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.

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).