Wisdom from a Toddler

February 5 is the 3-year anniversary for my practice.  Yes, my practice is now a toddler.

I could say the cliche\’ things about it seeming like yesterday, yet like it has been forever since I worked anywhere else.  I guess I just did…so there’s that.  But more to the point is the reality that I actually survived.  Many expressed confidence in me when I started doing this, while many others expressed supreme skepticism over whether or not this type of practice could actually work.  To both of those groups of people I say: keep waiting to make your final judgment.  The practice, while profitable and now growing steadily, is still not near to the point I need it to be.  It’s heading in that direction, but there are no guarantees; I still could mess this thing up.

So what have the past three years taught me?  What pearls of wisdom can I give to doctors considering following my journey away from the sick-care symptom that is quickly burning doctors out?

1. It is much, much better

This is a huge understatement.  There is no comparison of life in this practice and my previous existence.

I was on a collision course with burn-out when I left my old practice.  I was seeing 25-30 patients per day, spending a distressingly large amount of my time away from my patients, documenting and submitting data so I could get paid.  I was feeling less and less able to give them the good care I was capable of.  I was making people wait for 30, 60, and even 90+ minutes to have a few minutes with an inreasingly depressed and distracted doctor.  Our EMR system, one which I had championed for many years, was becoming increasingly difficult to work with, focusing more and more on meeting documenting requirements and “meaningful use” criteria, and significantly less on improving care and ease of use.  I was certainly sad to leave my patients and set out on this new project.  I didn’t really know what I was moving toward, but I was not sad to leave the system which made it impossible to give these people the care they deserved.

My new practice has surpassed my expectations.  Now up to over 650 patients and with 2 1/2 employees (one is part time, not sawed in two), there still isn’t a wait when people come in to be seen, and I still have much more time with them than I ever could have had.  A “busy” day now is when we have more than 8 patients coming to the office.  I get far more hugs, many more delighted customers, and people are evangelizing their friends and family so much that I’ve hardly spent anything on marketing.  We rarely hear complaints, and when we do we fix problems as quickly as possible.

My nurses are happier too.  They are far more engaged in direct patient care than they ever were in the old system.  The reality is that in the old system they were simply “support staff” who enabled the doctors to see as many patients (and make as much money) as possible.  Since we are paid each month based on how happy we keep our customers, they are on level playing ground with me in being profit-centers for the business.  Their willingness to save people money, to quickly handle problems, or even to fill out paperwork people need for their care, is one of the main things that keeps people paying each month.  Both Jenn and Jamie say that I’ve spoiled them forever, and they’d never be able to go back to the old assembly-line type of practice.

2.  Patients are better customers

I’ve read some doctors who balk at the idea of patients being called “customers.”  The truth is, it is absolutely wrong to consider them as customers in practices like the one I left 3 years ago.  If you define customer as being the person who pays for the product sold, the true customer in most of healthcare is the insurance company or government payor.  Considering patients as customers in most practices is like dairy farmers considering cows as their customers: they are interested in keeping their cows happy and healthy, but only because they make more money that way.  

But now, working in a practice where I am paid by the people I treat, I see that they are far better customers than the third-party payors.  I also see that I am a far better doctor when I consider my patients as my customers.  The reason for this is simple: it aligns my business motivations with what is truly best for my patients.  Having patient customers motivates me:
    •    To be more efficient
    •    To be responsive to their needs
    •    To save them money whenever possible
    •    To keep them well (which allows me to grow my number of customers)
    •    To listen to what they truly want from me.

So what about the idea that the customer is always right?  Will this make me more prone to give antibiotics or addictive drugs when doing so would be inappropriate, to tell people hard truths, or to avoid controversial topics that may upset them?  While such behavior may turn away some people (and I’m sure it has), it tends to turn away those who I don’t want as my long-term customers.  Plus, the assumption that people don’t want doctors who insist on doing the right thing is one which paints them in a very negative light.  It assumes poor judgment on the general population, which I think is wrong.  When I go to get my car fixed, I want a mechanic to listen to me, but I won’t tell them how I think the care should be fixed.  But should that mechanic ignore what I have to say, I’ll likely find another when I next need help with my car.  

3.  The primary product I sell is accessibility

Contrary to what most people would say, the epicenter of healthcare isn’t at the doctor’s office or the hospital; it is wherever the patient is between office visits or hospitalizations.  To phrase it in another way: the best measure of the quality of my care shouldn’t be how many office visits I have with my patients, but how few of them there are.  If this is true, then the question is, how do we minimize patient visits without giving worse care?  The answer is obvious: use different forms of communication and lower the threshold for which the patient can communicate with us.

One of the clearest examples of how bad our system has gotten is when patients told me that they waited to see me “until they got sick enough.”  That’s like waiting for my “check engine” light to go on before addressing problems with my car.  Why not handle problems before they get big?  Why not check people’s blood sugar and/or blood pressure between office visits instead of waiting 3-6 months to see how things are going? 

The biggest difference people see when they come to my office is that I am not afraid of my patients.  I don’t have nurses handling calls in a way that “protects” me from them (as was the case in my old practice).  The quicker and easier we can handle problems, the better my practice works.  If someone has poison ivy, they send me a picture of the rash and I treat it.  If a person needs a note for school or home because of a virus with a fever or diarrhea, I give it to them without forcing them to come in and prove to me they have either (i.e. bring in the diarrhea).  We can hear the history on the phone or via secure messaging, and then if the person needs to be seen, it is only to fill in the gaps of the history we already have.

This doesn’t lower the quality of care, it raises it.  People are more willing to communicate with us, and are less likely to let small problems fester and turn into big ones.  Plus, they get a far more pleasant experience in the office, as the wait times are still close to zero for most office visits.

I set off on this journey with the lofty idea that this practice model could change our system.  While I still believe that fact, I am far less interested in preaching that fact and far more interested in doing what I’ve always wanted to do: give as good of care as I can for as many people possible.  Three years behind me and even this business amateur hasn’t messed this up.  My practice is more fun, patient centered, simple, fulfilling, and personal than my old practice ever was.  I also give much better care than I ever could, and I do so paying much more attention to saving people money.  To those who said this never could work, I say: so far it is working far better than I ever thought it would.  To those who expressed implicit confidence in my success, I say: It wasn’t ever a sure thing I’d survive, I did spend most of my savings to get through the first two years, and we still have to grow enough to make this thing sustainable, but doing so without diminishing what makes my current practice so much better than my old one.  

We are not there yet, but perhaps the goal is coming into sight.  If it doesn’t, I may just throw myself to the ground and scream.