Then & Now: 7 Years In Practice

Ever since we moved into our office around March 2010 and opened our practice the following month, both my partner (in both practice and marriage) and I have felt an overwhelming sense of a time-warp.

Somehow, time supernaturally speeds up the minute we walk through the office door, and returns to its normal clip the moment we leave.

This applies across all common measurement units of time, too–minutes, hours, days, weeks, months, and now, years.  Thus, even though it’s cliche to say that it’s hard to believe it’s been 7 years, we mean it: it actually is hard to believe.

In school, we were told that how we begin practice is just that: how we begin.  How we practice after that first year will be radically different.  And, how we practice after 5 years will be practically unrecognizable; the same goes for the 10- and 15-year markers.

Having hurdled the 7-year mark as of several days ago, I thought I’d take a moment and ponder, sort of in a compare-and-contrast fashion.

This particular post is directed mostly to those docs who are either fresh out of school or they have been working for someone else but nevertheless find themselves in the position of starting their own practice.

However, this post may also speak to doctors who’ve been in practice for themselves for a while, who may find themselves nodding knowingly at the parallels in our experiences.

So let’s play a little game of compare-and-contrast, shall we?

In terms of office space and location…

Office Space:

Our first office was a quaint-but-snazzy 1,200 square feet, out of which we found ourselves bursting at the seams.  I wrote things down on a notebook in my lap because I had no desk space left.  My desk was shouldering the ever-growing collection of medical textbooks, printouts of every mysterious condition from Lyme Disease to Chronic Fatigue to Vertigo, as well as binders full of copied proprietary neurological exams and lots of other informational materials.

So was my chiropractic manipulation table.

I had no room to organize books because I had no more bookshelf space because I couldn’t buy any more bookcases because I didn’t have any more space in my office.

My partner didn’t have the same problem yet, but eventually, he would.

Our physical activity therapy area tripled as our break room and sink area, in addition to a meeting area wherein we conducted health talks and New Patient Orientations.

Limited cupboard space burgeoned with supplements.

The end of the hall was our only storage space for larger items, like the cold laser on a stand, the diathermy unit, and several other pieces of equipment.  The sole barrier between that chaos and the stubbornly-maintained sanity in the office in general, was a semi-decorative tri-fold divider, the kind that screams faux Japanese Zen.

Heh.

Everywhere we turned, we were tripping over something, running into something, knocking something over, or haphazardly putting something “temporarily”, until we could find a place for it–a goal that was becoming increasingly lofty.

Several years later, we’re in the bigger office space (2,100 square feet) that we moved into as of February 2012.  Oh my!  We could breathe again.

Plenty of cupboard space for supplements.  Plenty of counter space in the reception area for patient educational handouts and files to be processed.  There was even enough floor space for the bigger laser printer that stands higher than waist-height from the floor.

There’s enough space in my office alone for plenty of bookcases, which easily hold all of my books.  My partner has tons of space in his new office for books as well, which meant that he could begin adding to his own library again.

We now have enough space to separate chiropractic manipulation from my partner’s desk/work area.

And we have more than three treatment rooms this time!  And they don’t even double as offices.

Services:

In the beginning, we offered Spinal and Joint Manipulation, Functional Medicine, some Clinical Nutrition, a little cold laser therapy, and Massage Therapy.

And that was it.

Seven years later, we offer Spinal and Joint Manipulation, Functional Medicine, more Clinical Nutrition, practically zero cold laser therapy, and a bit less Massage Therapy.

Oh, and we’ve added Acupuncture to the list.  And Traditional Chinese Medicine.  And phlebotomy.  And a little homeopathy (scowl if you want, I don’t care; it hasn’t survived for almost 300 years for nothing).

We’ve played a little musical chairs in terms of positions and roles, too; my partner does the Initial Consultations for Functional Medicine, he does the acupuncture that we had previously contracted with someone else to do, and we’ve both delegated the Clinical Nutrition aspect to a real live Registered Dietitian.

Go us!

Staffing:

Back on Day One, it was just the two of us, my partner and me.  We each played chief cook and bottle washer.  We took turns treating patients, answering the phone, and doing anything else that needed to be done.  I think I even did some massage therapy.

The massage therapist was the first person to join the team.  Then we hired her life partner to work our front desk a year and a quarter later.

Then, throughout our third year in practice, we hired (and lost or fired) several more front desk assistants, the original massage therapist left, a second one came on board, and a third one came and went, as did a third doctor.

During our fourth year, an acupuncturist came and went; during our fifth, a phlebotomist came and went, and a second one came and stayed, where she remains today.

During our seventh year (the one we just concluded), a front desk person doubled as our dietician, where she remains today.

So, to sum up our office now, we have two doctors, a part-time massage therapist, a part-time phlebotomist, a part-time dietician, and a “full-time” (according to office hours) front desk assistant.  The assistant is the only employee; the other three part-timers are independent contractors.

Policies and Procedures:

These have certainly changed.  It was a mistake on our part to believe that by being lax and “human” and “life happens” that people would respect us and not bother to push the boundaries in attempt to weight the dice in their favor.

Ha.

We’ve tweaked our policies and procedures so tight they squeak, and every policy/procedure revision was brought about by some glaring example of painful experience.  It’s enough to make you question the Sanity of Humanity.  The collective hive-mind is mentally ill.

No, really–the general public can’t seem to separate their fantasies and wishful thinking from reality and fact.  They’re often wishy-washy folk who have no clue what they want, but they want it all, they want it now, and they want it for free.

This doesn’t apply to everyone across the board, of course–just the tiny and loudest few, who, unfortunately, are also the most memorable.  They create situations and incite emotions you never want to experience again, and these events and their resulting feelings are so intense that you’re motivated to enact policies (or more strictly enforce existing ones) to ensure that those situations Never Happen Again.

That sounds like a lot of pessimistic woe-is-me, but I promise you, it’s real, and I promise you also, that it’s a sliver pie-piece of the overall experience, which in itself is relatively fulfilling and rewarding.

The main policy/procedure revision we made is that we began to screen incoming potential new patients with a slightly more critical eye, being sure that realism won out over the surrealism, the ecstasy of having the intake forms of a potential new patient on your desk.

I learned to set a lot of boundaries, to manage my time more efficiently and reliably, and to get The Little Things done first so that I could simplify my to-do list and focus on the major projects left over for the rest of the day.

Forms, Paperwork, and Other Written Materials:

All Things Paper changed.  First, the entire patient database moved from AppointmentQuest to (I think Appointment-Plus?) to finally, our own EMR (Electronic Medical Records) system by December 2014, which became mandatory for all healthcare providers on July 1, 2015.

I still do maintain paper copies of my records.  Sure, it’s redundant.  Sure, it takes time.  Sure, it’s a violation of the Work Smarter, Not Harder maxim.

I get that.

And I don’t care.

I put more trust in paper.  Hard copy records don’t crash.  They don’t become inaccessible in the event of a power failure.  They don’t slow to a crawl for reasons unknown.  They don’t need upgrading.  It’s bliss.

Intake forms, I have found, are pretty critical patient screening tools.  We started out with a very basic, bare-bones, sophomoric-looking packet, consisting of miscellaneous stray questionnaires found here and there and assembled together in tandem.

Over the years, we only added to it.  The picture we were able to obtain of the patient even before meeting them, became more complete, more telling, more revealing.

But the packet itself was pretty clunky.  Every section was radically different, including in its appearance.  Some of the sections emerged into the limelight, having utmost importance, whereas others faded into a misty background, hardly ever to be looked at.  By the end of our first year, in early 2011, I had already begun mentally hashing over an Intake Packet 2.0, but that didn’t happen…

…until now.  I’m both relieved and proud to say that as of today (ironically enough), I have finished with a brand-new paperwork packet that gets its final finishing touches tomorrow or Monday, and will likely go into operation sometime next week.  This project is six years in the making, having been a fixture on my long-term to-do list.

Other paper materials underwent transformation as well.  Educational patient handouts all got facelifts to bring them up to speed and up to date, donning a more contemporary and more consistently uniform look.  A “signature” word processing “template” emerged, with specific-sized page margins, certain fonts, and specific spacing.  There are set characteristics for both headers/titles and bodies/text.  It’s becoming (much) less obvious that these handouts were all created at different times and phases of the practice/self-employment learning curve.

Self-Confidence:

This is quite possibly the most gigantic aspect.  As I gained knowledge (through conferences, post-doctoral classes, and interacting/mingling with other practitioners in the field), experience (especially with more challenging, mysterious cases), and all the rest, I felt more comfortable in my own shoes.

I took training and added to my knowledge base through the academic information and clinical/applied experiences of others.  I learned about tendencies of patients that don’t ultimately serve anyone’s interests and how to circumvent and prevent them.

I visited the offices of other providers, most of whom had been in practice much longer than I, and I realized that their modus operandi didn’t far outrank my own, and in several cases, was actually inferior to my own (I don’t mean that with ego; I mean that as neutral fact, or at least my perception thereof).  I also realized what they were charging for their services, and how those rates compared to my own, and did some changing.

And then there was my own experience.  Most importantly, I stopped apologizing for the fact that for all the work, effort, time, and even money that I was investing in expanding my knowledge, building my way of doing things, solving challenging and difficult cases, and developing ever-more-comprehensive written resources for patients, needed to be compensated.

Over time, our efforts–and their results–began to surpass those of most of our local and regional colleagues.  (We probably put too much into the project, but we would have rather put too much into it than too little.)  And we knew that we may not be the biggest, the richest, or the best-known, but we strove to be the best.

With that under our belts, we decided to stop apologizing for asking to be paid, and instead, we asked to be paid more.  We were nervous about raising rates, but we also knew that it had to be done.  We updated our rate schedules and prayed.

It worked.  We attracted fewer people, but more compatible people–those who were more serious about getting better, and doing what it took to get there.

We look toward the future with cautiously optimistic gazes.  Stay tuned.

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