Rivulets make a river

After returning from a two-week vacation and finding his coffers almost empty, my FP buddy Jeff was feeling glum about his bottom line. “You just can’t make any money in family practice with what insurance companies pay us these days,” he proclaimed.

“Balderdash,” I said. “Family physicians are in an ideal position to prosper because, unlike specialists, who wait for referrals and have a limited scope of practice, we are able to see anyone who walks through the door. Of course, we can’t treat everyone, but we can take care of most folks and refer the rest. Maybe you need to start thinking differently about who else you can see besides patients with acute and chronic illness.”

I rattled off a few examples: department of transportation physicals, workers’ compensation for minor injuries, pre-employment physicals, annual exams, insurance exams, collections for mandatory drug screenings, sports physicals, allergy shots, immunizations, house calls, nursing home visits and flight physicals.

“I also think we should each develop a niche,” I said. “Mine is wellness medicine, but I can easily see yours being office dermatology or a sub-specialty area such as thyroid disorders or diabetes – or you could become an expert witness in court – or try them all. Remember, rivulets by themselves may not mean much, but eventually they form a mighty river.”

A few weeks later, he got back to me. “I’ve found another rivulet!” he said. “I just got a check from the AAFP for reviewing an upcoming monograph. It was fun and intellectually challenging, and I think I’ll get to do more of them.”

“Great work,” I said, “I’d be proud to call you my protégé.”

Patients bearing gifts

Mabel appeared in the office on Friday with a sore throat that looked like strep. I see pharyngitis so often, I’ve developed a spiel to deal with it:

“Mabel,” I said, “I don’t know whether you’ve got strep growing in there, and there’s no way to tell for sure without a culture. If I do the culture, it will take 24 to 48 hours to get the results and we’ll have to delay treatment that long, but we won’t lose anything by waiting. Your throat will hurt for a week with or without antibiotics. If we start treatment today without a culture and with the presumptive diagnosis of strep throat, you’ll have to take a full course of antibiotics whether or not you need them. If it turns out that you don’t have strep, you’ll have taken antibiotics unnecessarily, which can be harmful. You decide.”

Mabel chose to wait for the results, so I did a swab, sent it off to the lab and suggested she get some lozenges in the meantime.

I always mark “call report” on my lab tests, and the techs know that means not just on weekdays but on weekends and holidays too. Saturday morning, Marcia, the tech, called to let me know that Mabel’s culture was positive for strep pyogenes. I left word on her answering machine that I had called in a prescription.

Today, Will, her husband, came in for his wellness exam follow-up with a jar of Mabel’s homemade apricot-pineapple preserves. “She really appreciated you dealing with this on your day off,” he said.

“Will,” I replied, “Let’s schedule Mabel’s next lab test for Christmas day. This stuff looks delicious!”

Helter skelter

A relatively new specialist in town recently asked Isabel, my office manager, to give him a hand in setting up his practice, as he had no staff of his own. It also turned out that he had no idea how to set up an office. There was no computer in sight when Isabel arrived, nor was there an obvious place to put one. He had been seeing patients without registering them and, consequently, had no way to bill. Appointments were made through an answering machine; patients would call and leave a message, and he would call them back, recording their appointment time on a scrap of paper. Office notes were kept in an expandable file. There were no super-bills in sight, but with some digging, he was able to find some HCFA-1500 forms. There was, of course, no way to use them.

As nature abhors a vacuum, Isabel abhors disorganization. She gets upset when her desk gets cluttered. “Look,” she told him, “this is what you need to do,” and she proceeded to give him a crash course in Office Management 101. He listened distractedly, probably hoping Isabel would do it for him, which she wouldn’t. She did give him some of our superbills and registration forms to copy and admonished him to have a computer there ready to go the next time she showed up.

“You can do it, Isabel,” I said, trying to encourage her. “You can save this doctor’s life! But remember, you’re only out on loan.”