Thursday, September 25, 2008

Why has no one mentioned the dollar and oil?

We are in the midst of one of the biggest economic crises probably since the Great Depression, so they say. What caused the economy to weaken they say is the defaulting home ownership market, with people's finances overstretched too far to pay for their home mortgages. Home mortgages were handed out like free candy to anyone who applied. Then with the strength and crazy rise in home prices, companies like Bear Stearns and Lehman Brothers decided to package these mortgages like securities (seems absurd, right?). They took something that at the very least is backed by the real value of a property, and packaged it into something that has no value other than what is on paper, and if it loses value there is nothing to back it up. I'm not an economist, but that seems to be the gist of the problem.

However, I don't hear anyone on the news asking why did our economy really collapse? Why did our hard-working citizens stop being able to pay their home mortgage? What is the true root of the cause? Is the reason really lack of oversight? It seems that on one level you can blame the lack of oversight over the banking industry that allowed the loosening of mortgage lending rules so that people could qualify for amounts that normally they would never have been able to acquire. But for some time, they were able to pay these mortgages. Is it the rising unemployment rate? Is it unemployed people who are defaulting on their mortgages? I doubt this, given the number of foreclosures on the market right now (and foreseen to come in the next 16 months).

No one mentions the falling value of the U.S. dollar, along with the rise in oil prices? Oil has affected everything, and this rise preceded the current economic crisis spearheaded by the crashing housing industry. The rise in oil has obviously made gas more expensive, so that commuting costs are up. But then that also means that the cost of transporting goods has gone up. Companies do what is in their best interest -- increase the price of their goods. So the price of food and the price of electricity have gone up. Consequently, this affects the small business owner, so then they need to raise their rates to survive. Eventually, the market can't withstand the upward pressure, and we thus end up in the situation we are in. People can't afford their lives, so they're defaulting on their home mortgage loans. The falling U.S. dollar along with rising oil prices has been a "double-wammy" to main street America. One would have hit hard. Two his four times as hard.

Add to this a poorly regulated credit card industry, which can sneak up charges as high as a 30% APR on unpaid balances (which I think is ridiculous), and it is a setup for economic collapse. Is it really Wall Street that needs to be bailed out? Does that bail out really help middle America? And why do we really have to wait for a crisis to make the type of decisions our Dept. of the Treasury, the Federal Reserve and Congress are struggling to come up with to resolve this matter.

The best analogy I can think of is the patient who has waited until their disease is so advanced that only desperate measures can save them. We all know as doctors that this involves highly expensive care and taxes the healthcare system. Had this same patient been approached judiciously with ongoing preventive measures, this type of catastrophe would most likely have been avoided.

The U.S. government acts in the same way. Why can't they get their act together and legislate sound policies that support the ongoing health of the nation's economy? Why does Wall Street have so much say over how the government's economic policy is written? And why does the government make no mention of the fact the rising oil prices are the underlying root cause that has taxed main street America into default.

Wake up everybody. We need to free ourselves from oil dependence!

Monday, September 22, 2008

How are doctors faring in this economy?

Today, a front page article of the Wall Street Journal spoke about how people are cutting down on healthcare spending in the wake of this shaky economy. The article noted that for the first time in 10 years, the amount of money spent on prescription medications had dropped. However, it wasn't clear from the article if this drop was due to falling demand or due to the fact the insurers are more and more forcing people and/or their doctors to choose lower-priced drug substitutes for the brand-name pharmaceuticals they take or prescribe. The article assumed that the drop in prescription spending was due to patients skipping a month here and there on their costly prescriptions. I'm not saying this isn't true, but there may be another explanation. After all, I get incessant faxes, mailings, crazy insurance people calling me, airplane trailer announcements, and the list goes on, to remind me that the drug my patient is on has a cheaper (forget about effectiveness) alternative.

The other major problem, that being in Manhattan I don't have to think about so much, is that people are choosing not to drive because of the cost of gasoline. So an Internist in Tennessee in this article noted that his summer volume was down 10% from the year prior. The assumption is that people are just not driving to see their doctor for minor stuff, because the cost does not outweigh the benefit. Sorry country doc, it seems that people are more willing to stick out their illness. Well, the article also reported that remote doctors were having a more difficult time getting their patients to specialists that may be a 40 minute drive away. Again, the culprit -- rising gas prices. Really, it's about the rising cost of living that has now outpaced most employee's rise in salary. I spoke about oil's effect on the cost of healthcare in this country in a prior post; see What I didn't consider there is that people would simply self-select and not spend money on healthcare if they already have to spend too much money on gasoline and electricity. Maybe rising oil prices will cut the cost of healthcare?

No, I don't think so! Less access means that instead of presenting with elevated cholesterol and maybe some decreased exercise tolerance, people will not present until they're rushing to the emergency room with crushing substernal chest pain. The cost of treating that high cholesterol just rose as they are wheeled away to the cardiac cath lab with $1000 medications dripping into their veins to get that blocked artery unclogged after a highly expensive visit to the emergency department. The cost of delaying healthcare is immense!

Then, of course, boo hoo to the laboratory giant, Laboratory Corporation. Their self pay patient volume is down. When everybody talks about controlling the cost of medical care, no one ever mentions lowering the cost of laboratory testing. Tests for a typical comprehensive exam can run over $1000, whereas the cost of the doctor's visit and expertise averages $350 in Manhattan. The doctor's time is cheaper than the automated laboratory results. Amazing!

So, I'm curious, how are the doctors out there faring in this economy? Is healthcare as recession proof as people have said? Post your comments and share with the rest of us.

Sunday, September 21, 2008

1 Year Anniversary in New Office

1 year ago I took a big chance, jumped off a financial cliff (much like the country is in right now, except I had a back-up parachute), and opened a new office designed for the future of my practice. Now a year later, I can say that as scary as that step was, it was the best thing I did for my career.

Calculated risks can push us forward beyond our limits and into greater success. Reckless risks (otherwise called "gambling") can put you in foreclosure. Being able to make the distinction is the mark of a keen businessperson. How the distinction is made, is hard to explain -- you gotta trust your gut or your instincts. You create a business plan, come up with projections on how much you will make, check to make sure your practice is pacing in that direction and hope for the best. It turned out that things worked out even better than I thought they would. So well, in fact, that I didn't realize how far beneath its potential my practice had been.

There is no substitute for having not only your own staff, but being able to create the atmosphere you want your patients to experience. Atmosphere these days is just as important as the service you provide. I have emphasized this in many of my prior posts. Sure, it's just bells and whistles, but hey, that's what has made big companies grow and grow and grow. Take Starbucks as an example. Who doesn't like to hang out in a Starbucks with the jazz music playing in the background and comfortable couches or a cozy corner to perch at. Not that I expect patients to want to come in and lounge in my waiting room, but creating a pleasant environment can ease the pain on days you run a bit of a delay.

The atmosphere goes beyond just having a waiting room. Atmosphere is a 3-dimensional experience. It's the height of the ceiling to give a roomier less-crowded feeling. It's the arrangement of the waiting area (crowded seats or loungy couches with pillows). It's the music playing in the background (much like Starbucks, I like jazz, but mix it up with other genres, like bossa nova, ambient, chill out, and zen). Patients come into my space and experience calmness. It doesn't matter how flustered they may be walking through the door, the space calms them down. The empiric evidence is that patients that used to be "difficult" to deal with have actually become nice and pleasant (something I could have not predicted). Who's to say that the environment could affect how your patients behave when they come in to see you? I was shocked to see patients I had classified in my mind (and you know we all do) as "difficult" or requiring extra time, become agreeable and much easier to deal with.

The extension of the atmosphere is how your staff treats your patients. The same way a pleasant atmosphere affects the patients, so it does your staff. Having a pleasant working environment makes for a more harmonious staff. We took that into account when designing the space, allowing for plenty of sunlight to enter from the outside rooms with transoms above the doors. The space is happy and airy, so the staff feels less heavy, lighter in their tasks. There are no neon lights to bog us down with its low-level flickering. Plenty of light, both direct, and indirect makes the space happy and bright on cloudy days or those dark winter days. With all these softer items covered, then keeping the staff sharp and on their game means having weekly meetings.

Weekly meetings cover all necessary office business. Having them as part of your operation, allows you to bring up areas where the staff needs to improve without sounding like you're just having a meeting to chastise the staff. Office meetings cover a set agenda, from the front desk to the lab, and help the office keep running smoothly. Supplies are discussed. Operating procedures are emphasized and corrected (as new situations come up). Staff has time to express any concerns or offer suggestions for improvements. It's important to have these at least monthly if you can't do it weekly.

Finally, the 1 year anniversary is a good excuse to throw a networking event to bring in all physician referrals. They can see what a wonderful atmosphere their patients go to when sent over, and it helps to reinforce our referral relationships.

Never underestimate the power of a few details to make your space homier and more pleasant to visit. If you've got all the other areas covered (good doctor, excellent bedside manner, great staff, quick follow-up, good referral network), then you are set!

Friday, September 19, 2008

Wall Street sinking, housing in crisis.....What does it mean for us?

The walls are caving in all around us. But stay calm, the foundation is still standing. Don't worry that the foundation is sort of rotten.

My practice is in Manhattan, so I take care of employees at Lehman Brothers, Merrill Lynch, and the former Bear Stearns. For the last few months, the stress and anxiety has been of astronomic proportions. However, none of them saw this incredible collapse coming. The foundations here in NYC have been rattled, and possibly soon all around the world. Will it affect a medical practice? I'm not sure. My practice continues to be as busy as ever. Is medicine recession proof? It seems that it would be, because no matter what, people need medical care regardless of economic situation. What does it mean for the employees of Lehman Brothers? What does it mean for jobs in this country? I'm just in awe of the events in the last few weeks.

For one, I am grateful to be my own boss right now. Regardless of the fact that the solo practitioner gets slammed with taxes (don't we all?), it's still best to be the captain of the ship. No one can fire me, except for myself. And as long as one continues to provide service that sets one's practice apart from the rest, there will be no famine. With stressful times ahead, providing the support our patients need will be of utmost importance.

Friday, September 12, 2008

Another beached whale!.....

Read this article and wonder if the circumstances we are in right now, with a devalued U.S. currency, rising oil prices, and terrorism used as a chest piece to support our military agenda, were not engineered by the current administration. Bear Stearns is gone. Freddie Mac and Fannie May have been absorbed by the U.S. government, which everyday seems to become more "communist" in its operation. And Lehman Brothers is next in the line-up. How many big corporations do American tax-payers have to bail out? Is it really for the good of all?

Notice the date of this article. It's fascinating to read it now.

Greenback Game
Will the Bush administration's cheaper-dollar talk backfire?
By Matthew Benjamin
Posted 10/5/03

Wouldn't it be swell if there were a silver bullet that, with a single shot, could stem manufacturing job losses, shrink the huge and growing trade deficit, and hold deflation at bay?
Some economists say there is, and the White House is locked, loaded, and firing at will.
The bullet is dollar devaluation. Make the greenback cheaper relative to other currencies, and suddenly foreign imports become more expensive, U.S. exports become more attractive, workers are hired to manufacture them, and prices of many goods stop falling.
Savior. A cheaper dollar will also help rebalance a global economy that is overly reliant on the United States, says Morgan Stanley chief economist Stephen Roach. "It will save the world."

But some believe that the silver bullet could be a boomerang in disguise. "No nation that has debased its currency has done well in even the medium term, let alone the long term," says Jim Rogers, cofounder of the famous Quantum Fund, one of the hottest hedge funds ever.
It is more than an academic debate. Terrified that job losses in manufacturing will hurt its re-election chances, the Bush administration has hitched its wagon to a weaker dollar. Although publicly affirming a commitment to a strong currency, Treasury Secretary John Snow in May began hinting at the possible benefits of devaluation. The "weak dollar" policy was cemented in the minds of many economists and currency traders last month when the Group of Seven nations called for more-flexible exchange rates. Since then, the dollar--which had already been weakening since early 2002--has dropped 4 percent against both the euro and the Japanese yen.

Last week the dollar hit a 33-month low against the yen and a three-month low against major European currencies. "We're big bears on the dollar," says Michael Rosenberg, head of global foreign exchange research at Deutsche Bank. He expects the euro, now trading near $1.17, to rise to $1.40, while the dollar, which now buys 111 Japanese yen, will purchase less than 100 yen within three years.

"The strong-dollar policy is dead and buried," says Fred Bergsten, director of the Institute for International Economics. The IIE estimates that every 1 percent drop in the value of the dollar narrows the U.S. trade gap by $10 billion. A 10 percent drop could mean a $100 billion trade swing and lead to as many as a million new jobs, according to IIE economist William Cline.
Intervention. But there's a catch. China accounted for some 22 percent of the $468 billion U.S. trade gap last year--more than any other nation. Yet because the Chinese have pegged the yuan to the dollar, devaluation is no help there. Similarly, the Japanese, who also desire a cheap currency to boost their own exports, seem unwilling to let the yen sink below the 110 level and last week intervened in currency markets, selling yen to maintain that threshold.

And devaluation carries risks of its own, to the economy and the markets. If investors lose confidence in the dollar, watch out, says James Stack, president of InvesTech Research. Interest rates can rise suddenly and bring recessions and bear markets with them. That scenario played out in the mid-1980s, when the G-7 pushed for a weaker dollar, which was then trading at an all-time high relative to major currencies. For two years, the greenback fell sharply. Then in 1987 a sudden loss of confidence in the falling dollar brought on the October stock market crash, Stack says.

Of course, the dollar's current decline is less dramatic, and confidence in America's currency remains high, as foreigners continue to buy up U.S. treasuries. And there are few other attractive places for foreign investors to put their money. "We've got to take some responsible risk to rebalance the world, and the weaker dollar is it," says Roach.
Devaluation is strong medicine, though, and getting the dosage just right is the hard part. "Trying to predict when a falling dollar affects interest rates is like trying to catch a falling pitchfork," says Stack. "It's a neat trick if you can pull it off."

Thursday, July 17, 2008

It only takes a few seconds......

It only takes a few seconds....

1. To say "Hi" with a smile.
2. To answer the business phone with a kind hello and your name.
3. To ask, "How was your weekend?"
4. To empathize, "How is dealing with your ailment(s)/pain affecting you?"
5. To ask, "How do you feel about your diagnosis?"
6. To remember, "How's your dad doing after that fall and hospitalization?"
7. To help someone with directions on the street.
8. To ask the toll attendant, "How's your day going?"
9. To bring light and cheer into every day.
10. To remember an anniversary.
11. To stop and be grateful for everything you have, no matter how much you think you still don't have.
12. To take a b-r-e-a-t-h. Breathe calm into your life.

It really only takes a few seconds to make a difference in your or someone else's day.

It really only takes a few seconds to make a difference in the World.


Sunday, July 13, 2008

Dare I Return? Part II - Brooklyn, A Cat and Mouse Game, and an Angel?

This is the second in a series of blog entries describing the incredible events that took place in the creation of my new office space. I'm not sure how long the series is going to be, but it will continue until it ends. While I was in the midst of this metamorphosis, it didn't seem like all fun and games, but as any hardships are in retrospect, they don't seem as hard, and usually there's something to laugh about. The process was transformative and educational and contributed to my growth as an individual. It made me a better businessman, and gave me the confidence that I can accomplish anything I put my head to. For that matter, anyone can! Our biggest defeater is ourselves, when the doubts set in. They are this nagging voice that crops up out of nowhere, but if you're not careful, can become a very strong character player in our lives. The challenge we have is to turn off the naysayer inside all of our heads.


It was only 2 1/2 weeks from the opening date of the new space, and things certainly were not going at the right pace. The walls were not finished, the IT wiring had not been started, we were still dealing with plumbing issues, we didn't know what type of doors we would use, and the list went on and on.... I was about to lose my head, but given the even-tempered person that I tend to be, I was doing my best to keep my cool, while exploding behind the scenes. The contractor would say whatever I wanted to hear, and then not do what was agreed upon. It seemed he and his business manager had mastered the art of con. Anyway, it was too far into the project to change contractors mid-ship, but still so far away from completion. But it wasn't too far to learn how to manage the contractor to get the results I wanted.

Meanwhile, I wondered what I had gotten myself into, and really thought at this point that maybe my colleagues were right. Doing something at this scale, to this extent, maybe was overzealous. No, it was crazy! I wasn't even sure the volume of my practice would support the cost of the new location. How could I ever think I could pull off constructing an entire office from scratch? Little did I realize 3 months prior, how many details went into one little (well, maybe not so little) space. Every single wall socket, light fixture, switch, doorknob, nail, screw, etc... (you get the picture -- every little detail) had to be accounted for. It was a lot to manage at once. I had my doubts, and I wondered, 'Did I make a mistake?' Man, how do I explain this one to my parents. Well, no time for that. When you're a small businessman trying to make it in this business environment and the insurance medical jungle, there is NO turning back. Survival itself becomes a prime motivator. When you have no other choice but to succeed, you find a way to do things. I put all doubts aside and just kept treading forward with faith in the final outcome, as I had already jumped off the edge of the cliff. No turning back! I was in freefall, and the only thing to buffer my fall was a well-executed, usable space.

A Game of Cat and Mouse

Well, when a contractor is not doing what they're supposed to, it's time to start dangling the money carrot slightly beyond their reach. The project kept coming to a halt with complaints that he was running out of money and that he needed such and such to continue. Well, my only choice was to pay less and give him bits at a time to motivate him to speed up the job. It became a game of cat and mouse. Things got pretty hairy at times. Payments were delayed until certain check lists had been fulfilled. There were tears, there were random threats. It was getting to be quite intense, but I knew below it all, the contractor wanted to please, because this was one of his first commercial projects. I had been honest and paid easily in the beginning, but had to change the tune when I realized what was happening. Nice guys get trampled by savvy contractors. But a contractor always wants to get paid, which means if criteria are created for that payment, they will fulfill them to get paid. It can become a face-off.

Unfortunately, he also enjoyed having me pick up the slack for their lack of competence and organization. One of the things I found out when I got back from Florida was that the counter-tops had not been selected. Small detail, but BIG problem. Fingers were pointed, but hey, it's the one who needs them the most that is motivated. That would be me. So the contractor came up with a place I would meet him at in Brooklyn the same day I had to run another errand there to find lighting fixtures.

Somewhere in Brooklyn

It was a hot summer day. A patient/friend had hooked me up with a buddy of his that has a lighting store in Brooklyn (far out there). I didn't realize at the time, but to get to the store from the subway, I had to go along the outskirts of East New York, not the best neighborhood to be in, and this was at 10am. There were beatnecks randomly hanging out on street corners, drunks asking for money. It did not feel safe. Damn, 10 blocks to go, I walked fast enough to move quickly, but not too fast to look like I was nervous. When I got to the store, the door was locked. "S&@t!" I thought it was closed. 'Oh, a buzzer.' The store had a security lock -- they had to buzz me in -- and I understand why. With random shootings happening there everyday, it was not a neighborhood to be taken lightly. The only stores I know that do that are the diamond dealers in midtown Manhattan. But a lighting store? Wow, the staff looked at me cross-eyed when I told them what subway stop I had walked from. I guess I should have called to get better directions. At least, the lighting was one of the easier problems to resolve.

Well, lighting fixtures solved, I was ready to have my contractor pick me up to go to the stone cutters where we would choose the countertops, but guess what? He can't. He calls me all apologetic. He can't pick me up, but he'll meet me there. He gives me vague directions, and says to just go there and speak to Elijah. If I had known I would be playing tourist in Brooklyn for the day, I would have brought a map. Good thing I had the foresight to ask the staff at the lighting store another way to a subway stop, which actually took me directly to the stone cutters. I camped out at a nearby coffeeshop to figure out a plan. Everyday had a plan -- a list of things to do, places to go, errands to run. A project like this is a 9 - 5 job!

An Angel Intervenes

So a 30 minute treck to the subway, another 5 stops, and I was within walking distance. At this point, the traveler spirit in me had kicked in, and I was in for the adventure. It was a get down on your knees and get dirty type of day. I had lived in NYC for 8 years, but had never been to these parts of Brooklyn. Granted, there's nothing touristy about eastern Brooklyn, but it was an adventure nonetheless. Besides, I was supposed to meet my architect to give him a payment, and I much rather be doing this. I called to cancel on him, because at this point, a deadline was more important. Brooklyn is bigger than it looks on the maps.

Around a big field, down a deserted street that seemed to mostly be lined with construction-related businesses, I found the stone company I was looking for. I just walked in, into a tiny lobby. A bearded man with a yamaka who was busy working with other clients asked me matter-of-factly and with a slight Israeli accent, "What are here for?" I guess they weren't used to people just walking in off the street. He directed me down a corridor to the back door. The door led to a gigantic warehouse, where there were rows upon rows of BIG stone slabs of all different types, colors, dimensions, patterns, etc... There were over-sized clips hanging from a ceiling device that could navigate the entire floor area picking up a slab and moving it to another position or truck for cutting and processing. I watched as they moved what looked like an 8ft by 14 ft slab onto a truck. It must have weighed a ton. Giant slabs, over-sized machines, a towering 40 ft ceiling, made my 6 feet feel short. The whole scene was very IMPRESSIVE.

I had an idea what color(s) I was looking for, so I set off walking down the aisles, seeing everything they had. A young gentleman -- I'll call him Elijah -- asked me if I needed any help. I obviously did not look like I belonged there. He showed me around, and explained to me the different types of stone, their strengths, and cost. It wasn't long before he got distracted by a high-priority client, an Eastern European couple shopping for slabs for their home remodeling. They were well-dressed -- that type of dress that exudes money. I, on the other hand, certainly didn't.

By now I had forgotten about my contractor, who had bailed on me. I was once again alone with no support, trying to figure out how I was going to solve the counter problem. It wasn't really coming together for me.

When Elijah was done with the well-to-do couple, he came back to me, and started asking why I was looking to buy stone. I explained to him that I was a doctor, building a new office for myself in Midtown Manhattan, and that I wanted to have durable surfaces for the front desk as well as the treatment rooms. In his slight foreign accent, he couldn't believe that I was a doctor at my age, and I guess felt some sympathy for what I was going through. He told me, "Look, if you buy from us, it's going to be very expensive for you, but I can give you a name of someone who buys from us wholesale and can do the job for you for much cheaper. But, you can't let my boss know I'm doing this." "Are you serious?" I looked at him incredulously, but with a smirk of inner joy. I had been through one of the most heart-wrenching weeks of the project. Nothing had been working right, and to have someone just offering to help me out, felt like I was being offered water in the middle of the desert. He went as far as calling his friend, putting him on the phone with me, and directing me on how to get there. It was his Palestinian connection. In retrospect, I don't know if I was dealing with mafia, but hey, they got the job done. I walked around the warehouse a bit more, figured out which stones I wanted, and made note to tell the stone cutters what I wanted. It seemed like the tide had turned, and there was a moment of light in what had been a very stressful week. I headed yet to another remote area of Brooklyn.

On my way there, I couldn't help but remember one of my favorite books, The Alchemist by Paolo Coelho. When you find yourself in a series of circumstances that seem fortuitous and not completely in your control, but seemingly along the right track, even though not the one you expected, you must be on the right path. It's as if the path is directed for you by a series of events that are leading towards a resolution of the problem. The day had started with a simple trip to one part of Brooklyn, and ended up in this meandering adventure around the burrough, with one event dictating the next. Only when things are born through journeys like this can one really appreciate the final result.
Off to the Brooklyn shipyards....

To be continued...

Dare I Return?: Part I

April 19th, 2007 was my last post. What happened after that was a tornado of chaotic, but somehow organized activity to manifest the new space where my practice would boom. My philosophy has always been more patient-centered, than doctor-centered -- thus, my dislike for sterile, white surroundings which seem to have become the norm in the doctor world. When did doctors become so boring? It seems that doctors were at war with their patients, rather than in the consciousness of making them feel comfortable and healed. Well, I'm not sure how I developed a sensibility for the patient's side, but perhaps it came from my very love-hate relationship with this career. Now that I have created the holistic, earthy and inviting venue from which healthcare is administered in my office, however, I realize that it was not medicine that I disliked, it was the way it was delivered, from staff attitude to environment, that I hated. I despised my time at the hospital and working for a thankless multi-specialty group, with all the politics and territoriality it involved, but now I love getting up and going to work everyday. Being a solo practitioner, a doctor under my own terms, is where I have found my fulfillment in this challenging profession, especially in its forgotten step-sister -- primary care.

So, I stopped writing last year because suddenly the daily tasks to accomplish this move the way I wanted it to happen, while still running what felt like a full-time schedule at the time, overtook me. I am no Donald Trump, but I sure felt like one: weekly meetings with real estate broker to find the space, weekly meetings with the architect once I chose a space working on the details of the layout, figuring out how I was going to do the billing once I left my sheltered shared services lease (which in retrospect I realize was more detrimental than helpful), and finally, the hiring of my own staff for the very first time.

Standing on the Edge of the Cliff

I was watching Donny Deutsch's "The Big Idea," a great show for any up and coming entrepreneur (which any solo doc running his or her own business should think themselves as), and he talked about the moment in an entrepreneur's life when you've got all the bases loaded, and it's time to take that big risk. He called it "that edge of the cliff moment" when you look down and you know you have to throw yourself off the edge to get to your goals, but it's scary. Well, my edge of the cliff moment was when I hired the architect to draw up plans on a space I would totally demolish and rebuild into a doctor's office. I had searched and searched for a space for months, and nothing I saw satisfied me, until I found a space with a very desirable layout in a building I knew to have good management I could work with. So I decided to move into my own space, and for a business decision I will explain later, take on space greater in size than what I needed, which has turned out to be the best decision I made, and build it out from scratch. If I had taken a space that only fit the needs of the small practice I was running at the time, I would have outgrown it overnight. After all, I knew my practice would grow. So I stood at the edge of the cliff, and began writing checks for the demolition and build-out that followed. Of course, somewhere in there I projected what my expenses would be, obtained a business loan, then started making the payments when work commenced -- probably the greatest risk I have taken in my medical career to date. As they say, innocence is bliss. Once the money starting flowing out, the feeling is of a free-fall off the edge of the business cliff. Well, that for sure is the point of no return.

Beyond the Point of No Return

Things got sticky. In any project, Murphy's Law always makes its facetious face known, I feel only to test the doer's commitment and resolve. When building anything from scratch in an old building whose use has probably been modified several times, watch out for the traps. A bathroom absolutely had to built within the space, because I would not have patients walking down the hall to the community bathrooms with urine specimens in hand. You never know who your neighbors will be, and it's always best to keep biohazards under control. Anyway, only 4 weeks into the project, and 4 weeks away from opening day, a minor glitch with the bathroom. They couldn't get the pipes through for the toilet. The walls, the connections, etc... something didn't fit. This is where one is tested. I had absolute faith that a solution could be found, so I stood by that commitment and as team leader for this project, I urged the contractor to find a solution "ASAP," since I was beyond the point of no return. It had to work! No ifs, ands or buts!!! Well, it finally did, but other glitches soon made the craggy face known. The main one was problems with the contractor's ability to stick to their own proposed schedule. Well, if you've ever worked with a contractor you'll know that that's just par for the course. It didn't matter to me, because the job had to get done, and I didn't have another 3 months for it to finish. I had left my old lease behind, taking the dive off of the cliff head first, and was headed towards my future at an accelerating pace. We had solved the toilet problem and conquered the NYC building department, what else could be harder?

A Detour for the Parents

Well, now the ball was rolling in New York City. The location had been chosen. After multiple revisions, the plans had been set with 3 treatment rooms, and 2 consult rooms, a big enough waiting area and an expansive reception desk to meet the future needs of the practice. Any wrenches had been removed from the construction engine, and now I had to leave New York to help my parents move out of the house I grew up in. My fellow doctors thought I was crazy. "You're gonna what?" "I'm going to take a month off to get all affairs in order for the move, and spend 2 weeks of that month in Florida helping my parents move out of 30+ years of memories and pack-ratting." They retorted, "What's going to happen to your patients?" I arranged for a doctor to cover for my practice for the month, and off I was. I had ended my lease with the doctor I was sharing space with so I wouldn't have to pay rent for that month off. He agreed, graciously, to allow me to continue to receive mail at the old location and have the in-house biller continue to follow-up on claims from the prior few months. I was a free man. They thought my patients wouldn't return to me, but they all did. I knew they would -- when you offer a good service others are not offering, you know your clients will return.

Anyway, back to Florida, parents now moved to new apartment, and the house is a residual mess of memories and junk. My task: to separate the memories from the trash. Thankfully, my aunt flew in from California to assist, as both my father and mother could not due to ongoing health problems. I really needed to do this. This was the house I was brought home to from the Hospital when I was born. I was attached to it. 2 weeks was just the right amount of time to say goodbye, as I enjoyed it for the last time. Everyday we took bags upon bags of donations to the Salvation Army. At the very least good would come from the dissolution of the house I grew up in. I enjoyed the pool for the last few times, and said my goodbyes. As I saw my parents grow old in front of me, a chapter in our lives was ending simultaneously. Draw what parallels you may from these two moves -- it was a cleansing, a rebirth out of old stagnant stuff. We cannot sit in the past forever, no matter how scary venturing into the future unknown may seem or feel.

Cloudy Skies ahead....

Upon my return to New York, I found the project at a stand-still. Apparently, in my absence, the contractor diverted most of his workforce towards other projects, knowing that I wouldn't be there to monitor its progress. For anyone doing any sort of renovation or construction, remember, never look the other way. As great as it was to make peace with the changes at home, I returned to a mess here in New York City. Now with opening day only 2 1/2 weeks away, I could not see how everything would be done by then. I was furious!!! I called the architect and arranged an emergency meeting with the contractor. A lot of stuff needed to get done, and since no one (including the contractor) was taking a leadership role, I grabbed this runaway bull by the horns and became the project manager. I had to be tough. I had to be shrewd. I had to go to the Brooklyn shipyards looking for cimstone for the counter-tops. [All part of the vision, my friends.] But most importantly, I had to not take no for an answer! Good thing I had watched a few seasons of The Apprentice -- perhaps it helped me take the reins with confidence. As a doctor, I work to be a compassionate healer, but as a project manager, one has to be a tough and ruthless SOB or they'll walk all over you. It was a crash course in Hard Knocks 101. Doctoring makes us organized and detailed and those skills came in handy while directing how this project would be completed in as close to schedule as possible. But, it didn't happen without a few more glitches, and with a few angels to let me know I was on the right track.

To be continued....
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