Doctors are a pretty conservative bunch. We get to where we are by saying no to many things that are a lot more immediately enjoyable than studying biochemistry. It can and has been said that doctors are a risk-averse group. Why then would any physician in their right mind say “yes” to private practice when there are no financial guarantees, no colleagues, maybe even no employees, no 401(k), no one paying your malpractice insurance, maybe you have some patients, but maybe you don’t even have that!

Why on earth would you say yes to private practice?
Well, for me, it felt like a necessity, and I suppose many adventures start out that way. I have run a private psychiatric practice for the past 5 years. I call this a “holistic” practice because I want to work with the whole person, not just in a reductionistic, psychopharmacology model and also not in a 10-15 minute medication check, high “productivity” practice. I started a private practice because I felt it was the next step in my ongoing medical education.

After I had been running my practice for awhile, I came across the term, “micropractice,” and I realized that is what I was doing. Low overhead, no employees, 30-90 minute appointments (longer sometimes for initial evals), I came to call what I do quality care as opposed to the quantity care that I had experienced in other practice settings. So, I found out that I wasn’t the only doctor striking off into this hazy territory of private practice who was compelled to practice medicine according to my own rules rather than the rules of health care delivery systems. It reminded me of the old punk rock DIY (Do It Yourself) attitude!

For the first year or so of private practice, I found I had to say no to a lot of other things in my life in order to really stay on top of the responsibilities I had taken on. Learning how to do billing, tracking down denied claims, figuring out the multiple reimbursement systems (Public Aid, Medicare, and the myriad of private insurance companies), returning phone calls, scheduling and rescheduling patients, phoning in prescriptions, all of these things took exponentially more time than I had thought they would. If you have “support staff” where you work, I can tell you that you are probably not fully appreciating all that they do for you!

After about two years, I felt like I was able to take a deep breath. I started having more of a social life again. I started to get back into things that supported me, exercise, painting, music, watching movies, and seeing friends. I found that it was really important for me to start saying yes again to social life, and let me tell you, with a private practice, it can be a constant struggle to keep the practice from eclipsing the rest of your life.

Eventually, I realized that with the full-time clinical work, coupled with the late nights and weekends of doing administrative work, I was not feeling like a whole person anymore and as I am fond of saying to anyone who will listen (unfortunately, I myself am not always that listener) you have to be a whole person to treat a whole person. I then started saying yes to anything that would get me out of the office and put me in touch with other people, teaching at the community college, getting an appointment at the local medical school, running workshops, sharing both sane and crazy ideas with colleagues, intentionally networking with other people, not always sure where that might lead – curating an art show in my office space, ok, why not!

In the movie, Yes Man, Jim Carey’s character is putting all of his energy into avoiding anything life has to offer. He joins a cult-like self-help group and takes the challenge to say yes to anything someone asks him, any opportunity that comes up, no matter how crazy. Things go exceedingly well for him – up to a certain point, and then they don’t go so well. He learns that you cannot literally say yes to everything. Certain “yeses” exclude other possibilities. There is only so much of oneself to go around. It could be said that what he learns is to not say no out of fear, out of arguing for one’s limitations, out of a fixed risk-averse attitude. What he learns is that what is important is saying yes to the right things, saying yes to the things that your heart is really in. That leads to the question, how do you know what is really in your heart. Maybe you are lucky and you already know, otherwise you just have to try something different and see if you like it.

Here I am, encouraging you to say yes to private practice. What am I doing? I am closing my private practice! Why on earth am I doing this after putting so much work into creating this darn thing that was supposed to free me from the restrictions of other health care delivery systems? Well, it may seem hypocritical writing about starting a practice at the same time I am closing mine. What I am realizing, though, as I go through this process is that I am seeing a lot of things more clearly in my practice now that I am starting to get some distance from it. Sometimes you don’t know what you are learning when you are in the thick of things. I’ll invoke H.D. Thoreau, here, “I left the woods for as good a reason as I went there. Perhaps it seemed to me that I had several more lives to live, and could not spare anymore time for that one,” (The Portable Thoreau, Walden, p. 562).

The truth is, I felt like my practice was getting imbalanced. I looked at several ways to re-balance it, I spent more time teaching and networking (and my income went down proportionally), I then tried to see as many patients while still squeezing in the things that I loved and needed to do (the outcome is probably obvious: a frazzled, stressed, and sleep-deprived “holistic” doctor), I hired a part-time office assistant, I looked into finding a business partner, I looked into the possibility of starting a non-profit holistic health center, but none of these seemed to get things back in balance. I felt like I had committed myself to saying yes to things that my heart was no longer in. I don’t know if I would say that I burned out so much as that my heart had moved on before the rest of me followed. It was kind of like realizing that I had learned all that I needed to learn in the practice.

So, what am I doing instead of the practice? Well, my wife and I are moving to New Zealand! I haven’t been this excited about something since starting medical school. The idea of moving someplace new and experiencing different cultures and working in a new health care delivery system (a national health service) sends a thrill of excitement through my core. Saying yes to this new reality means saying no to private practice, at least for now.

However, I really do feel like I have such a clear perspective on my practice as I am ending it. I hope to share more of my experiences and what I have learned, here at PrivatePractice.MD, about starting and running a holistic psychiatry micropractice.

Medical practice experts will still be part of this goal, and many of the upcoming podcasts will feature these experts. But I realize that there are many fine brick and mortar and internet resources for medical practice management information available to physicians.

Living the doctor lifestyle encompasses more than patient care, and certainly more than running the small (or not so small) business of a medical practice. Training interferes with the trial and error lessons of the late teens and twenties that most non-physicians experience and learn when they’re young. It’s just a different life education path for most doctors, compared to their non-medical family and peers.

Medical schools are great at teaching young doctors how to diagnose and treat disease. But medical schools forget to teach doctors the other lessons they need to learn about the business of medicine, and how to manage all the other aspects of their lives.

PrivatePractice.MD hopes to fill that void. Upcoming articles and podcasts will reflect this new direction aimed at rounding out a doctor’s training. There will be informational articles, and articles spotlighting successful doctors and innovative medical practices. But I want this site to be a conversation. Please join the discussion. Listen to the podcasts (coming soon!). Leave comments here and on the toll-free comment line (coming soon,with the podcasts). Find the PrivatePractice.MD Fan Page on Facebook. Share your thoughts, hints, and experiences. Ask questions so other doctors and medical practice experts can answer. Time to finish our education. Doctor, heal thyself! It will be good for your health and the health of your patients and practice. It will be true Reform.

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I am not sure how I feel about this new niche being carved out on the business side medicine. I am told that it is not the same as a doctor creating a boutique practice, one in which insurance is not accepted. The company courting my client is currently reviewing various aspects of the practice not the least of which are the demographic, insurance and age factors. Through use of marketing tools as well as I guess some quantitative and qualitative analysis, the company will decide which patients should be invited to stay with the practice for an annual fee (I have heard these fees to be between $1500 and $2000 payable over four installments).

As a billing service, I will not lose this client because insurance will still be billed. The annual fee is a private contract between doctor and patient. I will make less money probably because my earnings are based on the doctor’s receipts and he will see less patients every week This is NOT why I am unsure how I feel about this relatively new idea.

My concern is for the 1400-1600 patients in his practice who will not be asked to “rejoin” the practice. Where will they go to find another primary care physician who isn’t already overloaded? Where will the patients who have no insurance go (as I don’t think they have an additional $1500 to pay for an annual fee?) Where will patients who have a Medicaid plan go as fewer and fewer doctors are participating in those plans?

So you can see why I am conflicted. For the 400-600 patients who will have more access to the doctor, this could be a way to decrease what sometimes is a stressful experience. And for the doctor who can and will spend more time with each patient there will also be a decrease in stress on all aspects of the practice. But my conflict continues.

There are now stacks of balance bills for patients who are unable to pay. Many of these patients have been seeing the same doctor for years (primary care or a specialist for a chronic condition). Some patients doctor hop to spread the debt around.

Some patients come in with expired insurance and if eligibility is not checked, the patient gets a free ride at least for a while. Some patients might give a check that will be returned for insufficient funds while others may think twice about using a credit card should your office accept that form of payment. Some people will simply ignore the bill because they are overwhelmed with all the other bills, so what is one more?

Now is the time to set policies for patients who have no insurance. Certainly checking eligibility makes sense even in better times. A partial payment can be advised while making the appointment and if you take credit cards, ask the patient if you can expect him/her to use it. Set up a payment plan at the end of the visit and keep one employee or your billing service informed of the arrangement. Make notes in the computer as to what was discussed. Consider a courtesy on a case by case basis especially if you can obtain payment in full at the visit. This saves time, creates loyalty, and a good feeling among the staff who collected the money.

You know your patients best and when they hopefully obtain insurance again, do you want them going to another doctor who might have been more flexible during this rough patch? Is a collection agency really the answer that may take a portion that is larger than the courtesy you may give? Most people want to pay their bills; be clear on what you are billing them for and communicate your policy with your patients

Most of the practices that we advise and that are using some form of EHR are struggling to make their adoption successful. The struggles range from the minor troubles such as workflow disruptions and input irritations that drive staff nuts, to the “what have we done to ourselves” sentiment. There is a common theme among these practices, and that is that every one of them made major missteps key areas of the project before the first piece of software was ever installed. They were not adequately prepared, and as one physician recently shared with me, his practice has been “harmed” by their EHR efforts.

To be fair to all sides, there is plenty of blame to go around in these struggles; practices often times don’t understand the enormity of inertia required to make the transition successful. As a result they do very little to in the planning phase. Throw in aggressive EHR vendors into the mix, whose sole purpose is to convince you as to why they are the best choice, and you have a recipe for disaster. Decision makers in the practice often rely too much on these sales people for objective guidance, and often times end up making their decision based on their feelings for the sales people, rather than what is best for their practice.

The problem with this approach is that it often results in a practice that doesn’t understand the long-term effort that is going to be required to make the implementation successful, and therefore is not prepared to move forward. In any EHR implementation, planning is the single most important phase. Good planning can make sub-par EHR software work well (and there are plenty of sub-par applications out there) and no planning can make the best EHR software a miserable failure.

You can never over-plan your EHR adoption, but under-planning is always a constant threat.

I sometimes get criticized for being too discouraging of EHR adoption, and that certainly is not my intent. Anyone that knows me knows that I understand very well the tremendous benefits of a practice EHR system, and how those benefits can transform a practice in a positive way. What I do discourage is a poor adoption strategy. Poor adoption strategies can do a lot of harm to a practice and will cause substantial setbacks. Physicians and their staff work too hard to provide the best care for their patients to be misled about the challenges that their EHR is going present.

The standard advice that I give when talking to physicians and practice leaders is to slow down. Don’t allow yourself to get caught up in the frenzy of EHR’s without first giving it serious consideration and careful thinking. If you feel like you are being passed up by all the other practices out there and are tempted to put the pedal to the metal, resist the temptation. There is still plenty of time to begin the process, to develop a solid plan for evaluating, selecting, implementing and supporting the implementation for your practice.

The integration of an EHR into your practice is an important step that can pay some hefty dividends when it is done right. Take your time, be careful and deliberate in your planning and seriously getting outside, objective help in the process. By following this simple advice you can avoid doing harm to your practice.

Mark Bebout

http://www.softworksco.com/