PRACTICE DIARY

Chapter 35

 


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Fam Pract Manag. 2002 May;9(5):66-71.

Taking advantage

Susan, a person who ranks somewhere between friend and acquaintance, called Sunday morning for what I knew from the get-go was going to be a favor. “I hate to bother you on a weekend, but … Jake has a terrible case of poison oak. It’s all over his body, even on his genitals.”

I was already three steps ahead of her, anticipating being asked to call in a prescription for her son, who was not even my patient – nor was she. I’d been down that road many times before and always wound up feeling used. If she had wanted my advice on, say, what kind of mountain bike to buy for Jake, that was one thing, but prescribing was what I did for a living. Didn’t Jake have a doctor, or did she not want to inconvenience him on a weekend, or not want to pay for the service? After years of being hit up for advice like this, I really didn’t care.

“Susan,” I said, “Who does Jake see for medical care?”

“No one, really. He always has been healthy.”

“Did he ever have a sports physical for school?” I asked.

“Well, I guess he had one several years ago with Dr. Mahon.”

“Then call the hospital operator and ask them to page Dr. Mahon or whoever is covering pediatrics this weekend. I don’t feel comfortable prescribing for someone I don’t have a chart on and who isn’t an established patient.”

“Oh,” she said, feigning surprise, “I didn’t know I should do that.”

“The reason doctors take call is for predicaments just like this,” I said. “If it doesn’t work out, let me know and I’ll meet you at the office, register Jake and take care of him. But I will have to bill you for the visit.”

She never called back.

Low overhead

Assuming physicians are efficient in their billings, there are really only two ways to make money in this business: increase patient flow and decrease overhead. Since it’s easier to control costs than the number of people coming through your door, I’ve always felt the key to a winning bottom line was in limiting expenses. I’ve succeeded by having only one employee for all the years I’ve been in practice and, more recently, by eliminating the other major practice cost: rent.

Many years ago, when I was searching for a medical space to buy, I had an inspiration. Why purchase a medical office building when a building designated for commercial or residential use would give me more flexibility? After all, people always need a place to live, but some medical areas are overbuilt and offices can at times be difficult to lease out. I took it one step further and bought a four-plex apartment building with a partner, took one apartment for my office, rented the one above me (to very quiet tenants who worked during the day), and split expenses with my partner, who was responsible for the other two units. Over time, I overpaid my monthly payments as my circumstances allowed (such as when I shared my office with another physician who paid me rent), eventually paid off my half of the building and bought out my partner. My current rental income is in excess of my payments and allows me not only to have a free workspace but to pay my building’s property taxes, insurance and utilities as well.

In another year and a half, the entire building will be paid off and I’ll be able to use the money I’ve been paying toward the mortgage to cover my employee costs and most of my other expenses. I am imagining having a medical practice with almost no overhead. It doesn’t get much better than that.

Search and rescue

In an effort to legitimize my off-road motorcycle riding, and in the spirit of giving something back for all the trails I’ve torn up, I joined my community’s search and rescue team. This eclectic bunch of men and women, made up of police officers, shopkeepers, homemakers, some professionals, a few teenagers and several senior citizens, trains and comes together whenever necessary to find missing people, dead or alive, in the woods or in the ocean.

So far, I’ve been out twice. The first time was a search for a presumed homicide victim. He was found the fourth time the team went looking for him, and even though he had been dead for almost a month, there was the excitement that comes with a job well done. The second unfortunate chap had gotten tangled in the kelp and drowned while free diving for abalone. Our divers found his body the next day. It was a sad occasion, but at least his family had closure.

I am finding this type of activity rewarding and am particularly enjoying working collectively, which is something I don’t get to do much as a solo physician. In addition, I am looking forward to using my knowledge of the woods to help find a missing person who’s still alive, perhaps a hiker who wandered off the path or a mushroomer who lost his way. If we physicians are in the business of saving lives, then search and rescue seems an entirely appropriate use of some of our spare time.

Mentors

Bud was an internist specializing in infectious diseases while I was a medical student in the same city in the 1970s. He had been an academic physician after his residency – one of the young Turks at the university –but time and politics had soured him and he had dropped out of academia to pursue the greener pastures of private practice. In addition, he ran a community burn center, consulted at just about every hospital in town, did his own immunological research and had written several manuals on critical care. He also had a reputation as a maverick, which suited me just fine.

In the month we spent together, I collected two speeding tickets while attempting to follow him through town on his daily rounds, saw four cases of septic shock, attempted vainly to write a how-to manual on renal dialysis (at his request), and read a lot of his writing, including an article he had collaborated on with a patient who was a Joycean scholar whose central thesis had been that in the book Dubliners, James Joyce was analogizing Dublin to a patient with tertiary syphilis. Bud was a Renaissance man.

He was also way ahead of his time. A full 30 years before the Internet and search engines, he said to me one day, “You know, Sandy, we should be putting a review article of every patient’s diagnosis onto their hospital chart for the edification of nurses and house staff. Patients should have handouts to explain their diseases as well.” He was, even then, into the demystification of medicine and patient’s rights.

At the conclusion of our time together, he asked me where I was going to intern after graduation. “Actually, I had been thinking about going into preventive medicine and not practicing,” I said.

“Why do you want to do that?” he asked, incredulously. “Didn’t you see how much fun medicine can be? Don’t throw away your clinical skills. Go get yourself a bloody boots internship and go out and practice your healing art. You’ll love it, and besides,” he said, with a twinkle in his eye, “you’ll be rich.”

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.


 

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