Is it a bad thing?  Certainly.

I recently heard an interview of Mark Cuban, the owner of the Dallas Mavericks basketball team, billionnaire entrepreneur, and one of the \”sharks\” on the show (that I have never watched) \”Shark Tank\”. Apparently, the show involves entrepreneurs the opportunity to pitch their \”next big idea\” to propel with real money who can fund the business and ensure its ultimate success.  The interviewer asked Cuban what the biggest mistakes entrepreneurs and business owners make are.  His answer was that most small businesses or start-ups fail not because they lack a good idea, but they simply don\’t execute on the good ideas they have.  A good idea, even brilliant and ground-breaking one, is not enough to ensure success.


The reason the Internet was Created: A cat in a shark costume on a Roomba chasing a baby duck.

I have lived this. I know it is true. I believe strongly in the idea behind my practice: that doctors should work for patients, not payors; that communication, not documentation, should be the center of care; that rewarding doctors for healthy patients who do not need expensive procedures is a better business model than the opposite. I see the look in people\’s eyes when I explain how I do things — a look of both understanding of what I am doing, and complete confusion over why such a better business model as mine is not dominant in our country.  I have heard repeatedly that I will succeed. The concept at the core of my business is too sound to fail.  I\’ve learned to ignore this kind of talk.

This kind of talk used to really bother me.  How could I get praise for an idea (much less one that is not originally mine)? I felt that this kind of praise simply gave me more pressure to succeed without helping me get to that point of success I so coveted. I am not so bothered by them now, instead choosing to simply ignore them.  The words of Mark Cuban spoke to why listening to them is so seductively dangerous: no matter how good of an idea I have or how hard I work, the secret of success is in the execution and implementation of the idea, not in the idea itself.  

This has been borne out in recent events.  In December we seemed to hit our stride.  Everything seemed to be working well and Jamie and I felt like we had finally figured out how to do this new practice thing right. January was a banner month here at the office, with a flood of new sign-ups and a surge in our office revenue. February was similarly successful, but brought with it a sobering realization: we were falling behind. I had planned on hiring another employee to help us stay ahead on things, but the fear of messing up our chemistry, the dread of training someone new in a system (which we were inventing while we were doing), and the increased cost of that employees salary made me hesitate. 

Normally I see hesitation and caution like this as a good thing.  A good idea will still look good tomorrow, so sleep on the big decisions (my Dutch ancestors are now standing and applauding) .  But in this instance my hesitation allowed us to get overwhelmed by the work we needed to do. We felt like we were getting more and more behind, with more on our plate than we could handle.  The quality of care started to suffer, and for the first time ever we heard complaints. 

This made it clear that the risk of hiring someone and bringing that big internal change in our office ecosystem was far outweighed by the risk of not hiring someone and letting our accomplishments be washed away in the work created by our success. So when I was contacted by Jenn, a nurse from my old practice who both Jamie and I got along with well (notwithstanding her propensity to be a bit too \”spunky\” before 9 AM in my opinion), I jumped at the chance to bring her in.  This week is her first full week of work, and we are already wondering how we made it without her.  Now Jamie and I actually have time to work on things that need to get done, rather than just field the flood of new patient requests, lab results, pharmacy requests, and computer glitches.  

My goal is not to have fodder for good blog posts.  My goal is not to impress people with my great ideas.  My goal is not to get pats on my back or praise from my colleagues.  It\’s not bad to have any of those things, but the goal I have is much bigger, and is long-term.  I want to be part of the proof that we can do better than to give people the sickness-centered, treatment-heavy, over-priced, and chaotic care most Americans are getting! 

Proving something, however, is far harder than explaining it in a way that sounds sexy.  So that is why I\’ve become more quiet.  My focus is to build a sustainable business that will grow, sustain me and my family, offer excellent service, and serve as a template for others to do the same.  We are not there yet.  We have made a good start, but the goal is to finish well, not to start well.  

Here are my goals as we move ahead:

  1. Build a highly organized system that handles my patients\’ medical needs effectively and efficiently.
  2. Build a record system that focuses on care quality, not on E/M compliance, ICD and CPT codes, and defensive medicine.
  3. Give patients access to that record, and give them the ability to update and edit it as needed.  Since most of my updates are made by me asking them what has happened, why not have them do it directly?
  4. Integrate communication tools with the collaborative records.
  5. Integrate task management tools with these records as well.
  6. Go through patients systematically and see who is due for care, then reach out to them.
  7. Find ways to grow without diluting the personal care they have gotten over the past year.
  8. Find other ways I can save money for my patients, such as dispensing of prescriptions (at wholesale), negotiating prices for radiology tests and other procedures, and working with specialists to create a \”cash economy\” where they are paid cash up-front in exchange for a discounted price.
  9. Increase the number of services I offer to better meet my patients\’ needs.  Dietary education, exercise plans (and perhaps memberships), counseling services, and other things that could improve the quality of care my patients receive.
  10. Working with small businesses to save them money and give their employees care that is not excruciatingly expensive and annoying.
  11. Building a community within my patients that will let them interact (anonymously or in person) so they can help each other.  Having \”group visits\” for patients with similar needs, for example.

There are lots more buns in the oven at this point, and which direction I go will be largely determined by what my patients tell me.  The bottom-line is that, while I am happy/proud/relieved to have made it to this point, the hard part may still be ahead.

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