Help me design my ideal medical practice!

In My Humble Opinion
1

So in about six months I will finally be done with nine years of medical education and be ready to get a real job. I am planning to open a private practice, and offer this thread as your opportunity to tell me what you would like to see in a medical practice. Are there things your own doctor does that you would like to see more of…or not? What could you hear about a doctor that would make you think “Wow, I want to switch to that guy!!”? Let your imagination run wild!

I am thinking that I will be a one-man operation at first, without staff. I am a psychiatrist specializing in addiction, but am interested in hearing general as well as specialty-specific comments about what people like and dislike about their doctors and the environments in which they practice.

2

I don’t know if this is standard but I have needed the services of someone like you before. Night and weekend appointments are essential for many people. You could work like places with customers that have similar needs and take a day or two off during the week and throw in a Saturday or a few late appointments.

3

Also, doctors offices at the front end tend to be pretty low-tech. Some type of automatic appointment reminder for people would be nice and probably save you money. A computer and phone or e-mail based system is rather cheap these days. I hear no-shows are a big problem but sometimes people just forget or get the days mixed up.

4

For cryin’ out loud, please get some comfortable chairs! And please think of people who are 5 feet 5 inches or shorter–most chairs in typical doctor’s offices are incredibly uncomfortable. Either they’re too tall or too hard. I would think this would be very important in a psychiatrist’s office where the patients are SITTING.

Sunlight. Bring as much sunlight into the office as possible. Too often doctor’s offices look like the pit of gloom. And if you’re going to have plants (which you should), please make sure they’re nice plants, not dusty, on-the-verge-of-plant-suicide plants. (You know the ones that always look like they’re half dead? They be all leggy without many leaves, or pasty grey-green color when they’re not supposed to be that color, or drooping.)

Current reading material in the waiting room that offers a variety of material. No magazine should be over three months old, and if the cover is torn, worn or colored upon, then toss it out. Offer a variety of material–everything from National Geographic to Good Housekeeping to Sports Illustrated.

If you decide to provide toys for kids, please, please, please have a “quiet zone” for the kids away from the general waiting room. There is nothing more horrible than sitting in a waiting room with someone else’s little angel who is beating on blocks, or whining about a broken crayon.

Unless you’re trying to put up with Little Angel, while reading a magazine that’s six years old and has no cover and half the pages are missing, while sitting in a chair when your feet are swinging because they can’t rest comfortably on the floor… :dubious:

NO TELEVISION IN THE WAITING ROOM! (Sorry, did I scream that???) It’s either too damn loud, or too soft to hear it, and/or the channel isn’t on the “right” channel. At the very least, it’s a horribly annoying background noise.

Golly, I could go on forever…

5

Sorry for the double post, but it would be nice if there was an Entrance door and an Exit door.

I’ve run into people that I know professionally when I’m visiting my therapist, and it always makes me uncomfortable. I’d like to be able to “sneak” out the back after my appointment has been completed.

6

No unavoidable distractions in the waiting room. This includes television, radio, any type of music or Muzak, fountains with running water, etc. Particularly when waiting to see a psychiatrist, people may want to be able to quietly organize their thoughts. If they don’t, you can provide a variety of current magazines for them to puruse.

But the most important thing from my personal experience – SHOW UP FOR YOUR APPOINTMENTS. Yes, I have arrived at the offices of various medical professionals only to find the door locked and no one there. Make sure that if there is an emergency, you have the ability to contact your patients and let them know, and then do it. People rearrange their schedules to see you, and for therapy sometimes they rearrange their emotional lives as well. Missing an appointment can be devasating.

Always have a way for your answering service to get in touch with you or someone covering for you. There is nothing more frustrating than desperately needing medical assistance and speaking to someone who can’t help you and only repeats “I’ll give the doctor your message.”

7

Don’t schedule for more people than you KNOW you can see in day. This might be less of a problem with a psychiatrist, where it’s more likely that people are there for a pre-determined amount of time, but it sucks to have an appointment at 12:30, and not see ANYONE (including just a nurse,) until 1:00. At the very least send someone out to tell me that a certain patient is taking longer than normal, or you got back-logged with some paperwork. People are more willing to forgive you for things that that if you communicate with them why.

8

Well, if you hire staff in the long run, please hire people who have some amount of kindness and compassion for other people!

The office manager at my (beloved) primary-care doc’s is a total bitch, and nearly made me ditch my doc over something so stupid that it doesn’t even warrant a description (she neglected to make a necessary 5-second phone call that my specialist needed her to make. And was a bitch about it. Grrr.)

I also second the good office hours, my s/o sees a therapist who has awesome weekend hours, that’s why he goes there. It also doesn’t hurt that the psychiatrist has a really lovely office and she often brings in her adorable dogs on Saturdays…

9

I was thinking maybe you could change the whole philosophy of how you treat patients. The American medical system is all about emergency health care, I have a problem, give me a pill. As a psychiatrist, you probably know well that everything you do in life has an effect on your mental well being. I’m not sure how popular or profitable it would be, but it would be nice to have a place where preventative medicine was practiced.

Nutrition, exercise, meditation etc… are all very important parts of life. Emphasizing the benefits of good self care goes a long way in preventing many of the more common everyday psychiatric problems as well as maintaining a healthy, balanced lifestyle. Instead of people avoiding health care because they expect problems, they will go to you specifically to prevent degenerating health.

10

After spending 16 years in a very busy and hectic practice, I took a 6-year hiatus in order to work from home (non-medical) and help raise our 2 young girls (one of whom had major complications from a rare congenital condition). I’ve just recently started back with a new practice—one that is completely different from my original one. I no longer do surgery (allowing me to drastically reduce my malpractice coverage); I no longer accept medical insurance (even taking the drastic step of opting-out of Medicare); I no longer have multiple offices nor employ a dozen or more people. In short, my new practice is less business/more clinical and more fun/less stressful. Of course, I didn’t have the option of going this route when I first started out (things like staggering college/business loans, mortgages, obscene legal fees [what I paid lawyers could have purchased a nice beach house] and other costs of living prevented my doing so. There are a few things I miss about my old practice (making money, for one), but, ratcheting down and evolving your practice into one you really enjoy may be something for you to strive for down the road—it’s good for you and your patients. Other general pointers: learn to spot and deal definitively with the malingerers and narcotic shoppers (*“doc, I’m allergic to all oral anti-inflammatories. The only thing that eases my *{unspecified} pain is…”; “Let me guess, Dilauded?”). These dopers are savvy, unrelenting, come in all guises—and they love to prey upon newly-minted docs. Saturday hours seem like a good idea, but ironically, patients avoid them like the plague (unless they have the plague, then maybe they’ll weekend appoint). Empathy good: sympathy bad. When you contemplate a particular treatment paradigm for your patient, imagine for a moment that they are your mom or dad, and then confirm that you would still recommend the same treatment. When you hear hoof beats, think horses, not zebras (unless you’re in Africa); remember ontogeny doesn’t really recapitulate phylogeny…yada, yada, yada…

11

I am a Practice Management Consultant. My advice to you is to find a good Practice Management Consultant. If you get it right from the beginning, your life will be a lot less stressful than having to do cleanup a year from now. (Although thank goodness for me, new practices so rarely think they need this type of service until there is no money coming in.)

12

I was going to say about the same. Get your insurance company contracting and such done before you start seeing patients. Your patients will appreciate it when their billing goes smoothly, and you will appreciate having income, I’m sure. Be aware that it can take months, sometimes as long as six months to get set up with certain companies, and deciding to change your practice address or even your bank mid-process can start that wait time anew.

Unless you love bureaucracy (you must fill out the application in blue pen, and include all pages, even those with nothing to fill out, and you must sign with your toes whilst whistling yippee kai yai ay and standing on your head or 4 months later your application will be rejected, things like that) , it will probably be nice to hire someone for such things.

13

I am a psychologist, and I would LOVE to have this sort of arrangement. Unfortunately, no way to do it right now.

I really enjoy having a stripped-down, do-it-all-myself practice, and hope you will, too. My evening (5 and 6PM) appointments and Saturday morning appointments are very popular and I think they really helped me build my practice quickly (within 6 months or so, I had all the clients I needed).

The biggest complaints I hear about psychiatrists are that they don’t listen and that they don’t take time with clients. Become known as being different, and your clients will flock to you. Also, get to know the psychologists in town. I make referrals to psychiatrists all the time.

14

You need:

  1. 1 attractive and sensible spouse.
  2. 1 goofy neighbor who works for an airline.
  3. 1 goofy dentist office neighbor.
  4. 1 whacky red-headed receptionist.
  5. 1 hostile patient to zing you and your other patients.
  6. A network deal.

Yes, I know Bob Hartley was a psychologist, but just throw in a drug cabinet and you’re gold.

15

I’ve been seen at the Veteran’s Hospital for 10 years regarding drug induced depression and seen scores of interns. I can usually tell who’s in the top half of their class after one visit. Those that are superior are ‘engaged.’ They don’t have a checklist in their head that they refer to while I’m explaining what’s going on. Listen, repeat back so the pt knows you’ve heard them. I don’t much like the ‘take it or leave it’ bunch, the ‘I know more than you’ school of thought.

I do a little research myself and not from bar tenders or vanity sites. I visit University websites, a few NIH articles, so I don’t like to be dismissed out of hand when I make a suggestion or ask a question. I want to learn as I go, so those that answer my questions–in lay terms–earn my confidence.

Two serious errors by my doctors cost me plenty. I’ll tell you so you don’t make them.

The first was by the head of psych at San Francisco General. He had me stay on 40 mg of prednisone for a year while we when thru the entire formulary looking for one that worked. We should have continued to reduce the pred since that is what was causing my depression. This does require working with two variables, I understand, but I am now paying a very high price, (osteoporosis, etc) for being on pred so long. My 85 year old mother has better bones than I do!

The second was when I had to change drugs when the original one stopped working. The next in line didn’t quite do the trick. For two years I rode a psychological roller coaster until an intern suggested we go back to the one that didn’t quite work and simply increase the dose. It’s worked fine since. If I had a kid, I’d name it Dr. Hagerty.

If you are asking this question, you stike me as someone who’s in the top half of your class. I’m betting you’ll do just fine.

Good luck,

Myself

16

Congratulations and good luck to you. The only advice I can give to you is listen, and care.

17

Talk to your patients like they’re intelligent people, not drones who know nothing because they don’t have an M.D. after their name. Chances are they’re probably pretty bright, and even if they aren’t, they’ll appreciate not being condescended to. I remember taking a dog into the vet to remove what I thought was just another lipoma. It turned out to e a malignancy. While we were discussing it, he pulled out textbooks, and even made me copies of the articles about the cancer and gave me copies of the lab results. Then we talked a day or two later after I’d had time to read up and make an informed decision to remove the tumor. I appreciated the fact that he understood that even if I didn’t know about this specific type of tumor, I was certainly capable of learn and deciding what risks to take with a geriatric dog with cancer.

StG

18

From all I hear, there are not nearly enough psychiatrists who know enough about AD/HD and how to treat it. Now, I gather it’s supposed to be a given that many addicts are self-medicating for other things and that one of those things can be AD/HD and I’m hoping that was indeed part of your training. If it wasn’t, and if you do whatever extra CME credits get you to a good knowledge of AD/HD issues, you’d be a heckuva lot of help to a lot of people with AD/HD.

19

–Go electronic now. It’s so much easier to do it before you already have hundreds of paper charts sitting around, and there’s no sense training your staff now just to re-train them later.

–Have your nurse and front office people keep all of your non-emergent* messages, incoming labs, etc., in one place outside your office. Have them bring everything in once a day, at a set time, at which you’ll address each piece of correspondence and hand it back. What you don’t want is a steady stream of papers being tossed on your desk all day long.

  • It’s important to teach your staff early on what constitutes an “emergency” and what doesn’t.
20

A friend of mine has a medical practice with an innovative approach. It’s not a psychiatry practice, but I imagine the same principles would apply. Here’s the website: http://www.idealmedicalpractice.org/index.php