Melissa Young, MD: The voice and face of my practice

Several times a day, I hear patients complain that they can’t stand the staff at other doctors’ offices:
“I like my doctor, but his staff is rude.”
“The people over there don’t know what they’re doing.”
Even some patients from my old practice tell me, “I’m so glad you left that office. I couldn’t stand so and so.”

I also hear complaints from my staff all the time that they called another doctor’s office for lab results or something and were treated very rudely:
“I don’t have time for that now.”
“[exasperated sigh] We sent that already.”
“Yeah, I’ll get to that when I have time.”
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I am incredibly pleased when patients tell me how much they like my administrative assistant and my medical assistant:
“She was so helpful.”
“She’s very sweet.”
“They are very efficient.”

When a patient calls, it’s their voice they hear first (ok, technically, they hear mine first because I’m on the phone message, but you know what I’m saying). The tone they set when they answer the phone, and the attitude they project is a reflection of the practice, and, in essence, of me.

They are also the first faces my patients see when they walk in the office. The way they are greeted and the way they are treated before they see me, sets the tone for the entire visit.

I believe it’s important for a practice to choose staff members that will portray the practice in its best light. It goes without saying that you want to hire someone competent, but you can educate people and teach them skills. It’s hard if not impossible to teach attitude and demeanor.

Melissa Young, MD: In house or not, that is the question

As an endocrinologist, I do fingerstick blood glucose readings in the office. I use the same glucometer a patient might use at home, courtesy of one of the companies that leaves me sample meters and strips. I charge for the service, and am paid anywhere from nothing to about $10. Not a substantial amount, won’t change my bank account by much, and I’d probably do it even if wasn’t reimbursed since it takes a couple of seconds and it doesn’t cost me anything.

Enter medical supply company reps hawking their Hba1c machines. They are fairly easy to use, they don’t take up a lot of staff or physician time, and allegedly they are decently reimbursed by most albeit not all payers. The machine is free, but the consumables are not. So after expenses, net reimbursement is about $5.

So the question is, is it worth it?
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Yes, I need the Hba1c in my clinical decision making, and yes, having the result in front of me while the patient is in the exam room sure beats calling them back with lab results. But I have a pretty good system in place, and although it doesn’t always work, the majority of the time, it does.

I have patients get their labs done before their visit. Like I said, not all of them do (“Really? Was I supposed to go to the lab?”, “Oh, yeah, I think you did tell me that.”), but most of them do. Besides, I have them get other labs, too – lipids, met panels, urine microalbumins – so if they come without an a1c I’d need to call them with their other labs anyway.

The rep’s argument was that I could order all those other labs to be done prior to the appointments, but plan on doing the Hba1c in the office, as an income generator. Really? For $5 a pop?

And just when he was beginning to sway me, he brought up other tests I could do, now or in the future. It started to feel too much like “business” than service, and that me uneasy.

In the end, I figured I’d give it a shot on a trial basis. I’ll have to see a) what it does to our work flow, b) whether or not it will actually get reimbursed as he claims, and c) how my patients feel about it.

Melissa Young, MD: Selection bias on physician rating sites

A couple of weeks ago, a patient from my prior practice said that she Googled me to find my new location. She said that in addition to finding my new address, she also found my practice address, and an article about me that had been written while I was at my old office.

Out of curiosity, I decided to Google myself. I found the above links, but I also found links to physician rating sites. I clicked on them to see how patients were rating me. I found that almost without exception, I had either no ratings or very poor ratings.

At first glance, my one-star ratings in nearly every category make me look like a horrible physician with no bedside manner, whom no one would recommend to family or friends. I also apparently had incompetent, discourteous staff. But a closer reveals that there is only one rating. One rating by a very angry patient. One who thinks I need “to learn to be a human.”
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These ratings were all dated (where available) in the spring of last year. I can only assume that they were made by the same person. One Web site had two ratings. One with single stars across the board, dated in the spring of last year, and one with four to five stars, dated within the last three to four months.

Now, personally I don’t care if one or two disgruntled patients rate me poorly. I suspect they are noncompliant and possibly were dismissed from my practice. But other patients might care, patients who may assume that these ratings represent how most of my patients feel about me. And what happens if the payers start caring?

Who is going to take the time to go to theses sites to rate a physician? Most satisfied patients don’t feel the need to rate their physicians. Even at the best restaurants, I’m sure the kitchen hears more complaints then praise. How many store managers have customers call about an employee’s good job? And how many get calls about a bad job?

Oh sure, there are customers who will let an employer know when someone goes above and beyond, but for the most part, satisfied people don’t feel it necessary.

And the same goes for physician rating sites. I have patients I have treated for years. Some who moved out of state who still come to see me. I have new patients who used to see other docs but have chosen to see me because I have seen their neighbor, coworker, friend, or relative, and have been told that they will like me and my practice better.

Would they do that if I needed “to learn to be a human”? Referrals like that beat online ratings any day.

Melissa Young, MD: How my EMR stacks up

In previous posts, I wrote about my journey towards finding an EMR. I did lots of research. I read multiple articles online and in print. I looked at the surveys. I asked the experts. I had demos, online and live. I did site visits. And eventually, I made my choice.

But despite this somewhat obsessive search for the perfect EMR (this was probably the most important decision I had to make at the time), I have still found imperfections. This part doesn’t work as smoothly as I had hoped. This needs tweaking. This part is inconvenient. This part is just nonfunctional. And since the grass is always greener on the other side of the fence, I have from time to time wondered if, perhaps, there could have been a better choice.

Now don’t get me wrong. Most of the time, the EMR works (nearly) flawlessly. It performs all the major functions that I need it to. It makes my life and the life of my staff infinitely easier than it would have been had we had paper charts. The schedule, chart, and billing information are at our fingertips. Everything gets documented without a six-inch stack of paper.
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Patients who come with their previous records of the last 10 years can leave with their epic saga in their hands because we don’t need to keep the hard copies. When a patient calls because he needs a refill, I can say, “No you don’t. I gave you 90 days and two refills on December 12. ABC Pharmacy on Main Street has your scrip.” Since I can copy their last visit, I can ask (as if from memory), “So has that ache in your left leg gotten better?” or “Has your daughter had the baby?”

But I was most reassured earlier this week when I attended an EMR seminar. I almost didn’t go. After all, I’m not in the market for a new one. But part of the lecture was going to be on getting the Medicare incentive for that all-too-nebulous “meaningful use,” and I figured it would be a good networking event, so I went.

The first third of the seminar was how to choose an EMR and how to implement it. The second was “the top 10 questions EMR vendors don’t want you to ask.” Although I didn’t “need” that information, it did make me feel good about my choice. And that’s because I knew from experience what the answers were. Questions about backing-up data, customer support, ease of implementation, work flow, etc.

Listening to the questions and the things to look for in an EMR, I knew that if someone asked me if I would choose my EMR again, I would have to say that based on what I had to compare it with, and knowing what I know about it now, I definitely would.

Melissa Young, MD: How much am I getting paid?

At my former job, as an employed physician, I didn’t really know how much I was getting paid for each patient encounter. Yes, we had a meeting with our billing department. I’m not quite sure why, since the bottom line was well, it is what it is, and the answer to any question was “I’ll run a report.” Yes, a report I rarely ever saw.

Oh, yes, I saw how much was charged each month and how much was collected and how much was written off. But I wanted more information. I asked on numerous occasions for a breakdown of how much we were getting paid for each E&M code. I asked for a breakdown of our contracted rates with each payer. Apparently, they could not tell me what the rates were per se, but they could tell me what percentage of Medicare “since that’s public.” Sure, they could. But they didn’t.

So when I ventured off on my own, and submitted my change of address and change of TIN to the insurance companies, I did so without really knowing what my contracted rates were and without knowing whether they would or had changed. Probably unwise on my part. But at the time, my only concern was being credentialed and getting paid something. Anything.
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So I mentioned in my last post that my husband is my biller. And he feels I am not being paid what I should be. I figured, I will get the practice up and going and look at the numbers and see what payers are paying what, and then go back and renegotiate as needed. Well, he got tired of waiting for me, so he spoke to someone who negotiates insurance contracts. He said she gasped when she heard what I was being paid. Apparently, not enough.

But she needs a copy of my contracts. And guess what. I don’t have a copy of any but one. Yes, again, foolish on my part. I need to know at the very least, when they expire, because if we are going to renegotiate, we need to do so around the time I am supposed to re-up.

I am going to have to have someone (me, my husband, my staff) call the insurance companies and ask for a copy of my contract. I wonder how cooperative they will be. It’s always a challenge getting a human on the phone. We have all spent many frustrated hours being transferred, getting disconnected and trying to get these stupid voice activated systems to work. I’d swear they do it on purpose. My secretary thinks they listen in on her and laugh as she swears at the phone in frustration. I have a sinking feeling that getting these contracts is going to be like pulling teeth.

Melissa Young, MD: My biller, my husband

After having paid about 10 percent of collections to our billing department when I was at my old group practice, I had to make a decision about who would do the billing for my new practice.

I had found a couple of billing companies that would take less (heck, no one I know has a company that takes 10 percent). But even 5 percent seemed like a lot. And I was pretty jaded after my prior experience. You know there was a time that our collections were way down one month, allegedly because the person responsible for our billing went on vacation and stuffed our billing slips in a drawer instead of delegating them to someone else.

Plus, anything less than $10 was just written off apparently. I know $10 may not seem like much, but let’s say that even two patients a day owed $10, that’s more than $7,000 a year! Now, I understand, if you’re paid hourly, you don’t care if you collect $10 or $10,000, you shuffle your papers and make an occasional call, but if you get a denial, then so be it.
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So, after careful consideration, we (meaning my husband and I) decided that my husband would do my billing. After all, other than me, who else truly has an interest in how much gets collected? Who’s going to look at every claim, every invoice, every EOB? And who’s going to figure, yes, it is worth the 44-cent stamp to send that statement for $2.29.

Now my husband’s not a biller by trade. But he took the requisite courses and is proficient at math, and quite honestly, I think he’s got a little obsessive-compulsive trait in him. This of course is great in a biller. But my husband also has a full-time “real” job, and because of my hours, he is also a very hands-on dad. So he does the billing during his lunch hour (he’s always grateful for the drug rep lunches), in the evenings, and on the weekends.

We had some technical difficulties at first, as he learned the practice management system and our clearinghouse’s software, but he has it down pretty good now. Sure, he gets frustrated at making phone calls to insurance companies, especially when he can’t get a human on the phone (which is all the time), and the phone calls from patients who say they shouldn’t owe anything because they have a secondary insurance (which would have been good to know when they came for their visit).

But he says, strangely enough, that he kind of likes doing my billing, and I like having him come to the office everyday. And if the time ever comes that the world doesn’t need engineers, he has something to fall back on.

Melissa Young, MD: The weather has been frightful

My practice is in New Jersey, basically central New Jersey, although people who live closer to New York consider us South Jersey, and people who live closer to Atlantic City think we’re North Jersey. We are also fairly close to the shore. This generally makes for a mild winter with one, maybe two, snowfalls that result in an accumulation of a couple of inches. And winters have gone by when I would wonder whether my children would ever experience the joys of building a snowman or sledding down a hill.

Well, I wonder no more. We have had more snow this winter than we have had in years. Oh, we had a worse storm a few years ago, but that was it for entire winter. This year, although the storms have not been particularly bad individually, they just keep coming, and putting new snow on top of old snow.

Now, why am I writing about the weather in a Physicians Practice blog? Because these storms come in the middle of workweeks. On days when the office schedule is full. Prior to the last storm, a couple of patients called the day before to cancel. The weatherman said the snow would start in the morning but it wouldn’t be bad until the afternoon, so I said we’d stay open for the morning and close early.
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But the snow started that night, and as I looked at the accumulation starting, I decided to cancel the morning appointments, too. I didn’t want patients or my staff driving through the snow or slipping on our walkways. I was unfortunately not able to get hold of everyone, so I went in just in case people would come.

One patient came. An 85-year-old woman brought in by her 60-or-so-year-old daughter. The daughter had knocked on the rear door, generally reserved for employees only, because they had parked right outside it. When I opened the door, she went back to the car to get the patient. I cringed as I watched her slowly make her way over, carefully stepping over mounds of snow. Mind you, I had actually spoken to the daughter earlier that day, and tried desperately to discourage her from coming, but apparently this was the only day she could bring her. When I was done with her visit, I walked them to the back door again, and held my breath as they walked to the car. I stood outside the door in my white coat until I could see she was safely seated inside the car.

The day after the storm, more people cancelled, either because they hadn’t been plowed out yet, they had no one to watch the kids who had a snow day, or they were just afraid of driving through what was left of the snow on the roads.

So two days of lost productivity. Tolerable, I suppose. But guess what? We just had another storm. I think this time people have just said, “whatever,” and decided life must go on, because aside from one 85-year-old woman, everybody else showed up yesterday, and she only cancelled because her ride cancelled on her.

Now granted, yesterday the roads were passable and the parking lots plowed. Not so today. One patient had already called yesterday to cancel, and another called early this morning. So I head to the office, and I guess I was the only one insane enough to do so because the parking lot was empty. Which was just as well because it wasn’t plowed. Nor were the walkways shoveled. And quite honestly, the town had done a pretty bad job at plowing our road. So I text my staff and tell them not to come in, and I get on the phone to start canceling patients. They all said they were about to call and cancel anyway.

So aside from yet another lost day of productivity, I am also faced with the problem of where to reschedule all these people. I didn’t want to push them out a month, so I ended up squeezing them in next week during times I generally go to the hospital to do rounds or at the end of my “short day.”

So what do you do when Mother Nature doesn’t cooperate?

Melissa Young, MD: The second physician

I was talking a couple of weeks ago to an internist. She had been in solo practice for a couple of years, and then she hired a former co-resident as a second physician. He left the practice after less than two years, and she has since hired a second “second physician.” I told her that I am currently in the process of finding someone for my practice.

During the course of the conversation, I couldn’t help but think back to when I was first hired at my old practice. When I was the second person. It’s a tough transition — for the new person, for the senior partner, for the staff, and for the patients. Even for new patients.

I still remember the sting of being told by patients that they had really wanted an appointment with Dr. Senior, but they couldn’t get in to see him soon enough, so they got me instead. Ouch. Well, most of them decided I wasn’t so bad after all, and actually were glad to see me in follow-up, or at least weren’t upset that they weren’t seeing their first choice.
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Well, what could I expect? My senior partner had been in practice in the community for over 12 years when I came around. All the local docs knew him. They spoke very highly of him to their patients. Who was this newcomer? Is she any good? It took years before I was recognized as my own person, someone worthy of sending patients to, someone to refer family to.

The staff had done things the same way for years. My partner’s way. He was the boss. He set the tone of the office. Sure, there were things I did my way, but it was often met with resistance. “Are you sure? Dr. Senior doesn’t do it that way.” And when we hired a third partner, he was met with the same reluctance to change things. “This is the way we do things around here; it’s how we’ve always done it.”

So when I bring a new physician on board, I plan to have new patients scheduled with her. I’m sure many of them will have been referred to me by their PCP’s, or that they will have heard about me from family and friends. Will they give my staff a hard time about scheduled with “the new doctor?” To make matters worse, she’ll be straight out of fellowship, just like I was.

I’m sure she’ll have her own unique way of doing things. Will my staff be flexible enough to handle it? Will I? Will she?

I hope for her sake that the transition will be minimally painful. I’d hate to have to look for a second “second” and start yet another transition.

Melissa Young, MD: Getting ready for doctor No. 2

I verbally offered a position to another physician. She has verbally accepted. Now to formalize the agreement.

By the way, she called me the other day because her husband is in a panic that she is declining other offers without having seen a contract from me. Let me say here, that I know this person. I’ve known her for the last five years. We joke that I have taught her everything she knows. I know her family. I visited her in the hospital when she had a baby. We have visited each other’s houses. She is confident that I will not bail on her or be unfair.

So I spent some time this past week preparing a skeleton contract.
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I spent an hour or so with a lawyer discussing other contract stipulations. Aside from the obvious salary, benefits, and vacation time, there was discussion about termination – with or without cause – ownership of records, revenue other than that from patient care, etc. Points I really had not given a lot of thought to. It did seem rather boilerplate, and sounded familiar, having had a similar contract when I was an employed physician.

I want to be fair to her. But I also want to be a smart businessperson. How much can I spend on her as far as CME? How much PTO can I really afford for her to have? How much am I willing to share of what comes in, and how much should she contribute to the practice? What counts as expenses directly related to her employment?

I’m not sure if it would have made a difference if I were hiring a stranger. Would I be less generous? Or would I be worried that the other person would balk at my proposal, and therefore would I be more lenient, say with the restrictive covenant?

The lawyer was quite helpful, going down a checklist, telling me if I seem overly nice or too stringent. She will have the written contract to me in a couple of days, and after I review it, and amend it if needed, I will send it off to my potential future partner. Will she have a lawyer review it? I don’t know. I know every advice column says you should. I have yet to meet a doc who has. Will she just sign on the dotted line, or will we go back and forth with changes?

I also had a conversation today with a solo doc who is now on her second “second physician.” That transition from solo to group is tough, not just on the senior partner, but also on the patients and the staff.

I remember being that second doc. More on that next week.

Melissa Young, MD: More on the patient portal

So just when I was about to give up on the whole patient portal thing (see last week’s blog entry), a patient decides he wants to sign up.

You know that foreign language class you took in high school, after which you could sort of carry on a slowly spoken grammatically incorrect conversation? You know how you can now recognize certain words in that language but can’t put two words together?

Well, that’s how it was for us the first time a patient actually decided to plunk down his portal registration fee and sign the authorization form. Heck, our training was three months ago! We got as far as scanning in the form. Uh, now what? Some e-mail is supposed to be automatically generated, right? And then…?
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Before we could completely figure that out, two more patients signed up. We thought we had followed all the necessary steps, but something seemed to be missing. We called a patient to find out if she received an e-mail with her username and password. No. Hmmm.

We broke out the user manual. We went through the steps again. Ah-hah! We had missed a step, a click of the mouse. We rescanned the authorizations forms and clicked away. Ah-hah (again)! Now we got a window with the patient’s username and password. We must be in business now.

I checked the administrator’s account on the portal. Yup. There were three patients on there. I sent one a message. I didn’t hear back. I sent another. Still no answer. I have no way of knowing whether the messages went through. I have not received a “read receipt.” I’m a little embarrassed to call and say, “Hey, you know that thing you paid $25 for? Is it working?”

I like having an electronic medical record. I really do. I like having minimal amounts of paper sitting around the office. I am also one who enjoys e-communication in general. I e-mail, text, IM, Facebook, chat, and (obviously) blog. I would love a secure way to communicate with my patients. And apparently, some of my patients want to e-communicate with me. I just wish there was some way to verify what goes on in the ethereality that is the Internet.

Melissa Young, MD: The patient portal

A patient portal has been touted as a time saver, an efficient and secure way for patients to communicate with the office. It’s supposed to save money and effort, too, by decreasing time spent by the staff and the physician on the phone.

I cross my fingers. Quite honestly, two weeks ago, I considered ditching the whole thing.

First of all, it took more effort than I envisioned to get it going. It doesn’t help that you are required to develop a “portal authorization form,” something for the patients to fill out saying that they understand the purpose of the portal and what their responsibilities are, etc, etc. But the vendor can’t give you a template for this form. They can’t give you an example. I didn’t really understand the explanation for why they can’t. Ah, but Google is a wonderful thing, and I found one.
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Then there are the various disclaimers you have to post (that the vendor can’t help you with either). You know the disclaimers like, “we try to keep your information private, but well, stuff happens and we can’t be held responsible if someone hacks into the site,” and “if you received this in error, please tell us, otherwise you will be in big trouble.”

And let’s talk about the cost. It seemed like a minimal expense compared to everything else at first. But now that there are a million other things to pay for, and I’m looking around to find the least expensive toilet paper, I realize that there is no such thing as a minimal expense. I had planned to offer the service for free, but I was advised to at least charge an administrative fee. I chose to have a one-time fee, as opposed to a yearly one.
And I figured that two to three patients a month would cover the annual fee I pay.

Well, perhaps I over-estimated the number of patients who would be interested. After having the portal up and running for almost three months, we had people express interest in using it, but nobody who had actually signed up.

Until two weeks ago. And that just gave me fodder for next week’s blog entry.

Melissa Young, MD: The day the network went down

I don’t know why I didn’t immediately write about this on the day it happened. I must have blocked the painful memories, but somehow they resurfaced today.

It was an ordinary day. I saw patients in the office in the morning. Everything was running smoothly. I entered all my notes in the EMR. We had Internet. Nothing extraordinary.

I went to do rounds at the hospital at around 2 p.m. At 3 p.m., I get a text from my receptionist: “The computers are down.” Down? What does she mean “down?” They were fine an hour ago. And computers? Plural? Oh, no, no. This can’t be good.

So I texted her back (I do love texting): “Just the EMR or Internet, too?”
“EVERYTHING”
Good mother of all that is good and pure, what happened?!
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I ran back to the office. Sure enough, the computers were on, but none of them could connect to the network. Therefore, none of them had an Internet connection, none of them could run the EMR. And there in the waiting room was my next patient. I tried rebooting each computer. Nothing. I checked the server. That was on, had Internet, and could run the EMR. Now if I could see my patient in the computer closet that it was in, I would have been fine.

I called my IT company. They couldn’t “see” my computers. I was offline. Oh, sweet baby James, I was this close to having a stroke. OK, they said, unplug the switch, then plug it back in. Unplug the modem and plug it back in. I really hate that unplugging and replugging things just seems to be the way to fix things. Still nothing. My IT guy says he’ll send someone out immediately. Nothing could have been immediate enough for me at that point.

Meantime, I remember the patient in the waiting room. She fortunately had a good sense of humor and was rather amused at my agita. I took a step back. She’s a new patient, so it’s not like there was really anything in the EMR that I needed that second. I’ve seen patients for years without templates, and I’ve written notes on paper before. So, I forged ahead.

Funny, after only three months, it seemed almost foreign, but I went forth. And it was fine until I asked her if she had had recent labs. She said yes, and her doctor had faxed them to me. I slapped myself in the forehead. Of course, she had. But I couldn’t look at them, because all that would be in the EMR. She looked bemused again, “You don’t keep a hard copy?”

“We don’t get a hard copy. All faxes go directly into the computer.” So I go out to tell my staff to call the patient’s PCP to have them re-fax the labs, this time to our “old-fashioned” fax machine.

While they do this, I get a call from IT, “Turn off the server, then turn it back on.” Really, seriously? Fine. Now, a regular computer takes but a minute or two to reboot. “A server has a lot more going on” I’m told as I stand there impatiently. Then after what seemed like an eternity, it was back on. And, lo and behold! One by one the other computers on the network came alive. Hallelujah! We were back in business.

This happened about a week or two ago. It has not happened again. I have no explanation for what happened. Just the new-found wisdom that if it happens again to reboot the server. And a bill from IT for “minimum service – 2 hours” plus tax.

Melissa Young, MD: Planning for a partner... already?

So I opened my practice four months ago. The influx of patients has been steady. The schedule is pretty full each day. The wait time for a new patient appointment is a manageable two to three weeks. The no-show rate is fair, roughly one patient out of 15. I get about one new in-patient consult (oh, yeah, there are no consults, just “new patients”) a day on average, and the hospital census is relatively small.

So why think of bringing in another physician?
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Before I answer that, let me say that I am not planning on having anyone start before the practice’s first anniversary. But it takes so long to get a license in New Jersey. And then there is applying for a Medicare number, credentialing with the insurance companies, and getting hospital privileges. Plus, the new physician may have to move and look for a house, etc., etc.

I am hopefully optimistic (is that redundant?) that by the time the practice is a year old, that I will have a sufficient number of follow-up patients and a decent sized in-patient population to justify having a second person on board.

I have visions of being able to make the office even more accessible to patients by having more office hours, maybe even the occasional Saturday. I also look forward to having my first day off — no office, no rounds, no phone calls. Sigh. Eight months is a long way to go.

My original business plan called for hiring a nurse practitioner at the six-month mark. I loved my nurse practitioner at my old office and feel she was an invaluable resource.

Having said that, I’ve gotten a lot of feedback from my old patients, as well as from patients of other offices that have an NP. While most of them (but not all) respect NPs, and many were quite fond of mine, they really prefer to be seen by a physician. Their physician. Some of them have said that they are glad that I went solo because they want to see me every visit and not alternate with an NP.

So while hiring a nurse practitioner may make more business sense than hiring another doc, it seems that from a patient satisfaction standpoint, hiring another doc is the way to go.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Melissa Young, MD: Patients in transition

I’ve run into a problem with patients who are transitioning from one practice to mine — either from my old practice or from another physician’s office. Who is responsible for a patient’s care when they have indicated to one practice that they are leaving but have not yet been seen in the new office?

I have had some of my old patients ask for lab requests and prescriptions. Now while some of them I know quite well, some have names that only sound vaguely familiar, and quite honestly, some don’t ring a bell at all. Without their records, I haven’t felt comfortable ordering anything. And it’s even worse when they ask for medical advice.
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My old practice washes their hands of my patients once they indicate they are moving. Some patients have had their records sent, and that makes it easier. At least they were my patients, and with their information in front of me, I can make intelligent decisions even though they haven’t been seen in the new office.

Patients from other practices are both simpler and trickier. I had a patient call the other day. He had a new patient appointment to see me in two weeks and had his records sent to me from his prior endocrinologist. But he was nearly out of meds and his old doctor wouldn’t fill his prescription because he wasn’t going to follow up anymore.

While according to his records, it seemed reasonable to simply refill his scrip, it didn’t seem right to me. I didn’t feel comfortable calling in a prescription for someone I had never seen before. What if he never showed up? What if there had been a significant change since his last visit with his endo? Fortunately for this patient, I had a cancellation the next day and I was able to see him and take care of things. But what if I couldn’t?

What about the patient who insists she needs labs done prior to her visit otherwise “it would be a waste of time?” How do I know what labs she needs? “It’s not rocket science, I just have a thyroid condition.” Sure, I could order a TSH and be done. It would probably make her visit more meaningful.

But what if she looks pale or jaundiced when she comes in? Or what if I order a TSH and it’s 50 and she doesn’t show? I don’t know what meds she’s on or what other medical conditions she has. Who would be responsible for following up on that? Me, of course. And without seeing the patient, I don’t want that responsibility.

So what to do with the in-between patient?

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Melissa Young, MD: Thoughts for the new year

As the old year ends and the new one begins, I'm sitting here thinking about how much my life, my career, my goals have changed. Opening a new practice — a solo practice no less — in a time of financial trouble and uncertainty was certainly a new and challenging experience.

I'm about to start my fourth month. Patients are steadily coming in, although not in the droves that I had anticipated. I have started having more follow-up patients come back. My no-show rate has been relatively good, infinitely better than at my old practice. Of course, that probably had a lot to do with how far in advance appointments were being made. Hey, if I made an appointment six months ago, I'd probably forget about it, too.
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My schedule is much less hectic than it was at the old practice. That is much better for my family life and overall sense of satisfaction. Not so great on the pocketbook. Still, my kids are getting older and are starting to have more afterschool activities, and I'm glad to be able to leave my office on time, or even early when necessary and with enough notice. And despite the fact that I technically have no weekends off, there are many weekends that I don't have to go to the hospital, or if I do, it's only for an hour or so, as opposed to the five to six hours I had to work two out of every five weekends.

I have learned a lot about the business side of running a practice. Everything from making sure we never run out of supplies, including but not limited to such mundane things as staples, gloves, and toilet paper, to explaining to a patient that an EOB is not a bill.

No, it has not been an easy transition, but it has been a satisfying one. One quarter of a year down, I'm looking forward to the new year.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Melissa Young, MD: What to do about benefits?

One of the great things about being an employed physician was that I never had to worry about benefits like insurance. I had health insurance, vision and dental coverage, life insurance, and a retirement plan. My staff also had excellent benefits, and I didn’t have to worry about who paid for what.

Now, not only do I have to look for coverage for me, but I also have to consider my employees. And of course, I have to pay for at least part of it.
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I thought four choices were too many when I had to pick health coverage offered by my former employer, but now I have to choose among dozens of options. Blue Cross, Oxford, HealthNet? PPO, HMO? And what about vision and dental?

I have dentists and doctors that I already go to, and I want to pick a plan that they participate in. And my staff has their favorite providers, too. Maybe, I am being too nice. Maybe I should just make my choice, and they’ll have to live with it.

How do you know? How do you choose? And how much of the premium should the employer pay?

I’d love feedback from any reader.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Melissa Young, MD: Employee No. 2

When I started my new office, I knew I wanted to keep expenses at a minimum. Less overhead equals more profit for less work. I did want to make what I felt were smart investments. I paid for a wireless computer network and an EMR. I spent money on renovating my office space to make it pleasant and efficient. And I wanted to pay reasonably well for good, reliable, trust-worthy staff — even if that meant just having one staff member to start.

When I opened the office, I figured all the patients would be new, and even “old” patients from my prior practice would need to be treated as if they were new (even if I didn’t get paid for a new patient visit), because all their information had to be entered into the EMR. So, patient appointments were relatively long at 45 minutes a piece, which meant that on any given day, I saw about eight patients. So my one and only employee, my front office person, could handle the phones and the faxes and the mail, and I could handle entering clinical into the computer, taking my own vitals, calling patients and pharmacies back.

Now, into my third month (wow, can it really be true?), the follow-up patients are coming in — meaning shorter visits, more patients per day, more prescription refills and more phone calls. I recently hired my second employee, a medical assistant.
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She is helping to enter patients’ histories and medication lists, and she is taking the vital signs. This affords me a few extra minutes to spend with patients, to return phone calls, and to just take a breather from time to time.

Bringing in a third person is tricky. My receptionist and I have been doing this for two months. We have established a rhythm, a flow. We know who’s supposed to being doing what and when. And we get along fabulously. It helps that we are of similar age and have compatible personalities. I was anxious about bringing in someone new. Of course, I had interviewed her and thought she would easily fit it, but you never know.

She has been with us for a week now. So far, so good. She is eager to learn, eager to work. Again, she is in the same age group as we are, and maybe that helps. We are still in the orientation/training phase, and we are going to have to rethink our workflow. My MA has to remind me to stop cleaning up the exam rooms between patients, and I have had to rearrange some computer space, and I’ll have to order different sized gloves for her, too.

It’s an additional expense (my husband thinks perhaps a premature one), but it frees me up for what I think is more productive time, and despite the need for change, has given me a little peace of mind.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Melissa Young, MD: Reading what I write

I have been blogging for several weeks. I have gotten responses primarily from people I don’t know. I have received a couple of responses from people I know only over the phone or through different Internet venues. And somehow it did not occur to me that people I actually know, or may soon know, would read my blog.

Tonight, I was at a hospital function, and I met, for the first time, one of my “competitors.” I had heard about him. I had seen his picture. I was told that I may never actually meet him in person because he isn’t big on social functions.

So imagine my surprise when I saw him at this dinner. I wasn’t sure it was really him. Like when you think you’ve seen the Loch Ness Monster — you see what you see, you’ve heard that it’s out there, but you didn’t really think that you would see it in your lifetime. But nonetheless, I walked up and introduced myself, and, lo and behold, it was him.
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And imagine my even bigger surprise when he said he had read my blog. He even knew what my latest post was about. I was flattered. Then as he walked away, I began to wonder — was there anything I said in the comfortable distance of my own home that may have offended my neighbor and colleague? I don’t think so. I certainly hope not.

It is so much easier in this day of computer anonymity to freely voice not only one’s opinions, but also one’s biases and sometimes an exaggerated sense of one’s self. I have certainly been witness to others’ rantings, beratings, and just down-right rudeness. I admit to being much more free about my opinions online than I would ever be in person. Still, in retrospect, I’d like to think that I have maintained a sense of decorum and professionalism.

And it just occurred to me, that two days ago, a patient had mentioned to me that she had read my blog, too.

Why write this now? Maybe it’s because I’m tired of the ill-mannered postings on other sites. Maybe it was the startling realization that, yeah, people actually do read what I write, even though only one person responds. Or maybe it was the open bar at the function this evening. I don’t know.

But I do know, that from now on, whether I write for this blog, or another site, or the local paper, I have to remember, idle as my ramblings may be, there are people out there who read them. And it may be a colleague, a hospital administrator, or a patient. And if I don’t have the guts to say it to someone’s face, well, then, maybe I shouldn’t’ say it at all.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Melissa Young, MD: Are patients expecting too much of me — or vice versa?

Last week, just as I was about to give up on my 12:15 patient, she called — at 12:25 p.m. — to say she was going to be at the office in 15 minutes. My receptionist, knowing full well what I was going to say, asked her to hold, turned to me and asked me if I would see her. See her? Twenty-five minutes into a 45-minute visit? When I had a meeting at 1 p.m.?

I said, “No.” Well, what I actually said can’t be published, but the bottom line was “no.” I listened to her politely explain to the patient that I would no longer be able to see her and that she was welcome to reschedule. I listened to her try to reason with her, saw her put her on hold and turn to me. “No.”
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She tried talking to her again, and then in exasperation asked me if I wanted to talk to her. Of course, I didn’t want to, but fine. Let me interject here that she had already “no-showed” for a new patient visit two weeks earlier and probably should have been given another appointment anyway. So I take the phone and try to explain to her that she was going to be too late, and that, no I would not, could not see her. She insisted that she was “right there,” argued that she was coming “all this way for nothing.”

I reminded her that her appointment was at 12:15, to which she replied “So? It’s only 12:20 now!” First of all, it was by then 12:30, and even if it was 12:20, she was still going to end up at least 20 minutes late. I finally said that she can reschedule or not come at all. To which she replied, “Well then I don’t want you for my doctor. You’re mean.”

I nearly laughed. Instead I said, “That’s fine,” and I hung up. She later called and left a message about how unhappy she is that we would “dare” to ask her to reschedule, and that she doesn’t want me as her doctor. Part of me wanted to say, “No, no, no. I don’t want you as a patient.”

Another patient, one I had yet to see, had called the office numerous times, asking my receptionist things such as, what is my feeling about alternative medicine, will I do a thyroid cyst aspiration on her first visit, can I order this test and that test before she comes.

One day she called and asked to speak to me, and I spent a good 15 minutes trying to tell her that I cannot make any clinical decisions on someone I haven’t seen. So no, I will not plan on an aspiration, no I will not order tests. I don’t care if your other doctor thinks you should have it; if that’s the case, he should order it. Then I finally have the, uh, pleasure of seeing her, and make it through without killing her or me with the sphygmo tubing.

The next day, according to our caller ID, she called at least 10 times. She left a message once asking to please send my notes to her primary. I did so immediately. Then two days later, she called again, and asked to speak to me, to ask me to send my notes to her primary. I said, “I did, why? Didn’t she get it?” Oh, she doesn’t know because she didn’t ask her primary. But she figured she could call and ask me?

Is it too much to ask that patients respect my time?

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

Melissa Young, MD: My EMR - I'm getting excited again

I won’t kid you. Using an EMR — even one chosen after hours of research, demos, and site visits — isn’t easy. I still get periodic connection problems and these funky little messages telling me I’ve had an “access violation.” There are still patients who come in with stories or complaints that just don’t fit any pre-made templates (even those made by me), whose history I have to type in manually.

But a few things have happened in the last few weeks that have me all excited over it again.
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First of all, patients are starting to come in for follow-up visits. And with one click (OK, a couple of clicks), I can copy their last visit, and instantly have their HPI, ROS, and exam on the screen. Sure, I have to add new complaints and delete findings that are no longer present, but since my patients tend to complain of the same things every visit, and unless there’s a new issue, their exams are generally the same, I can document the visit with a couple of clicks.

Second, I got a new paper tray for my printer, so now I can print prescriptions instead of writing them out. The patient’s name, address, and date of birth are printed on every one. And if it’s a refill, just click on amount and number of refills and, voila! a perfectly legible prescription — which, by the way, eliminates the calls from the pharmacies because (surprise!) they can’t read my handwriting.

Third, the second point may soon become a moot point, because now I can e-prescribe. With the same number of clicks on the screen, I can electronically send patients’ prescriptions directly to their pharmacies. It (so far) seems more reliable than faxing. And it saves me the expense of both prescription paper and toner. And maybe, just maybe, I’ll get a little stimulus money in the deal.

Yes, I had a connection problem bright and early this morning. But it resolved itself after a minute or two, and by the end of the visit I had e-prescribed two prescriptions, printed a lab slip, and created a consult letter that was faxed to the referring provider. Yeah, I’m all atwitter with excitement.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.