Coming Soon.......

How much is your Time worth? A look at RVU's.

Life Coaching.... A new means to achieving your goals.

Part II of the Series: So you want to open your own private practice.

Come on Oxford..... You've got to be kidding!

Today, I got paid for a comprehensive check-up I did for a patient on December 21st, 2004. Can you believe that!?! This is a joke, right? Seeing the check almost a year later brought up some uncontrollable hysterical laughter. Let's say that I give the insurance plan a 30-day leeway. This means, Oxford, that your payment is 278 days LATE or 9 months 5 days off the mark. This doesn't account for all of your other transgressions, when your payments were 60-90-120 days late, which is unacceptable for a claim that was submitted in a timely fashion. Yes, you may counter that we didn't follow-up. But no, I guarantee my staff has been on top of you. You could at the very least have saved us another letter and have included the interest owed, according to the law, for claims that are filed on time, but paid later than 60 days after that. How did we become subject to such a system? Go ahead, call Oxford or any other insurance plan that is typically late in their payments. I challenge you to find someone coherent you can speak to on the other end of the line! Perhaps the only way is by exposing them, or dropping them all together.

Don't Get Crucified....By Your Scripts

Woes me! Writing scripts has become the toil of medicine. Don't get me wrong, medicines do great things for people, but they also do bad things too; nevertheless, remedies are here to stay, and the nitty gritty of any day at the office may involve refilling a number of scripts for patients you don't necessarily have to see that day... All doctors do this, but let's admit, most hate having to spend minutes or hours of valuable time everyday on the phone with the pharmacies authorizing refill requests. If it's not you, it's your staff -- tying up valuable resources that could be used otherwise. If you live in a cosmopolitan city like mine, you'll also be frustrated by the global variation in accents of the pharmacists who answer the phone -- the connection is usually staticky, the person barely speaks English, and they barely understand what you're saying. No wonder there are as many as 7000 deaths per year from prescription errors, which amount to about 5 percent of the 3-4 Billion prescriptions written and filled every year in the United States.

Recently I experienced my own brand of prescription error when a pharmacist, of their own accord, decided to substitute an antibiotic eyedrop for my 1-year old with conjunctivitis, for one that contained a combination steroid and antibiotic. I caught the error when I got home and looked at the bottle. I couldn't believe it! Had I not been a doctor, I would have administered an eyedrop that was changed without the pediatrician's consent, by the pharmacist, who obviously didn't know what they were doing, potentially risking a corneal ulcer for my infant son, due to the steroid content. I'm careful about prescribing such steroid-containing eyedrops for adults without an ophthalmologist's consent. However, the point is that medication errors are a real thing, and eventually they do hit close to home.

Thus you get a great company like SureScripts that is trying to integrate electronically the communication between pharmacists and doctors, so that prescription information can be exchanged electronically while preserving efficiency, quality and safety. Let's not forget that part of those prescription errors are unrecognized drug-drug interactions. This is where an electronic prescribing database, with its built-in alarms for potential interactions that may be overlooked by today's information-overloaded and pharmaceutical honey-coated-drug-courted physicians, is a great solution for improving safety and patient outcomes, as well as controlling costs by alerting the physician to non-formulary medications and their in-formulary alternatives.

One such program is DrFirst, which won Top Honors at the 2005 TEPR AWARDS. I had a chance to demo this program online today. The nice thing about it is that it allows one to either use an online portal for sending secure scripts electronically to the pharmacy, or transmission from your cellphone, such as the handy Treo 600 smartphone. I have to say the cellphone portability of this program with its patient log and history of last-prescribed medication(s) were the bells and whistles that caught my attention. I use the Treo 600 smartphone now as my pager to avoid having to carry around another device, and enjoy receiving my pages as text messages from which I can select the number to call back the patient or doctor or pharmacy. Now with drfirst, the same phone turns into an e-prescribing solution. What a great idea! No more waiting on the phone, or trying to get the pharmacist to understand your English. It all sounds great, but DrFirst still has a ways to go on online presentation. They need to improve navigation on their website to make it more visually intuitive. All said, they deserve their TEPR top honors, and I would consider this program in a practice that is keeping costs down and not quite ready to jump to a full Electronic Medical Record solution [which is much, much costlier].

So the thing about SureScriptsis that it is not a program you buy. It is a communication network that the other applications available for purchase, whether e-prescribing solution or EMR, use to transmit the information securely to the pharmacies. SureScripts is the intermediary that communicates with the pharmacies' computers. This all sounds great, but its implementation and ease of use is going to depend on the pharmacies. During my recent visit to the pharmacy, I noticed that the computer they were using had an interface that reminded me of the old Commodore computers. Yes, ye-olde dinosaurs of the early computer age -- that is what the program the pharmacies are using looks like. So while they're trying to incorporate this great modern network, they're doing it into an ancient computer system. This is the Jetsons meets the Flintstones. I asked the pharmacist at Duane Reade if they were SureScript ready, and she said yes, but that the system has its flaws..... Surprise, surprise.... I could not have guessed by looking at those old computer monitors that I once used back in the late 80's when learning what a computer was! Anyway, the program is unable to tell the pharmacist when a new prescription request has arrived. So it's basically relying on the pharmacist to check it periodically, which this pharmacist admitted does not happen all the time. Then, to receive a soon-to-be irate patient, arriving at the pharmacy, asking where their prescription is, and the pharmacist likely telling them they haven't received it because they are looking through their faxed requests, where the surescript prescription will not be. It still does not seem to be in the psyche of the pharmacists to check the computer, unless told to do so. So, it seems, that if you plan to switch to e-prescribing for greater ease of use, make sure you contact your most frequently visited pharmacies, and make them aware, as well as tell your patients to know how to ask for their prescription in order to avoid the very well-known scenario of the frustrated, angry patient calling your office asking where their prescription is. But just think, at least you can look forward to easily transmiting prescriptions electronically without consuming more than a minute of your time, when the hair on your back rises, as you hear the patient asking on the way out in the presence of a full waiting-room, "By the way, do you think you could call these scripts in for me?"

With my recent struggles with clueless pharmacists, who seem to be trying to take as much time as possible filling any prescription, much less attending to you, it seems that we have a major implementation problem in our hands. While the doctors are being sold Rolls-Royces, the pharmacies are still driving station wagons. The concept behind SureScripts and all of the e-prescribing and EMR platforms out there that enable this is great, but someone needs to speak to the CEO's or whoever heads these national pharmacy chains about updating their computer systems and improving their store service ethic in order to create a system that works on both ends seemlessly, efficiently, and accurately.

So you want to open your own private practice.......?

And you're positively not intimidated by today's ever-complex medical marketplace......then, READ ON.

What do you need to do?

Part I. The Technical Stuff.

These are things I wish someone had told me while I was a medical student or in residency training, or even early on in my career, because planning is everything. And planning eliminates lost time waiting for things to go through that should have been done long before. But how would you know? I certainly was not told that I needed to get a UPIN and apply to be a provider on the major insurance plans in my area by any of my residency mentors. Here's what you need to know to be ahead of the game.....

FIRST OF ALL: IT'S BEST TO CHOOSE TO DO YOUR RESIDENCY IN A LOCATION WHERE YOU PLAN TO SETTLE LATER ON. IT'S NOT A REQUIREMENT, BUT THIS WAY YOU CAN MAKE THE BEST USE OF YOUR TIME LEARNING ABOUT THE LOCAL MARKET, AND ESTABLISHING RELATIONSHIPS AND CONNECTIONS THAT WILL HELP YOU GET STARTED.

IN RESIDENCY: 1st YEAR

1) PASS USMLE STEP 3. Do this as soon as you can, because much of the knowledge you will have acquired by the time you're 6 months into your internship. You need to have a passing score in order to apply for a state license.

2) OBTAIN YOUR STATE MEDICAL LICENSE. Every state has different rules for this, but for the most part all that is necessary is evidence of successful completion of medical school, USMLE Step 3, and an accredited internship program. Each state has a different licensing authority, so I recommend asking your residency program, or searching on the web using the phrase "[your state] medical license." There are two reasons for getting a license early on: a) it's good to get that out of the way, b) you can then moonlight for extra money.

IN RESIDENCY: 2nd Year

3) APPLY FOR A UPIN FROM THE CENTERS FOR MEDICARE AND MEDICAID SERVICES [CMS]. With the advent of the NPI [see my post: Another Layer of Bureaucracy], it seems that the old UPIN and PIN may be out the door. The CMS website is no picnic; navigation seems to have been organized with top-level security to prevent you from finding what you're looking for. To apply for a new UPIN, the form you need to fill out is CMS 855I. Also, you may want to fill out the Electronic Data Interchange (EDI) Agreement so you can send your claims electronically [electronic claims = FASTER PAYMENT], and the Medicare authorization for electronic funds transfer, if you would like your payments deposited directly into your bank account. If you are confused, call CMS at (866) 709-1905 and ask for help. As a new provider enrollee, it may take up to a YEAR to get your UPIN, SO START EARLY!

4) APPLY FOR A DEA REGISTRATION CERTIFICATE. Alas, a website that is easy to navigate! Click here to apply for your DEA Controlled Substances Registration Certificate.

5) APPLY FOR A PROVIDER # FROM THE MAJOR INSURERS IN YOUR AREA. This will vary by territory, so the best way to figure this out is to speak to practicing physicians and find out which ones are most common, which are the better payers, and which ones are trouble, so that you know what you're getting into. If the hospital you plan to associate yourself with has an IPA [see
How to make up for the difference?], then find out which insurance plans offer enhanced fees through the IPA, and start there. Credentialing takes 6 months - 1 Year, so again, start early and brace for a tough few months with back-and-forth calls to the insurance plans' credentialing department. "No Dr. so-and-so, your application is still in the review process." For a more satirical look at this, see MMSPNexus Blog.

6) APPLY FOR HOSPITAL PRIVILEGES. Speak to the Department in the hospital you plan to affiliate yourself with, and explain to them your plans. Ask them if you can apply for hospital privileges while you are still in training. The process is long, and may take anywhere from 6 months to 1 year, so again, planning is everything. YOU NEED HOSPITAL PRIVILEGES TO BE CREDENTIALED WITH THE INSURERS. Yes, it may not make sense, but that's why it might be best to work for a local group before going off on your own, so that you have time to acquire your hospital privileges and be credentialed with the insurance plans. You can work under the shadow of the group while you set everything up. I would best recommend working for a hospital clinic or research project during this time, if need be, rather than a physician group, as the group may not take too lightly your forming your own practice and possibly taking away patients from them. If you think you need more experience after residency, be assured that you can acquire that on your own probably just as well as with a group or clinic. However, beware of RESTRICTIVE COVENANTS and lawsuits [It's the ugly side of medicine that we're mostly sheltered from during schooling and residency, but unfortunately, along with malpractice, it's out there. More on this later.]

IN RESIDENCY: 3rd/LAST YEAR

7) FORM A BUSINESS ENTITY. Yes, this is when you really start getting a flavor for what you're going to embark on. Once you do this, it's harder to turn back. If you're going into solo practice, I highly recommend a single-member Professional Limited Liability Corporation [PLLC]. Click here to read more about a PLLC. It is wise to have a business entity, such as a PLLC, in order to create protection for your assets in the future. Different states have different regulations, but in general, forming a PLLC has been made easier by new U.S. statutes. Your business entity can have any name you wish to assign it. Most doctors call themselves "John Smith, MD, PLLC," etc... Your business entity can also have a ["doing business as"] public name in the future, for example "Longevity Health Associates, PLLC". This may be a wise decision for marketing purposes. Each state has its own Department that handles the Articles of Organization for a new corporation. Look up the Department of State website for your particular state and inquire there. If you have any questions on which entity is the best for you to choose, consult with your accountant and attorney. If you don't have ones, now is a good time to start searching, because they are essential once you enter into the business world. [This is a good time in life to realize (if you haven't already) that it is important to network, meet people in different fields, and make friends with them, so they can be resources to you in the future, as you can be for them.]

8) APPLY FOR AN EMPLOYER IDENTIFICATION NUMBER (EIN) FROM THE IRS. An EIN is a federal tax identification number for your business. Generally, you will need this. Your accountant will use this number when filing taxes. You will also need to give this number to CMS as well as every insurance company you are a member of, for payment purposes. Click here to be taken to the online IRS application.

THAT'S IT FOR THE TECHNICAL STUFF. IN PART II, I WILL GO BACK AND LOOK AT HOW MUCH THESE STEPS ARE GOING TO COST YOU.

Another Layer of Bureaucracy....

HIPAA National Provider Identifier

We don't have enough numbers as it is, so on January 23, 2004 our Department of Health & Human Services published a final rule stating that all providers will need to use a new National Provider Identifier (NPI) to conduct HIPAA standard transactions (i.e. electronic claims, eligibility inquiries, claims status inquiries, etc...) by May 23, 2007. Wow! And I thought I already had useful, well-earned national numbers with my UPIN and PIN from the Centers for Medicare and Medicaid Services [which, by the way, took a year to obtain, because they lost my application]. How about all those other provider numbers I've been given by each insurance company to identify me within their network. No. Those aren't enough! Now we will have the mother of all numbers -- the NPI. And, I promise, no confusion whatsoever. This 10 digit number will supersede all others when conducting standard transactions with health plans.

Now when I call the insurance plans, oftentimes they don't know their left hand from their right. So, apparently this one number is the remedy to all problems. It will single-handedly improve the efficiency and effectiveness with which electronic claims are processed, because obviously the previous numbers didn't. So it makes absolute sense that the solution is replacing one number with another number.

Most payers must be able to accept NPIs by May 23, 2007. Smaller health plans may have until May 23, 2008 to get on board, because apparently they determined that if you're small, you need a little extra time. But remember:

Do not begin using your NPI until a plan notifies you it is ready to accept it.

I have a feeling that what we're going to end up with, is insurance plans using both the NPI and their own internal number to identify providers. This will not be seemlessly implemented. And probably will initially result in more confusion, and delayed claims, than help -- the same way that the ultra-modern new Denver International Airport baggage handling system flopped.

Nonetheless, being the rule-abiding citizen that I am, I have applied for my very own NPI, and you may too if you are a provider by going to:

Apply Online for an NPI

When did I sign away my privacy?

Last night I went to a pharmaceutical dinner, for which I candidly must admit I have a love/hate relationship. I like the networking, but dislike the implication that they're buying my scripts [which they never are]. As a solo practitioner [actually doesn't matter if you're solo or in a group -- everyone wants new business], one way to gain patients (especially when starting out) is to meet and create relationships with other physicians. We all know that is essential to a practice's survival; plus as a primary care physician you really need to get to know the people you are referring your patients to. I have a very high criterion for selecting those referrals: if I would trust them with one of my own family members, I will trust them with my patients. However, the point today is not networking, but how these pharmaceutical companies gain access to the quantity of prescriptions that I write. Unbelievable! They know how many prescriptions of _______ [e.g. Nexium] I wrote last month. It's almost like Santa Claus. They know if you've been naughty or nice. Haha.....or ho-ho-ho.

Yes, they actually can retrieve pooled data from local pharmacies and figure out how many of their prescriptions a doctor is writing, and compare the quantity to equivalent drugs in the same class. This gives the pharmaceutical representatives knowledge of whom to target, who to woo, and who to wine and dine extensively in return for their high prescription volume. This I have seen. It's almost like interest groups lobbying congresspersons and contributing to their campaigns in order to influence their voting behavior. It concerns me that this, along with speaking engagements, creates a financial incentive for prescribing certain drugs over others, without considering cost and which one is really best for the patient.

I'm curious to know why are they allowed to gain access to this information? I never signed a waiver giving them full view of my prescribing behavior. Should there be a waiver? And if so, should prescribing behavior then be made public, for the public eye to review any possible favoritism? Perhaps it's something to consider. Perhaps we should be lobbying our congresspersons to not allow drug companies access to this information.

Then you add the extra layer -- becoming a speaker for these pharmaceutical companies. You can't just go to a dinner and speak about their product. You actually have to go to their little "training camp" for doctors that want to become speakers and learn HOW to talk about their drug. Usually, these conferences end with the conclusion that the featured drug of the sponsoring pharmaceutical company is superior to the others in its class for such and such reasons. The data and slides are provided by the same drug company sponsoring the dinner, affording this conclusion. Usually negative data is obscured, or down-played. The speaker is paid an honorarium for discussing their medication in a favorable way. To many speaker's credit, I must say that not all speakers I have seen talk in magical tones about the featured drug of the evening. Some actually do provide a more objective view of the topic matter, but there are those who do not, and you have to wonder. Have we sold ourselves to the drug companies?

Let me say, returning to the opening line. I have a love/hate relationship with these dinners. They are educational programs. Most of the time one learns good new information from an expert that can be applied to one's practice. Oftentimes the topic veers away from just talking about prescribing and more into management, diagnosis, etc... Not to mention, it benefits patient care by integrating the network of physicians in the area. So there are good reasons for continuing to allow these functions. Congress did do away with the more flagrant abuses of influential money expenditures by the pharmaceutical companies by banning golf outings and other leisure, but non-educational, activities. I'm not sure that that accomplished much, except removing from the public eye activities that were more blatantly obvious attempts to buy one's prescriptions.

So what do you think? Should the drug makers be able to view a physician's prescribing behavior? Should it be limited to regional patterns, but not individual physicians? Should it banned all together? I think doctors should be asked for permission to access this information, so that they may have the right to refuse. Blindness to the number of scripts written per prescriber would force the pharmaceutical representatives and drug companies to focus more on the merits of their drug, and not on prescribing behavior.

Is the solo primary care practitioner a dying breed?

At least in the last decade, it seems that while specialists continued to profit, the primary care physician suffered from paycuts and a devaluation of their work by today's redefined insurance environment. Procedures are rewarded with money (i.e. high insurance reimbursements) but time spent face-to-face, counseling patients through the troubled waters of their overall health, is paid poorly. Every few months Medical Economics magazine has a new article about the bleak future of primary care. I peruse the magazine to stay on top of the business issues of running a practice, but often find it a bit morose and depressing. Frankly, I've learned more about the business of medicine by being in it, than by reading it in a magazine. If I had paid attention to everything they say, I probably wouldn't be in solo practice; in fact, I might be swayed to find another profession with a sunnier future. About 20-25% of family practitioners believe they will retire in the next 1-3 years. It's not just falling reimbursements, it's the continual battle to get paid. See Crazy Billing Analogies on the 10/16/2005 post at Medpundit. I couldn't have put it better myself. Apparently, our work has less value when it's bundled together on the same day. Whereas if it's done on separate days, it is fully reimbursable!?! When I get around to writing about billing, I'll show you possible ways around this. Yes, we have to use creative billing, or the insurance companies would gladly strip the value off of anything we do. Remember, they don't make money when they pay you!

Now the future may not be so great after all for specialists. Look at the Sept. 16 issue of Medical Economics with a story titled, Exclusive Survey: The earnings freeze - now it's everybody's problem. Median incomes are now failing to keep up with inflation across the board, because payers are increasing reimbursements by stingy numbers: in 2004, 1.5% for Medicare, 2.2% on average for other insurers. In contrast, consumer prices, a reflection of inflation and the power of your dollar, rose 3.3%. According to the Centers for Medicare and Medicaid Services, practice expenses, on the other hand, rose 4% in 2004. You do the math.

SO HOW DO WE MAKE UP FOR THE DIFFERENCE?

1) VOLUME! VOLUME! VOLUME! See more patients every day! See them till you drop! Multiply your daily visits by your current number [squared]. Yes, become a robot. Spend only 5 minutes with each patient. Sore throat? O.k. - Z-pack. Good-bye! Next. But honestly, how many patients can you see in a day before you start pulling your hair out (or losing it, for that matter), feeling dehumanized and compromising your quality of life, your philosophy of patient care and your availability to your loved ones? If you're like me, a balance is warranted.

2) Drop carriers that pay you little, and cost you and your office staff a lot of money. [Low reimbursement + Slow payments]/(Time on the phone chasing claims)= Lost money.

3) Acquire training in services that reimburse at higher rates than regular office visits, then offer these to your patients. Disclosure: I by no way endorse any of these programs or have any financial relationship to them, but I'm always getting brochures of this kind in the mail. One example is Empire Medical Training. There are dozens out there. To stay in business nowadays you have to be creative; you have to be able to market yourself.

4) Join an IPA (Independent Practice Association) - usually sponsored by a Hospital for its network of physicians. In exchange for a yearly membership fee, an IPA negotiates reimbursement rates as a whole for its physicians, thus having the pull of numbers to obtain higher reimbursements per CPT code than a solo physician could signing up individually with the plan. There is power in numbers! Being solo does not mean: be isolated.

5) If you're busy enough, perform tests in your office that you would normally send out (i.e. echo's, PFT's, Bone-densitometry, X-ray's, etc...). There are services now that assist you in doing this, and provide the skilled physicians to interpret the tests. It can be done, and it does not have to violate any of the Stark II regulations. If you're confused about this, consult your lawyer. If you don't have one, now's a good time. It's always good to have a lawyer friend or friendly lawyer on hand.

6) Have your mom or wife come work with you at the front desk. First, it's a salary that is actually coming back home, and second, it's a business expense to reduce your net income. Besides, doesn't mom bake the best chocolate chip cookies?

7) Outsource your billing to India. Hey, it's cheap! And they also have a pleasant accent! You could hire a team to badger the insurance companies so much, that they will want to pay you on time, just so that you will leave them alone! [In fact, just forget the rest. Let's just all band together and create a huge outsourced billing team in India!]

Call me stubborn, but I refuse to believe that the solo primary care physician is a dynasaur, waiting to become extinct. If you take away the mom and pop primary care office, you're basically stripping doctors of the right to free-enterprise that is continuously being challenged by today's rising and merging corporate powers. The same way that the president is supposedly working to protect small businesses, he (and hopefully she in the future) should recognize the need to protect solo physician offices from being destroyed by macro-economic forces. The same way that people have a right to medical care, so do doctors have the right to practice medicine the way they enjoy it, within the confines of accepted medical practice standards and ethics. So, don't be silent. Become active in your local and national medical societies. Write your congresspersons. Tell them that you will not tolerate cuts in pay, nor feeble raises in reimbursements that fail to match the prime economic indicator of the cost of living -- inflation. If they continue to do this, students will be dissuaded from pursuing a very rewarding [that is, in spite of the insurance conundrum] career in medicine. And secondly, doctors will never experience the most rewarding aspect of becoming a practicing physician in solo practice -- BEING YOUR OWN BOSS!

To Tell You the Truth...

Private practice found me -- not the other way around. However, being my own boss was probably engrained in my blood since childhood. Go ahead and ask my parents -- I was quite stubborn as a child. My Cuban parents came to this country as political refugees (please note, this is the correct use of the word "refugee" -- not to describe our own hurricane-ravaged citizens, displaced from their homes within this country). That was many years ago -- 1960 to be exact. And my father initially was not his own boss, but he had dreamed of it for years while working for the international elevator company, Otis. When my dad was in his early 30's, Castro took over our homeland and smoked it up real good! My father had attempted to start a company, but had to abandon the efforts due to the rapidly changing political climate. Approximately 10 years later, he got to live his dream. Having returned to the U.S. after a sojourn in several Latin American countries, he established his first elevator installation and maintenance company in the same month I was born. Whereas most small companies fail in the first five years, that company, and two others he started thereafter, thrived for the next 31 years, at which time he sold it.

That was a year ago. My dad was selling his life's work, and I was about to begin mine. The opportunity to open a private practice in Internal Medicine fell upon my lap. As a resident in training 2 years prior, I had never given any thought to the possibility of running my own private practice. After all, they don't teach you entrepeneural skills in medical school! We're only supposed to take care of sick people, right? In fact, the ensuing institutional mentality of residency made me think that as a doctor you have no choice but to work for somebody else, be it a hospital network, a clinic or established practice. No one seems to talk about hanging your own shingle and starting from scratch nowadays. The task seems almost implausible and quite daunting if you have no business sense. At the time, I was the product of that thinking, working first in a research project for a year following residency, then selling my soul (as it came to feel) to a large group practice that operated more like a factory than a doctor's office. I was assimmilated as one of many pawns in that multi-million dollar operation, but learned a great deal in the process. It was the latter experience that opened my eyes to the potentials of private medical practice.

Rather than ferrying patients through like cattle, as I dutifully did previously [and yes, at times, it felt like a cattle-call, calling 3-5 patients back at a time]-- with the endless stream of complaints from patients frustrated with the process, I knew I would enjoy a different patient care paradigm. This is not a criticism of that system, more so an insight into who I was. It was simply not the way I wanted to practice medicine. After all, I had become a primary care physician to care for people, really get to know them, and form enduring physician-patient relationships. That's what medicine was all about for me, especially when choosing to pursue a career in primary care. Having decided that in spite of the alluring salary, this would not be my life, I was simultaneously mortified and delighted to hear from one of the partners, after 9 months of employment, that they would not be renewing my one-year term of employment. As Martha Stewart says on her version of "The Apprentice," I simply "did not fit in." It was the catalyst I needed. I was simply not willing to compromise my values in patient care. The truth is that as distraught as one may have been knowing that they were losing their job in another 3 months, after the initial shock wore off, I actually felt a sense of joy inside. This was the sign that I was on the right path. The possiblities were greater than working for somebody else. Now I had no choice but to charge forward into my future.

Two months prior, that future had made itself known to me. I had called a former colleague from my training hospital who had been chief resident during my first year in residency. He had recently completed a specialty and had opened his own private practice. I wanted to pick his brain for advice. It was more than just advice I got. It was the opening of a new door -- new possibilities. He explained to me how everything could be done, and helped lead the way to my new path. While the main initial worries were obtaining hospital privileges, becoming credentialed with the major insurance companies [a very, very long gruesome and annoying process taking anywhere from 6 - 12 months; but more about this later], and obtaining the funds to finance the start of a new business [Yes, a private doctor practice is a b-u-s-i-n-e-s-s, and must be thought of as such!], nothing could be put into effect without a physical space. In our city [to be revealed later], medical office space is scarce and expensive. Albeit, I began the process of calling the major insurers, applying for privileges, and trusting that things would somehow work out. The funding was resolved with part loan and part angel investor. Starting off required a full-year's predicted expenses in loans. Wow! I had never dealt with that much money all at once. My heart nearly jumped, but a voice inside kept telling me this is it. Things seemed to be moving in the right direction, even when the road became quite bumpy. Luck was on my side! What is luck anyway(?), but the meeting of opportunity with preparation. I would say it was more opportunity first, and preparation that scrambled to catch up! It took a lot of hard work and preparation to reach that day doors opened for business. If capital were the only thing one needs to start a practice in medicine, then it would have been very easy. Determination, planning, flexibility, adaptability, and a willingness to keep going when things didn't turn out the way one expects -- the same character qualities that kept me going through premed, then medical school, then residency -- were being called into action once again to fulfill this dream. Perhaps an M.B.A. would have been useful, if I had the forethought. But there was no time to waste anymore. The time was ripe. The time was now!!

And as if I didn't have enough to do, I was busy certifying as a subspecialist in acupuncture as well. To top it off, my first child was on the way. Sometimes one's plate is FULL. Mine was OVERFLOWING!!! Nevertheless, tackling so many things at once is what you do when you're following your dreams. As scary as it was, I wanted to have my own practice so that I could create a venue of care that reflects my personality, philosophy of integrative medicine and the strong attention to quality of care I learned in residency. It was the freedom I was looking for.... [MORE TO COME]

Please keep tuning in for the next installments in The Solo Practitioner.

This blog is meant to show a path of possibility to those who have thought about opening their own practice, but have yet to put it into effect. It's meant to open the eyes of those who have never thought about it. And it's meant to share common and unique experiences with those that already have. Medical students and established doctors alike will find it fascinating and educational to read about my specific trials and tribulations in starting a private practice and my recommendations on what works and what doesn't work. I welcome you to continue to tune in as I write about my first year's experiences and what I have learned from them. Your feedback is encouraged and appreciated!