Staffing your micropractice

June 4, 2009

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.

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 AAFP Web site to jog your memory.

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:

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

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

David Albenberg, MD

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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 accesshealthcare@letssimplify.com

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