THE ANGRY JUROR

I had jury duty today. Essentially, it was easy and relaxing and a nice break from my otherwise very hectic schedule. If I was an employee of a big company or a school district or some public job, I'd have even loved to serve on a jury. However, in my case every day out of the office is lost income so I was a bit nervous at the possibility of having to serve on a 3 week trial. Knowing my luck, I'd be sequestered in some motel for 9 weeks.

Fortunately for me, I was excused relatively early in the process.

Every one seems to have advice about how to "get out" of jury duty. I was told everything from "tell the judge your a doctor" to "tell the judge your a racist." One guy seemed to have listened to some of this advice. Let me tell about him.

I first noticed him early in the day. He was in his mid-50's, gray haired, and he seemed very annoyed about having to serve in this way, on this day. For the entire 4 hours we were in the room, he was pacing and mumbling loudly. Apparently, he thought it was "bullshit" that we had to wait past noon only to be excused anyway. At 1:30PM, I overheard him telling some other men about his jury-dodging strategy. One or 2 hours later, I watched him try to pull it off.

And it was awesome!

About 100 of us prospective jurors were called into the court room at 2:30PM. This was a criminal case and present in the court were the judge, the prosecutor, the defense attorney and the accused. The judge thanked us for our time and then had us swear to be honest. Now here is where the angry juror's plan commenced.

"Your honor" he said with a very bold voice. "I do not swear to be honest." He was trembling imperceptibly, but I was so close to him I noticed it.

"Excuse me", the judge said. Then the judge added, "then we can have you affirm the oath." I guess "swearing" might somehow be religious while an affirmation is not and the judge was trying to assuage the man on these grounds.

"No" the angry man persisted "I will not be able to be honest." Then he added, to my utter amazement, "I just wanted to be honest with you, you honor."

My eyes were bulging out of my head: what gall! This guy was something else.

The judge seemed for a moment taken aback, but was not about to lose this argument. "Well then, sir, we just need you to sit with the court officer outside, and after these proceedings are finished, we will talk again. And then he added. "what is your name" and then the judge directed the stenographer to record it into the record.

The angry man was shaking, only now visibly. Seconds later, he as escorted out of the court room by an armed court officer.

10 minutes later, the judge excused about 50 of us for a variety of mundane reasons, no questions asked, and by 3:00PM I strolled past the angry man, who appeared to be in some kind of "jury-jail", and I received my certificate of appreciation and proof of service, and then I left the building.

I wonder what happened to this guy, the angry juror. Obviously he listened to some bad advice.

In any case, if you get called, don't sweat it. It is not painful. It is interesting. And it does make one feel good about our legal system.

And for Christ's sake, just take the oath.

The IU.

Pay Cuts, Again!

I am not happy either!

I just read this on KevinMD. I thought the cuts were tabled for 18 months. Wrong?

Physician reimbursement. Medicare is soon scheduled to cut physician payments in excess of 20 percent and cash-strapped states are slashing Medicaid reimbursements. At a time when the costs of running a practice are increasing, this blow would cripple many practices. Linking physician pay to patient outcomes, so-called pay for performance, is one often-discussed approach to mitigate the payment cuts. This has been controversial as the reward in payment is not commensurate with the costs of implementing the systems to measure performance.

Oh Oh!

In rough times, every little bit counts.

These are difficult economic times.  People are losing their jobs, their homes. . .everything.  For many others like me, "country club" dreams have vanished and mere survival has become the goal.  In times like this, times that I think are only going to get worse before they get better, every little bit counts.  As a solo physician, here are some things you can do to maximize your chances at surviving through the coming months.

1. Answer your phones 24/7.
2. Invest money or time in smart, cost effective marketing techniques.
3. Invest in technology that enables you and staff to work smarter and less.
4. Be in-network.  People just don't have the money now for out of network providers.
5. Focus on what you do best and refer out or outsource the rest.
6. Do CME, learn new things, and incorporate them into your practice.
7. Know your metrics inside and out.
8. Re-examine your long-range vision & refine your short term goals.
9. Back-word plan to achieve goals.
10. Keep staff happy and turnover low.

Good luck and let me know if you have any other suggestions.

The IU.

Some things I've been thinking about.

My mind has been full these days with lots of important decisions that must be made.

• I am in the final phase of a decision to go with a specific EMR vendor.
• I am combing through my P&L statement with a fine-toothed comb looking to cut any extraneous costs.
• I am looking at ways to partially outsource my phone systems during overflow periods.
• I am looking to hire a technical consultant to assist me with laboratory regulations and management.
• I am looking for more economical ways to spend marketing dollars.
• I am simultaneously shifting and tightening focus for my practice goals so that I can continue to thrive in a changing environment.

Exciting times, indeed.

The IU.

The Ultimate Low Cost Specialist Office

With costs rising for all of us physicians, cost containment has become more important than ever.  I've been thinking about how to keep costs super-low without sacrificing services.  I've brainstormed some solutions.  Here they are:

• Sublease office space from another office.
• Share office personell.  You can use someone else's front desk staff to check in your patients.  Of course, you must provide this staff, which technically is not your own, with your own workstations with your own PM-EMR system and teach them how to enter data into the system accurately.  And you probably ought to augment their salaries with your paychecks so that they work for you, rather than someone else, and are thus loyal to you.  You can even share the other doctor's office manager and pay them, then make them oversee the front desk staff.
  
• Purchase a good EMR-PM system.  You may wish to consider an ASP model--or internet based model.  These have no upfront costs to you and are payed on a monthly basis.  Plus, the vendor manages all the technical aspects of the technology, such as back-up, upgrades, and interfacing. 
  
• Outsource your phones.  Phone systems can get surprisingly expensive if one considers the cost of the systems themselves, the line-fees, maintenance, and the salaries + benefits of the people who answer the phones.  Check out this site for an alternative approach to phone managememt.
  
• Outsource your billing & credentialing functions.  Sure, there are pro's and con's to this approach, but with the right company and proper over site from you it could work.  Alternatively, with some of the better EMR-PM systems, you can do your own billing. 
  
• Use only automated laboratory equipment should you choose to provide some lab services in your office.
• Any imaging equipment, such as ultrasound units, and of course your workstations must be portable, lightweight, and networked to your central server.
• Outsource some marketing functions, like direct mail advertising or email advertising. 
  
• Make your own basic website and do your own basic SEO.
• Outsource payrole services, pension fund management, accounting, and book keeping (make sure the book keeper is bonded).
  

With this approach, you can function quite well and grow significantly with only one employee, ie a medical assistant.  Your costs can be half that of a tradiotional solo doctor's without much sacrifice.  If planned correctly and executed well, this approach could work well for even a specialist.

If anyone has tried this approach, let me know.

Destroyed in Seconds

There is a show on the Discovery Channel called Destroyed In Seconds.  Essentially, the program shows video footage of disasters that seem to have come out of nowhere.  In one episode, the viewers could enjoy a helicopter crash that happened with shocking rapidity.  In another episode, a speed boater loses control of his craft and in an instant is gone.

In medicine, good relationships can evaporate in seconds as well and we seldom see it coming.  In this first episode of "Destroyed in Seconds: Urology Edition" I am going to present some instances where a perfectly good doctor-patient relationship can get "destroyed in seconds."

• A previously passive patient receives an unexpected bill and calls the office ranting and raving about it: relationship destroyed in seconds.
• A patient receives an unexpected phone call regarding the need for additional pre-surgical testing and is inconvenienced.  His frustration and vehemence gets turned upon staff and you and the relationship is destroyed in seconds.
• A patient being followed for rising PSAs is told by a "friend" that he should have been biopsied and he accuses you of negligence: relationship destroyed in seconds.
• Above patient has biopsy done by you and is negative for cancer: relationship restored in seconds.
• Above patient has terrible complication from above biopsy that you initially advised against and relationship destroyed in seconds.

Medicine is a crazy business.  We walk a fine line between hero and goat. 

And any doctor patient relationship can be "Destroyed in Seconds."

(Disclaimer: the above examples are fictitious and do not represent actual encounters.  Any similarities are purely coincidental."

Leaving a practice? The Essental List

Sometimes the group thing just does not work out and people find themselves with no other option than going solo.  Follow these essential rules and you'll land on your feet.

1. Determine your short term intermediate, and long term goals and list in backwards order how you plan to attain each of them.
2. Leave your old practice on good terms, this will only serve to help you in the future and trust me, you WILL need them in the future.
3. Develop a plan to attract your old patients, so long as it does not ruin your relationship with the old office, and separate plan to attract new patients.
4. Organize all credentialing material and higher someone, even per diem, to assist you with credentialing.
5. Look for an office or sublease on a temporary basis.
6. Go electronic, even a web-based ASP model for an EMR and PM/scheduling system.
7. Get a website, just don't pay a lot for it.
8. Get a blog and start posting to it.
9. Look for staff (personally, I recommend Craig's List.)
10. Get a phone and answer it 24/7.

If you follow these 10 steps, you'll be up and running in no time flat.

Good luck,

The IU.

The Copay Sign

In this day and age, every dollar matters.

While I find that 99% of people pay their copays without problem or complaint, 1% will ask for it to be waived. We simply direct them to sign above and that answers their questions succinctly, forcefully, yet with some humor.