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Practicing solo, but not alone


Soloists don't have to be isolated. This physician teaches colleagues how to share information.


Practicing solo, but not alone

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Choose article section...That's a good idea, but how do we do it? PACE: An incentive for excellence Questions physicians ask each other . . . and answer

Soloists don't have to be isolated. This physician teaches colleagues how to share information.

By Steven F. Isenberg, MD

As a solo physician, I long felt isolated from my colleagues. I believed I was providing quality care, but I still wished for a way to share information with other soloists. And as managed care and the medical practice consolidation craze emerged, I wondered about the future of independent office practice. How would it fit in, and how could I help convince other soloists—primary care doctors as well as specialists—that it still made sense?

Then, about 10 years ago, I had an idea: I could organize a group myself—a means for soloists to connect with colleagues and share tips and information that would lead to better care for their patients. Side benefits? They'd also make friends and get more satisfaction from medicine. The annual meeting of my specialty association was coming up in a few weeks, and that seemed like the perfect place to start. So I called the executive vice president of the association and told him I wanted to gather a group of soloists to discuss common problems. He said I could use one of their rooms and suggested that I post a notice on the message board at the meeting inviting other soloists to a small gathering, which I did.

What would the response be? I arrived early, unsure what to expect. I needn't have worried. Three other doctors were already in the meeting room. When we left an hour later, I said good-bye to almost 100 solo practitioners, and Project Solo was born.

As members of Project Solo, doctors go to seminars, visit Web sites, and share ideas and problems with others in the same boat. Our goal is to proactively help each other, rather than just follow rules imposed upon us by third-party payers or the government.

Because patients are a soloist's strongest advocates, patient satisfaction became the touchstone of Project Solo. We need to ask patients the same thing New York City's former mayor, Ed Koch, used to ask his constituents: "How'm I doin'?" If soloists can compare answers to that question—in other words, satisfaction data—we'd have another gauge of the care we're giving patients.

So one of Project Solo's first moves was to document what we already assumed to be true—that patients are very happy with our care. We used the same phone survey that managed care organizations use. In fact, we found that independent practitioners' rate of excellence in patient satisfaction exceeds that claimed by HMOs.

Next, we decided to share ideas about how to improve our satisfaction scores by, for example, listening more to patients and asking more questions (see "Questions to ask patients"). Once we'd gathered a good volume of information, we began to present seminars. To our delight, many soloists attended. People seemed to be truly excited about the possibilities when they left.

That's a good idea, but how do we do it?

There was a problem, though: When attendees got back to their offices, they had difficulty implementing the suggestions they'd heard. It's one thing to hear how to do something and another to actually do it. To help with that challenge, I developed a step-by-step plan for improving office procedures, based on the group's collective input, and I field-tested it in my own office. I set up five 10-week modules with realistic assignments for physicians and staff alike.

The assignments fall into 14 categories ranging from patient services to coding. You can find all the Project Solo tips at www.good4docs.com or by e-mailing projsolo@iquest.net, but here are some of the tasks included:

• Set up a patient log. To keep track of where your new patients are coming from, have the front office maintain a log listing each patient and who referred the patient. If you market your practice in newsletters, brochures, and journals, also have staffers note which patients chose your practice based on those sources. That way, you can measure the return on your investment.

• Sit in your waiting room. Is it clean and comfortable? Are facing seats at least 8 feet apart? Would your patients benefit from educational videos while they wait? Is the front office uncluttered? Is it equipped to ensure confidentiality?

• Have staffers check eligibility—not just approval. If a review of your insurance explanation of benefits forms shows frequent payment denials based on lack of eligibility or coverage, it could mean staffers don't understand the difference between those terms.

For instance, one department in a managed care organization may approve a child for a procedure because he has met the clinical criteria, but another might say he's not eligible because his plan has a pre-existing condition exclusion. Unless the front office confirms eligibility, you may perform the procedure and still not get paid. The back office can help by summarizing the proposed procedure for the less clinically oriented front office.

• Make sure the exam rooms are comfortable, clean, and safe and that they comply with OSHA regulations. Do they have OSHA-approved disposable bags and containers for biohazard materials and contaminated trash? Are exam rooms soundproof and childproof? Prevent theft of prescription pads by storing them safely or keeping them out of the exam rooms.

The modules became agendas for office meetings. Everyone on staff knew what his or her job assignment was, and it changed those deadly and dreaded monthly meetings from the usual grousing sessions into productive time. In a way, the strategy evolved into a history, review of systems, and physical exam of the practice, and it made everyone feel like they were on a team.

PACE: An incentive for excellence

One idea that sprung from our interactions came to be known as PACE—Patient Assessed Compensation for Employees. It's the best practice management tool I've ever used. The concept is simple: Link employee compensation to patient satisfaction scores. If satisfaction improves, pay employees more.

It's important to tell the staff that you're measuring patient satisfaction, and that if overall responses go up, everyone will benefit via increased salaries or bonuses. Each year, we finish the second set of patient satisfaction surveys around Christmas, and I try to link the results to bonuses. For instance, we gave each employee an extra week's salary last year, and this year if patient satisfaction scores are good—say, 70 percent of patients rate the practice as "excellent"—we might raise the bonus to two weeks' salary.

If your practice can't offer that much money, provide something the staff has been asking for. One year, my staff expressed a desire for a microwave in the break room. When good patient satisfaction scores came in, they got that plus a new coffee maker.

When customers are satisfied, any business generally makes more money. Many doctors have trouble adapting that premise to their practices, but Project Solo is helping soloists link practice management to the bottom line. We've been successful enough that the for-profit subsidiary of the American Academy of Otolaryngology– Head and Neck Surgery now markets Project Solo products to its members, and the Indiana State Medical Association and the Indianapolis Medical Society both endorse the organization.

As for me, I now enjoy a more profitable and satisfying practice; plenty of new friends; the opportunity to express my opinions; and renewed enthusiasm, even in today's challenging socioeconomic environment. I've also learned that it's important to accept obstacles as challenges—and unexpected ideas as potential epiphanies.


Questions physicians ask each other . . . and answer

Here are some of the top subjects that come up during Project Solo discussions and meetings:

• What should overhead cost for someone in my specialty with my demographics?
• How many employees should I have?
• Is useful software available for a practice like mine?
• How can I evaluate a managed care contract?
• Are there traps in managed care organizations?
• What have my peers been going through with IPAs, networks, and PHOs?
• Who are the best practice management consultants? How much should they cost?


Questions to ask patients

Here are some of the questions Project Solo asks on its patient satisfaction survey. For a complete copy of the phone survey, go towww.good4docs.com .

• How long did you wait to get an appointment?
• How long did you wait once you got here?
• How convenient is this office's location?
• How easy is it to get through by phone?
• How long did you spend with the clinician?
• How well did he or she explain what was done for you?
• How would you rate the clinician's technical skills?
• How would you rate the clinician's personal manner?
• How would you rate the visit overall?



Steven Isenberg. Practicing solo, but not alone. Medical Economics 2002;15:82.

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