The Great Practice Makeover: Too Well-liked for His Own Good?

“Not long ago, I went to my 35th high school reunion,” says endocrinologist Richard Plotzker. “People asked what I do professionally. I told them I sign stuff.”

Not exactly what he (or any other physician) had hoped to do after the years of stress and heartache required for membership in one of the world’s most noble professions.

It’s an unfortunate reality, though, that the number of papers a practice is obliged to shuffle increases proportionately with the number of patients who come through its doors. Plotzker doesn’t want to know how to attract more patients to his solo practice. Instead, he’s interested in learning how to manage being the most popular kid in class. “I’m always reading about how to increase your business, but the solo docs I know are all struggling to keep up!” He hopes that an honest examination of the processes in his Wilmington, Del., office will help him feel less harried - and benefit the many other physicians he suspects are in the same overcrowded classroom.

I’m dizzy with exhaustion just listening to Plotzker outline a typical day, which starts with 8 a.m. rounds in at least one hospital and ends no fewer than 12 hours later, after two jam-packed clinic sessions, nearly an hour of returning phone calls, and more hospital visits. About a year ago, he started setting aside Thursday mornings to catch up on paperwork, but that time is often filled with urgent patients instead. “My office resembles a jungle habitat, with charts piled by task,” he laments.

Truly, unless you go completely cash-only, there isn’t much to be done about the mountains of administrative work required of a modern medical practice of any size, in any specialty. But there are ways to tweak Plotzker’s practice operations, particularly the clinic sessions, so they run more smoothly. The question is whether this affable physician - I can’t resist describing him as having twinkling eyes - can adopt the radically different mindset that would allow such a paradigm shift. If he can manage it, this attitude adjustment, combined with a few simple best practices in practice management, will ease his strife considerably.

Sticky schedules

To begin to understand what’s behind the chaotic pace Plotzker’s constantly battling, I sit in on a diabetes follow-up visit. The patient has a medication list longer than a line at the post office on tax day, and plenty of specific concerns about those meds. Plotzker helps the patient get his shoes and socks off for a foot exam, all the while gently questioning him about a host of comorbid conditions.

Plotzker recently added clocks to his exam rooms - a first in his 17 years of practice - in an effort to keep himself on task. They’re not really visible behind piles of stuff, though, and he doesn’t seem to be consulting them. He estimates that we were in the room with this particular patient for 25 minutes; in fact, it was closer to 40.

This may be one clue as to why Plotzker feels he works more and more every year for less and less. Like the vast majority of private practitioners, he ends up coding most patient visits as Level 3. He only starts to think about coding a visit as Level 4 or 5 when it runs longer than 30 minutes - but if he doesn’t know he’s been with a patient for more than 30 minutes, he’s probably missing valid opportunities to code higher.

Make sure you’re billing for every hard-earned penny. If you’re not sure - and most small practices aren’t - you would benefit from having a coding specialist perform a chart audit. This is relatively inexpensive, and without making any changes to your work flow, you could start capturing many thousands of dollars you’ve missed.

Watch out for small drains on your time that add up, too. Starting and ending visits on time is obviously key to making good use of those hours you might set aside for catching up on administrative tasks. An unobtrusive solution for avoiding overlong appointments might be a clipboard with a digital clock. (Search for “clipboard clock” online or simply attach a dollar-store cheapie to your own clipboard or binder with heavy-duty double-stick tape.)

Also relevant to the quest for recouping lost minutes is the prospect of dropping your worst payers. In this case, that might mean those with the most labyrinthine administrative processes rather than strictly the lowest paying. Is it worth your time - and that of other patients who might be forced to wait for you - to jump through their complicated hoops?

Not discounting the clinical value of physician-patient small talk and relationship-building, the physician’s goal for an exam must be to begin the interviewing and decision-making processes as soon as possible after entering an exam room. Similarly, he must also begin seeing patients with appointments as soon as possible after entering the clinic itself. In other words, all ancillary tasks should already be executed and resolved, leaving only the work of the exam to the physician. This means that a patient should already have his shoes and socks removed by the time the physician walks into the room. Granted, helping diabetes patients with this task is a lovely way of showing them you care on a personal level, but frankly, it’s not the best use of the physician’s time.

As for macro-level scheduling, consider making these adjustments:

• Delegate the work. Enlist the services of a hospitalist if you want to concentrate your time on office patients.

• Make the schedule fit. If you’re always 10 minutes late for your first clinic session, either schedule your clinic session to start 10 minutes later or start hospital rounds 10 minutes earlier. (If you’re still frequently late for clinic after making this adjustment, you have a time-management issue and might consider consulting a personal organization coach.)

Key players

To help keep him focused on the care-related activities that only he can perform, another endocrinologist I know gives his staff explicit ownership of elements of the patient-management process. He tells them, “You are the person responsible for ensuring that this task happens.” Within reason, of course, he says, “You figure out how to accomplish it, and make sure it’s always done - and always done right.” With this tactic, you’re not only offering staff an increased stake in the business of directly helping people, which many appreciate, you’re also minimizing the amount of time the physician must spend on secondary jobs.

Angela Freeman, Plotzker’s office manager, and Valerie Harrigan, assistant office manager, could both be serving in a more traditional medical assistant role: helping Plotzker move more smoothly through that endless stream of appointments.

Indeed, if someone else is willing and able to undertake a routine patient-prep task, let her. And make sure the right person is doing the right job: The person rooming the patient should be helping the patient get her shoes and socks off so the physician can perform an expeditious foot check.

Plotzker says that “Val and Angie are worth their weight in gold,” and keeping them happy with their work is therefore a priority. But imagine the frustration inherent in a workday like this: “He has his own little systems,” Angie and Val tell me, and although these systems seem to work (mostly), “we just don’t know what they are.”

After 14 and seven years with the practice, respectively, Angie and Val surely have much to contribute in terms of operational improvement. And although the practice certainly belongs to the physician, Plotzker might consider bringing them into the planning process in a more formalized way.

Here’s a prime example: The office is cluttered. An old, disused copier has been sitting in the “storage” area - really a highly visible part of the waiting room - for years. “We tried to put a DNR on things, but he won’t have it!” they say. The front office is where Angie and Val spend most of their time, and so their ideas for streamlining the physical space should count for a lot. After all, physical clutter begets psychic clutter.

Helping hand

The obvious big fix when you’ve got too much demand for your services, though, is to hire another physician. In reality, that’s not an option for the vast majority of small practices, particularly in a specialty such as endocrinology, which has been experiencing well-documented provider shortages that are expected to continue until 2020 and beyond. Unless you live in a highly desirable locale or can offer plum perks, the limited pool of new graduates will likely look first to larger groups - those with a concrete possibility of partnership, or, in the case of endocrinology, academic or research positions.

Of course, a certain percentage of physicians will always be attracted to the perception of increased patient contact in the small private practice setting, but overstretched practices can’t bank on finding those individuals. For years, the medical management literature has been encouraging physicians to bring nurse practitioners, physician assistants, and other nonphysician providers into their practices to better distribute the workload and give patients more face time with a provider.

But when I bring this up, Plotzker objects: “I imagine I would have a very unhappy referrer if … they’d asked for my expertise and didn’t get it.” Based on his own past experiences with referrals, these fears are perhaps well-founded, but they can actually be addressed:

• Treat hiring a nonphysician provider in the same way you’d treat hiring an associate physician. This means ensuring that your care philosophies align, putting plans in place for productivity-based bonuses and ongoing education, and introducing the new provider to patients and referrers so they understand that this person is there to be a real part of the care team, and not just a second-best substitute for the doctor. Let patients know how often they can expect to see the physician and other providers in the practice, and under what circumstances.

• Look for a nonphysician provider specialist just as you might seek a physician subspecialist who’s keen on, say, thyroid disorders. Endocrine PAs, for instance, get high marks from top-ranking members of the American Diabetes Association and American Association of Clinical Endocrinologists, as well as from endocrinologists who have incorporated their services into a practice. Specialized nonphysician providers are still rare, although their ranks are swelling. Consider that training someone in your specialty may therefore be a good investment in the practice’s future.

• Get contracts and so on in place just as you would with a prospective physician employee.

Like so many of the physicians I meet, Plotzker clearly has a lot of things right, as does his staff. The trick is teasing out the trouble spots you can actually address - which unworthy “friends” you can drop without hurting your status as the most popular kid in school.

Laurie Hyland Robertson is a senior editor with Physicians Practice. Request a makeover of your own, or just let her know what’s bugging you, at lchrobertson@physicianspractice.com.

This article originally appeared in the February 2008 issue of Physicians Practice.