Learning to fly and getting my new practice off the ground

This is my new office.  I signed the lease for this property yesterday – another big step in the process of getting my new practice off the ground.  I should feel good about this, shouldn’t I?  I’ve had people comment that I’ve gotten a whole lot accomplished in the 4 weeks since I’ve been off, but the whole thing is still quite daunting.  Yes, there are days I feel good about my productivity, and there are moments when I feel an evangelical zeal toward what I am doing, but there are plenty more moments where I stare this whole thing in the face and wonder what I am doing.

Learning to fly and getting my new practice off the ground

I walked through the office today with a builder to discuss what I want done with the inside; it quickly became obvious that there was a problem: I don’t know what I want done, and nobody can tell me what I should do.  Yes, I need a waiting area, at least one exam room, an office for me, a lab area, bathrooms, and place for my nurse, but since I don’t really know which of my ideas about the practice will work, I don’t know what my needs will truly be.  How much of my day will be spent with patients, how much will be doing online communication, and how much will be spent with my nurse?  I want a space for group education, but how many resources should I put toward that?  I also want a place to record patient education videos, but some of my “good ideas” just end up being wasted time, and I don’t know if this is one of them.

I come across the same problem when I am trying to choose computer systems.  I know that I want to do that differently: I want the central record to be the patient record, not what I record in the EMR.  I want patients to communicate with me via secure messaging and video chat, and I want to be able to put any information I think would be useful into their PHR.  So do I build a “lite” EMR product centered around the PHR, or do I use a standard EMR to feed the PHR product?  Do I use an EMR company’s “patient portal” product, or do I have a stand-alone PHR which is fed by the EMR?  I have lots of thoughts and ideas on this, but I don’t really know what will work until I start using it.

Here’s the real rub in all of this:

  • There’s a large group of patients waiting for me to open my doors and take them in as my patients.  These people will need excellent care and all that goes into providing that care.  I am confident in my care as a doctor, but the doctor is only a part of the equation; there are referrals, labs, and other care-coordination services that need to be done.  If people are going to be trusting me enough to pay a monthly fee in exchange for better care, I have to deliver on that.
  • This must become a viable business.  I quit my other job, and now will rely on this new business to support me and my family.  The incredibly low overhead of it all helps a lot, but the final say of any business is this: do I offer a service that is worth what I am charging?  Decisions like how to redo the office, or what computer systems to use have a twofold impact on this: they impact the quality of the care, and they cost money.

It feels like I have been given the task of learning how to fly in three months.  But instead of taking flying lessons and flying in the conventional way, I have to build a whole new kind of airship from the ground up.  I need to design it, build it, and then learn to fly well enough to take passengers.  My ideas were good enough to take this challenge, and I have lots of smart people willing to help me, but I will be the one who has to make it fly.

That’s scary.

Some of this is ego.  I wouldn’t have quit my old practice for a new way of doing things if I didn’t have the confidence to pull this off, much less write about it for thousands of people to see.  So when people give me advice, my ego wants to assure them that I know what I am doing.  I want to say, “well, that may work for you, but I am doing something different.”  But then there’s the small fact that I don’t really know what I want, so I should at least listen to any advice I get.

In the end, all that matters is that I give good enough care for my patients that they are willing to keep me in business. Keeping that reality in front of me as the center of my focus will give me the best chance to get this baby off the ground.  Once I am flying, it will be much easier to know how to improve it from there.

In the mean time I just pray that I don’t crash.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

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  • Mary Ann Rose

    Best of luck–you will be fine, and your patients are lucky. Just remember–always return their phone calls, or their emails! Mary Ann Rose, MD

  • karen3

    Good luck, and I highly recommend sound insulation between exam rooms. I cringe when I head the guy in the room next to me discuss his hernia or whatnot.

  • http://twitter.com/usdmp US Medical Directory

    Congratulations, we wish you all the success in the months to come. If you are interested in listing your new practice in our directory for more exposure, please feel free to do so. This is a free directory aimed at connecting medical professionals with communities they serve.
    Best of luck!

  • http://www.facebook.com/sue.taylor.pendleton Sue Pendleton

    Where is the ramped entrance? Do you have an examing room with a ceiling lift and accessible examination table? How about a wheelchair accessible scale? It’s ok, you can also use it for your bariatric patients. You are a new practice and you need to look at the Americans with Disabilities Act Accessible Guidelines for Healthcare. Just Google that and then call whoever to be up to standards from the 1990s. And yes, many of us have decent private insurance. Welcome and I’m sure you’ll rock at this!

  • PamelaWibleMD

    Rob ~ I highly recommend that you allow your patients and community to design your practice for you. I led a series of town hall meetings where I invited citizens to design the clinic of their dreams. I’ve never been happier as a physician. I work for my patients now. It is a joy! Happy to help you learn how to fly in a real patient-centered and patient-designed medical home.


  • davemills555

    With ACO’s and big box healthcare delivery looking more and more like our future, why in the world would someone think the 1950′s Marcus Welby model can continue to be sustained? I don’t want to bust your bubble Rob, but if you haven’t been keeping up to date with the recent trends of the industry, things are beginning to change. In my suburban area, large hospital groups are quietly buying up small practices by the droves. The little guys can’t compete with a fully staffed, fully equipped, totally mechanized modern office facility that is strategically located in or near and state-of-the-art hospital. Patients are being attracted to a one-stop-shopping “Costco style” approach to healthcare delivery that the small office doc can’t possibly compete with. Not to mention, a very stringent consumer based grading system is coming that will survey all providers. Basically, if you don’t please the patient, your patients go elsewhere. Fee-for-service will gradually be phased out and be replaced by a new standard that focuses on wellness and outcomes. Patients will have much more input about their care. So, with all that’s coming in the future of healthcare, help me understand why you would be embarking on an adventure like this when it seems to me you begin by rowing against the tide?

  • LastoftheZucchiniFlowers

    Good luck my friend and stay well. I suggest that you first hire and retain a SMART office manager who won’t steal from you (your wife, sister or mom?) and who understands the ICD-10 in all its labyrinthine perversity! Prepare to work 15-20 hours days in the first year (I suspect you are young – so you can do this) and don’t worry about crashing. You will crash, but the good news is – it won’t be fatal; just world-view altering. You do not mention this, but I suspect you’re in primary care so make sure you have an adequate referral network to help out when you hit the wall. Also you’ll need to credential at your local hospitals if you’ve not already done so if you want admitting privileges. Don’t have more than three exam rooms and one procedure room and consider bringing in the local EMS providers for a ‘tour’ so they won’t think you’re an urgent care center for near amputations and occult Wolf-Parkinson-White rhythms waiting to code……, lets see – what have I left out? Solo practice? Consider a midlevel at some point if not right away because you WILL need another pair of hands and eventually will want some time off. Think about your sample closet and who will have access to it…very important in primary care where you’ll have many different classes of freebies. That can get dicey with all those people waiting for you to open your doors. Finally – DO NOT reinvent the wheel and try to ‘record pt. education videos’ That has already been done so get some CNN/Health Network feeds to run constant loops in your waiting room. You won’t have much time for group education but you might get a health educator down the road for your new onset T1 and T2DM patients because they NEED help the most. Ask your local DOH for help here…..There is so much more but I think that’s enough for now.
    God Bless you and eat your wheaties! As one who’s retiring after almost 40 years of having done what you’re about to do – I relieve you, sir.

    • davemills555

      Wow! I’m exhausted just reading your post! The question that comes to mind is, is it all worth the effort? Does money and profit and business success trump everything else in life? I remember lots of hours I spent at the office while other parents coached my kids on the baseball field or at the basketball court. Lots of hours nursing an office computer system back to life while my wife was at the PTA meetings and my next door neighbor took my boys to Cub Scout meetings. Was it worth it? Did my kids have a father for a doctor or a doctor for a father? Nearly 40 years and all I have to show for it is a big fat bank account and family relationships that need lots of rehab! Maybe I’d do things differently if I were just starting out. Many of my neighbors punched a clock and worked a typical 8 to 5. They enjoyed their lives with moderate incomes. Today, newly minted doctors have more choices. They can work for an employer and have normal hours. Will they be wealthy at the end of the game? Maybe not. But they will be sane and have family memories that I missed. My advice? Money isn’t the only reward in life.

      • LastoftheZucchiniFlowers

        what do your kids say today about having a doctor for a father? I suspect you were a good father and that your wife did what all drs wives did in our day: they picked up the slack and because they had the $$$ to get ‘good help’ – they paid someone to do what they did not have time for. Today – I urge young docs who’ve got the goods, into the elite subspecialties that still provide uberincomes: DERM (not a lot of emergency call and GREAT for family time), ENT, opth. (good for the meticulous ones) and the old standbys for the macho: ortho/thoracic surgery – but LOTs of emergency work in those despite the healthy $$$ stream. The latter two are best done in hospital run practices who can handle the admin, headaches, and medmal much more efficiently than the docs who just WANT TO OPERATE. Gotta love ‘em! The saints who enter primary care like Dr. Lamberts? My hat is off to them

  • davemills555

    Sound familiar folks? Don’t tell me, let me guess. Republican? Am I right? Repeal? Am I right? Obamacare has not completely rolled out yet and already we are hearing Chicken Little saying, “the sky is falling”! Obviously, some providers have a whole lot to lose if Marcus Welby fee-for-service style medicine comes to an end, right?

    • ninguem

      All this has nothing to do with Obamacare, it’s been going on for as long as hospitals have been allowed to tack on facility fees.

      I posted facts with references.

      All you have is mouth.

      • ninguem

        Here’s the same story picked up in a Seattle paper, it’s getting past the business press to the regional papers.


        Though not a fan of the ACA, it is the current Administration that’s keeping an eye on the facility fee pass-through, which ends up consistently doubling the fees for the same outpatient service.

      • ninguem

        And NPR from a few years ago, this having nothing to do with “Obamacare”, in fact precedes the Obama administration.


        which referenced discussion of the facility fees in state legislatures, Wisconsin and New Hampshire in this case.

        An appropriate quote from the article:

        health-care consultant James Unland told NHPR [New Hampshire Public
        Radio], “I basically think that in most cases hospitals count on the
        ignorance of the public and to some extent maybe the laziness of people
        in not exploring alternatives.”

        and laziness is an appropriate description of someone who chooses to
        ignore the extensively documented fact that the hospital-owned clinics
        charge double the private physician fee for the same service, then calls
        me “Chicken Little” for pointing out that fact.

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