David Albenberg, MD

 for my services. Some are initially confused by this arrangement, but to me it’s simple: you pay me and I’ll be your doctor. Since my staff and I work for our patients (and not their insurance companies), those patients are much more likely to trust and respect my judgment as a physician.

In the general population, there seems to be a paradoxical shortage of truth. In this era where information abounds, we as consumers are now finding ourselves in a crisis of trust. Nowhere is this more pronounced than in the field of healthcare, where trust is that much more important, quality is poorly defined, and transparency in cost and quality is almost nonexistent.

 ranked highest in trustworthiness for consumers. In the modern primary-care setting, most patients find their doctors through a listing from the insurance company.

However, when patients feel they can no longer trust their insurance companies to send them to a reliable physician, an interesting thing happens: They rely on the same tried and true mechanisms that they use to guide them in their nonhealthcare consumer decisions. They ask their friends.

Those of us with experience in consumer-directed practices are not surprised to find that word of mouth is the strongest mechanism for attracting new patients. Treat someone well and they will send their friends. Another interesting finding from the Nielsen survey was that just behind word of mouth, and well ahead of virtually every form of paid advertising, was 

This makes sense: If you can't think of any friends who might recommend a doctor, go online and see who others are recommending. Web sites such as 

 have been competing to capture the market for general consumer feedback.

As a testimonial to the importance of transparency in healthcare, myriad healthcare rating Web sites like 

 have seized the opportunity to empower consumers to make educated decisions in choosing their doctors. Tangentially, social media Web sites such as Twitter and Facebook are gaining momentum. In fact, Nielsen estimates that 18 percent of consumers begin their product research online.

So what’s the newest and latest marketing strategy to attract patients in the twenty-first century? It’s not print advertising; it’s not a radio or TV spot; and it’s definitely not handing out water bottles bearing your logo at a local 10K run. Here's what works:

 - your patients will recognize this and tell their friends
 

 - consider bells and whistles (like our logoed keychain flash drive containing a patient’s medical record) that might set up an opportunity for patients to talk about your practice
 

 by mailing out thank-you cards and a voucher for a free massage
 

Encourage online feedback from your patients

 - in our practice we send an e-mail to our patients with a link to leave feedback 

a board-certified family medicine specialist, opened South Carolina’s first retail medicine primary-care practice, Access Healthcare, in 2003. He focuses on disease prevention and wellness maintenance. He can be reached at 

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In my practice, patients pay cash for my services. Some are initially confused by this arrangement, but to me it’s simple: you pay me and I’ll be your doctor.

Marketing 2.0

Even though I have been practicing medicine in an atypical, concierge practice model, there are still instances where I sense a growing adversarial relationship between the doctor (me) and my patients. More so as our economy is strained to the breaking point. It got me thinking: What does it mean to be a modern day “advocate” for my patients? Has this role changed significantly from my earlier days where I felt I worked solely for my patients?

With the advent of the third party payers, physicians essentially entered into legal contracts with the insurance companies, unintentionally introducing a financial bias into the physician-patient relationship. In my view, this is in direct conflict with the Hippocratic Oath, which of course holds patient advocacy of primary importance. This new relationship has forced docs to re-examine their priorities. Are they working for the insurance companies? Or do they really work for themselves and their patients?

Think of the classic example where a physician chooses to code a preventative-care visit as a problem-focused visit, in order to help his patient. He may think he is being an advocate for his patient, but he is also committing insurance fraud en-route. Under the HMO capitation model, patients feared the reverse: Physicians withholding procedures in an effort to save the insurance companies money.

But the most frustrating example of the increasing disconnect between patients and their physicians is when a patient is 

 because of a diagnosis that was made (and submitted to the insurance company) by his physician. We all dread these types of calls from patients, “Doctor, something in my record prevented me from getting the preferred rate for my life insurance!” A CPT code made appropriately, or worse, as a stretch to attempt to cover a lab test or procedure, has now come between you and your patient.

If you are wondering how this happens, I can tell you that it is the work of the Medical Information Bureau, a 105-year-old, 470 insurance-company strong “information exchange.” Think of it as the DMV or Equifax of medical diagnoses whereby your diagnoses, quickly scribbled on the bottom of an encounter form after a seven-minute encounter, are submitted to insurance companies via a clearinghouse, and live on in the digital ether for seven years.

In an attempt to simplify my allegiances, I have decided that I work solely for my patients. I see them, make diagnoses, and treat them. In return, if they value this process, they pay me.

If you are concerned about your relationship with your patients, here are a few strategies to help you become a better patient advocate:

, and educate your patients about the potential for harm from reporting their diagnoses to their insurance companies;

Give thought to other areas of your practice where your role as a patient advocate has eroded; and

 to return to the days of pure patient advocacy and, as I call it, the “just say yes” mentality.

Even though I have been practicing medicine in an atypical, concierge practice model, there are still instances where I sense a growing adversarial relationship between the doctor (me) and my patients.

Being an Advocate for Your Patients


In 2003, after only seven years in practice, I had a patient panel size of 3,500. I referred to myself as a “premature casualty of a broken system,” although to be honest, I wasn’t certain it was the system. I had begun to suspect that I was broken. 

I felt crushed by the pressure to have as high a number as possible. Trouble was, my daily load - 25 patients a day - wasn’t very high in comparison to others. I remember learning about a legendary family doc in our community who was reported by many to see 70 patients a day. One of my partners was cranking through upwards of 40 - even through a painful divorce. 

Was I the only family doc who felt uncomfortable seeing more than 25? Any more than that and I wouldn’t be able to continue to call all of my patients back - an obsessive but patient-appreciated ritual that had become my trademark. Beyond 25, I couldn’t research unusual patient presentations and I couldn’t personally coordinate care to make certain the ball wasn’t dropped somewhere. And the hours? Anything more than 40 and I couldn’t take care of myself well enough to take care of my patients and really be there for them in their times of need. 

I realized that 3,500 was no longer a number with which I could be associated because it kept me from being the doctor I knew I could - and wanted - to be. So I left traditional, volume-based medicine to retool myself and my practice into one that centered on patients. I embarked in a new direction hoping to find, create, or perhaps, just stumble into an environment where even simple-minded, slow-moving doctors like me could practice good medicine and gain professional satisfaction. 

I wasn’t exactly sure what I was getting into, but I needed to find a new number that would work for me, and for my patients. With that mission, my practice morphed quickly into a retainer-based practice which we now know as “concierge medicine.” 

Sometimes I get asked about the ethics of “abandoning” patients. My answer? It’s not a matter of ethics, frankly; it’s a matter of effectiveness. I wonder, who established that one physician should be the medical home for 3,000 to 5,000 patients, and why is that the ethical high ground from which all physicians should be judged? If another doctor can offer an effective medical home for 3,000 patients, more power to ’em. I couldn’t and I won’t. 

Six years later, I have found my number - 300 - and I have found my peace. Want to find yours? Here’s how to begin figuring that out:

 Consider the idea that to be a better doctor and grow professionally as a physician, you may first need to reduce your patient volume. 

 As physicians, particularly as primary-care physicians, we are hard-wired to take all comers, to be “yes” people and to “work it in.” Give some thought to how this mindset - collectively built over decades - has contributed to our current access problems. Set boundaries and stick to them. 

 Time is finite. We can no longer “just see more patients.” Do today’s work today. 

Take-away thought: If we give to Peter, we must rob from Paul. If we give to 

 Peter and Paul, we will probably keep one of them waiting, and ultimately, we rob ourselves. 

a board-certified family medicine specialist, opened South Carolina's first retail medicine primary-care practice, Access Healthcare, in 2003. He focuses on disease prevention and wellness maintenance. He can be reached at 

This article originally appeared in the January 2010 issue of Physicians Practice.

Family-practice doc David Albenberg explains his move from traditional care to concierge medicine and offers tips for figuring out what number works for you.

What’s Your Number?

” as a way of staying on top of your charting, and getting home in time for supper. I have a better idea - I call it the one doctor, one patient, one exam room concept - a real-time, point-of-care approach toward patient management. Point of care, strictly defined (by me), is a mindset, a discipline, a systems approach where patient encounters are conducted in real time. Put another way, if it can’t be ordered, prescribed, integrated, communicated, documented, or otherwise completed before you leave the exam room, you’re not practicing patient care in real time.

Like you, I spend my day in front of patients, and like many of you, in front of a computer. My exam rooms (I actually have two, in case I need to administer IVs) are strategically designed to interface with both. Seven years ago, it was strange: a doctor typing and clicking vigorously in front of a patient. Seven years later, it’s what you expect when you come to my practice. I have an 

 at my hub of course, but it’s our systems that make point of care possible: our fax server; our integrated lab and ancillaries; our document management software; our up-to-date databases of medications; radiology tests; pharmacies and specialists; codes; and prices.

Also like you, my patients present with a random, chaotic, oftentimes nonsensical array of complaints; sometimes by appointment, but more often unannounced. That’s their job. Our job is to transition that chaos into an orderly plan. That plan predictably might include prescriptions, referrals, labs and studies, and follow-up and billing coordination. Each step of the way (and I’ve heard it stated that there are over 120 processes that make up an encounter from the time the patient calls on the phone until the time they leave the office) represents an opportunity for a point-of-care efficiency or breakdown. And while the fourth exam room may give you an opportunity to catch up on your dictation, it does not afford you the real efficiencies where they really matter.

Real-time documentation means that when the patient is giving you the history, you’re typing it into the EHR. After you do your exam and document your findings, you click the appropriate boxes when it’s time to write a script. When you want to refer your patient to a specialist, you choose the physician from a drop-down menu and document the reason for the referral. It all happens in the exam room in front of the patient. Then, as you sign your note and get ready for the next patient, a beautiful thing happens: The prescriptions get faxed, the orders go to your nurse, the referral (and your note from today) faxes to the specialist, and the follow-up plan and charges go to check out. You’re done and not 

Find a practice that uses the point-of-care method in your area and arrange a visit.

Critically analyze your systems, looking for areas of automated integration.

Practice charting in real time and work on completing your tasks before you leave the exam room.

Point of care, strictly defined (by me), is a mindset, a discipline, a systems approach where patient encounters are conducted in real time.

Keeping it Real: The Point-of-care Lifestyle

Much has been written of late on the subject of access to healthcare. But, what about patients’ ease of access to physicians? I’m not talking about the uninsured or being unable to find a physician that accepts Medicare, but patients who have established relationships with their physicians and are unable to get their doctor’s attention.

“I couldn’t get my doctor on call.”
“Waited two hours and I was the first patient scheduled for the day.”
“I just had a quick question and the doctor never returned my call.”

Over the years doctors have sequestered themselves in exam rooms; scurrying quickly between them, so as not to be exposed to lingering patients in the hallway. They’ve systematically secured their e-mail addresses, insulated themselves during office hours with circular phone-menu systems, and instituted incompetent answering services after hours. Just take a trip to your average primary-care physician’s office, where patients endure mind-numbing waits in the waiting room to spend an average of six minutes with a hurried, oftentimes standing doctor.

Seven years ago I set out to change this paradigm by removing all barriers to access, and then, for those still skeptical of an easily-accessible doctor, by branding our practice after this anomaly: Access Healthcare.

Want to be where everybody knows your name? Our patients are greeted by name by a friendly greeter across a slate desktop. Your time’s valuable too? We have only four chairs in our no-waiting room. Like to be heard? We schedule 30 minute slots for even acute care visits. Have more than one medical issue? We ask, “Is there anything else?” and mean it. Uncomfortable assuming that no news is good news? We e-mail all labs and study results along with commentary directly to our patients.

We also work hard to facilitate patient/physician communication. When you call the practice during office hours, only one of two people with direct access to your chart might answer the phone. When you call after hours, you get the physician directly. Tend to get hurt or sick after hours? We’re on call 24/7. Forgot the e-mail or cell phone number of your doctor? We print it on a key chain and give it to you.

Seven years later the results are in. The benefits of access are well known and well publicized:

Earlier identification and treatment of disease;


Less utilization of more expensive emergency rooms; and


But what about the downside? Is it possible that too much access breeds inefficiency as well? There is an expression that goes, “Give a person an inch and they’ll take a mile.” I fear this truism does apply at times to my practice, probably because of Americans’ insatiable demand for healthcare. I still get many calls over the weekend requesting refills of routine meds. And yes, there is often “one more thing.” And, I still struggle to be on time. 

So, is there a healthy middle ground? I think so. Consider the following points and don’t be afraid to “just say no.”

Choose your ports of access with work flow in mind. Does an online instant chat with your receptionist really save anyone time from the traditional telephone call?

Create and maintain clear boundaries. In the end, patients will respect you more for it. 

 a board-certified family medicine specialist, opened South Carolina's first retail medicine primary-care practice, Access Healthcare, in 2003. He focuses on disease prevention and wellness maintenance. He can be reached at 

Much has been written of late on the subject of access to healthcare.

Easy Access for Patients

The traditional practice of primary care is complex - let’s face it, you could more accurately predict the likelihood of a patient presenting with a subdural hematoma based on his or her symptoms than you might Blue Cross’ likelihood of accepting a preauthorization for the CT scan. This angst, multiplied by 30-35 patients a day, is what often prompts the traditional practitioner to look for another way to practice.

I began my search in May of 2002, just three months after the now landmark American Academy of Family Physicians’ article highlighting Dr. Gordon Moore of Rochester, Vermont, outlining what he had coined his “micro-practice.” Simply put, Moore’s practice succeeded in seeing 12 patients a day, giving 24/7 access, and re-discovering the doctor-patient relationship, all without any staff. You may recall the photo of the smiling, young, high-tech doc, stethoscope around his neck, headphones (presumably so that he could answer his own phone) on his head, and flat screen monitor in the background. If not, you can read the article on the 

At the time I thought this guy had a fantastic idea, albeit a bit extreme. I, too, wanted to see fewer patients, have “unfettered access,” and have more fun in the exam room, but I wasn’t prepared to simplify away my office manager, finance manager, front-desk administrator, and nurse in the process. After all, these are the people I get to do my scutwork. He had to be crazy.

Then, just as I was putting the finishing touches on my practice’s operational systems, the economic downturn came along, and with it, a marked reduction in the demand for cash-based services. And since I didn’t seem to have any significant control of the top line, like most other small businesses, I began to look hard at the bottom. That’s when I began to revisit my staffing needs. I was able to cut my staff by 40 percent through eliminating superfluous tasks and combining positions. I also consolidated patient scheduling from a five-day work week down to four, so that I could reduce my nursing overhead.

With each successive cut, something shocking and amazing happened: I didn’t miss ’em! Not only did my bottom line improve, but the work flow, communication, practice management, and patient-care aspects of the practice all improved as well. The systems were already in place - I just needed to reduce my staff to fully realize the efficiencies of them! And while I am definitely working harder - answering phones, making appointments, faxing refills, and taking out the trash - that increase is not in proportion to what I was expecting.

In the end, my practice was not much different than Moore’s in that we both had focused on a simplified model based on a solid operational system. The only difference was that I was hanging onto an antiquated notion that a doctor needs a “safety net” of staff to allow him to focus solely on patient care. In fact, the systems in place created a practice that was essentially “self-wound” and the management of extra overhead was actually distracting me, ironically, from patient care. So, if you are thinking about making a similar change, I challenge you to ask yourself:

 - Critically analyze your staff needs as you do every other expense in your office. After all, they’re your biggest expense.

 - The concept of an ideal medical practice is founded on returning to simplicity, albeit in a complex healthcare environment.

, this August in Seattle. Seeing can mean believing. 

The traditional practice of primary care is complex - let’s face it, you could more accurately predict the likelihood of a patient presenting with a subdural hematoma based on his or her symptoms than you might Blue Cross’ likelihood of accepting a preauthorization for the CT scan.