Since I started my new practice, it’s been an über hectic and very draining time, but I am happy to report that the end of the week was significantly better than the beginning.

Here are some things I am learning.

1. Starting a business is really, really hard. I did my best to make my business as simple as possible, mainly because I understand my own deficiencies when it comes to business-related activities.  Of course, being in a leadership role of a practice for the past 16 years helps me understand incredibly confusing concepts like accounts receivable, budgets, paying bills, and avoiding going to jail for spending all the collections on lottery tickets and reporting it as “research.”  I purposefully designed the business to require as little accounting as possible, and in general I think I accomplished that.  People come in to see me, pay me by swiping their card on the nifty card-reader on my  iPhone, and I email them the receipt.  That’s not the hard part (aside from people touching the “skip signature” button with their hand while they are signing).

The hardest part of starting a business for me is knowing what overhead items are necessary and what are not.  Building the office took a month longer than I expected and cost twice as much.  Yet I signed “yes” to all of the things that added cost.  Some of them were necessary, like doing the things needed to comply with ADA, compliance with electrical code, and having furniture.  But where to draw the line?  I want the office to send a message of “professional, yet welcoming,” which means it can’t look cheap but doesn’t look posh either.  I want the office to be consistent with my logo, a door opening that says “come on in,” and “welcome.”  But everything adds cost, and mounting cost is tough when delay in opening means I am earning nothing.

Everyone is willing to give advice, but most of the advice given has little foundation in my reality.  People say “it will all work out,” or “you’ll do great,” reassuring me that I don’t have to fret about things.  It’s as if I can sit back and relax while things “work out.”  The reality is that the reason they will work out is that I will spend most of my waking hours (and some while I’m not awake) working, worrying, thinking about details, and trying to plan for a very uncertain future.

2. EMR’s have gone over to the dark side. I wrote about it in an earlier post, about how hard I had to work to figure out my EMR system.  Well, I never really figured that EMR out, so am in the midst of deciding where to go next.  The problem I see is that instead of transforming health care by simplifying the process (what I imagined in the early EMR years), electronic records have been transformed by the system to add a complexity that was not possible without computers.  ”The system” thrives on complexity and documentation of that said complexity in complex ways.  It is job security to EMR vendors, hospital administrators, insurance and HHS employees, and the armies of medical billing staff over our great land.  Computers can turn difficult tasks into easy ones, but EMR has taken easy tasks and made them incredibly complex.

This has been much clearer now that I don’t care about documentation for the sake of payment, and am not trying for “meaningful use.”  I just want to document so I can give good care, using the EMR in a meaningful, useful way.  Yet, to enable a seasoned veteran of EMR (16+ years of use) to simply document a visit required hours of training.  After they bragging of the way I could send lab results to patient portal (complying with meaningful use) more than one vendor explained apologetically that they were unable to print a letter with those same results.  Adding problems and medications is another simple task made complex, not to mention finding them on the list after they’ve been entered.

3. Walk, then run. I had a crisis last weekend.  I was so frustrated that I wasn’t giving people the care I imagined.  It seemed all the work over the four months prior to opening the practice amounted to a bunch of wadded up balls of paper around the trash can.  I tried a lot of things that didn’t pan out.  I learned a lot about what doesn’t work.  While there is value in knowing what works (a lot of value, actually), it doesn’t help deliver the goods when it comes to actual patients.  And the plans I made showed their flaws once they were put to the test, giving me the task of re-solving problems I thought already had a solution.

Upon further reflection (and common sense from a person willing to listen to my anxiety) I realized the source of my frustration: me.  I wanted to have the practice working perfectly from day 1, something that my patients never expected.  It turns out that it’s not the business with the best plan that succeeds, it’s the business that responds best when their plans are flawed.  There was no way to predict everything that would happen when I saw actual patients, and so we’ve spent the first week and a half finding ways to make our practice fit reality, not trying to force reality to fit our plans.

So, what will this week bring?  I think things are starting to fall in place and we are getting a system set in many areas.  But I also think that I don’t know what’s coming.  Some things that worked for the first 2 weeks will show their flaws and perhaps better solutions will appear.

The head count:  35 families, and 73 patients signed up so far.  The total signed up or on the wait list is up to 250, and there are big prospects on the horizon.  We are slowing down a bit this week, focusing on building the systems that will let us manage a bigger patient population.  That’s what it comes down to: I left my practice because I felt like I was too busy to give good care.  Now I need to resist the temptation to grow the business too fast.  I want to make it worth the wait.

I explain to people when they ask about paying $30-$60 extra per month that if all they were getting was me as I was in the old practice, they’d be wasting their money.  I intend to give them far more than that.

One of the high points of the week was seeing a person in their 30′s who has very high blood pressure, but was too busy with school and a job to get it taken care of.  The hassle of calling a doctor, waiting in the office for hours, and getting very little time for the money paid kept them away from care they needed.  I told about the $40 monthly charge and was greeted with a grin.  The smile widened when I mentioned that the basic chemistry profile I was ordering would be an additional $4.50.  I’ll do a follow-up this week, with an EKG, but there will be no charge for that and nobody’s had to use my waiting room yet.  Perfect.  It’s what this is all about.

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