Alchemy In Medicine: How One GI Doc Spun Turds Into Gold

crispydoc Uncategorized 9 Comments

Image above is a 2000 year old child potty trainer from ancient Greece.

Accepting turds as a fact of life from an early age prepared me well for a career in medicine.

Growing up, my father and great uncle built a small outdoor aviary in our back yard, where we raised tropical finches and quail that we sold to pet stores as my father’s side hustle.

In grade school, I entered the aviary (the size of a modest bathroom) twice weekly as dad’s helper to feed and maintain the roughly two hundred birds that called it home.

I learned quickly that hats were a necessity, because turds dependably fell onto my head from the heavens.

When I became a physician, universal precautions could not protect me from the technological and bureaucratic feces that showered the practice of medicine. Electronic Health Records? Computerized Physician Order Entry? Press-Ganey? JCAHO? Sure, these turds went disguised by more elaborate names, but having endured such offenses since age eight, I brushed them away and labored on.

What I did not realize is that, rarely, the turds that are dropped onto our heads from the great bird of health care occasionally contain a golden egg. To understand this alchemy you need only approach it from the correct perspective.

A case in point is a friend we caught up with recently, a gastroenterologist in a town where the single university hospital is the local 800 pound gorilla that all physicians are forced to reckon with.

Let’s call my friend Dumplestiltskin.

Dumplestiltskin joined a private community practice out of fellowship, and a few years later he invested with his partners in new construction on an outpatient endoscopy center.

The goal was to avoid leaving money on the table by being able to charge for facility fees, and exchange outdated hospital facilities (which the university refused to replace) with state of the art suites.

Additional benefits for patients would be cost reduction for their patients, since hospital facility fees exceed outpatient facility fees. Benefits for his group included the ability to hire staff responsive to their needs.

The university hospital was not amused by the prospective loss of revenue and turf, and insisted that my friend’s group halt construction of the private endoscopy center or risk losing their hospital privileges.

Dumplestiltskin and his partners chose not to capitulate, and surrendered their hospital privileges.

Another turd soils the downtrodden GI doc, right? Not exactly.

My friend and his partners thought through the consequences of losing their hospital privileges. Their group is highly sought-after by patients for personable providers with impressive educational pedigrees who give excellent care.

Furthermore, Dumplestiltskin’s smaller and nimbler group offered a human touch that no large bureaucracy could match. Need a last minute appointment? How’s this Friday at 4pm? Need an urgent appointment via the university behemoth group? How’s four weeks from now?

Loss of hospital privileges would eliminate the need to provide consults on admitted patients. In addition to making weekdays end closer to schedule, it restored nights and weekends as seldom interrupted family time.

Call went from a dreaded reality to a minor inconvenience, since it was conducted entirely by telephone. Those patients sick enough to require admission were seen by the university gastroenterology service, hospital employees who now exclusively shouldered the burden of the ED call panel.

Had the practice been in sink or swim mode, losing hospital privileges might have dealt the group a fatal blow. Instead, it quickly made my friend’s job the best one in town.

His group became GI proceduralists who never entered the hospital, mostly slept through the night, and were in demand more than ever.

Before you resign yourself to the latest turd that falls from on high, take a moment to glove up and sift through the details. You might just find a golden egg buried within.

Or, as Arthur Miller so memorably put it in Death of a Salesman:

“The jungle’s dark, Willie, but full of diamonds.”

Might he unknowingly have been describing a GI practice? You decide.

Comments 9

  1. How could I not click on that title?

    It sounds like your friend played those moves well.

    I have been in the few situations like that over the years. All I can say is in the end politics are infinitely more important than pedigree or patient interests.

    In some communities and specialties becoming independent is the best route. They capture 100% of the smaller pie that they control.

    Other times, it is best to collaborate with the gorilla.

    Offering a 50% ownership sometimes provides a better outcome. Even though the physician group receives only 50% the pie- it can be much larger because of business from other specialists or from better insurance contracts and rates. The devil is in the details.

    Nevertheless, I love these kind of inspiring stories. We need more courageous physicians who are clear on what they want and who create a life that fits their needs.

    We can say No and still live! Fear should never be the primary driver for making these kinds of big decisions.

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      Interesting observations, WD. It’s hard for me to read if it’s the cynic or the experienced grizzled veteran concluding that politics wins in the end. Perhaps both. Independent tends to work with models where you control your destiny (think Doc G from DiverseFI working as a concierge physician). The volume benefits you discuss I’ve mostly observed when a specialist group contracts with an HMO to ensure referral base – great for a struggling newcomer making their name in a competitive niche, less beneficial to an established group.

      I do tend to appreciate the Davids who show firm resolve in the face of Goliath’s demands and end up coming out ahead in the end.

      Thanks for stopping by,


  2. You’re singing my song. We were “Anesthesia” at my hospital for 18 years until the hospital brought in a suite of Blackstone affiliates to cover ED Hospitalist and Anesthesia and maybe Pathology. We were invited to stay with every other night call, as they were severely under-staffing aka maximizing profit, so they wound up with a bunch of fresh grads running anesthesia, including fresh CRNA, total s-show. A surgery center was being built by local PO’d surgeons since the hospital admin got into a “contest” with Blue Cross over contracts and Blue Cross decided to make an example of them to the rest of the State and pulled out. Our surgical volume dropped 20% over night at the hospital. My partner and I took over being “Anesthesia” at the new place when it opened. 10 of the 30 surgeons in town were owners so the hospital couldn’t exactly kill the privileges of 1/3 of their surgical staff and still be a hospital especially with the Blue Cross hit on surgical volume, but they did try EVERY road block. No matter, we opened and took an additional 30%, the paying 30% of their volume. My experience was similar. My partner and I were “Have laryngoscope will travel, wire Palidin” kind of mercenaries so if you had a broken wrist, and were NPO let’s fix that sucka! The surgeons loved it because it gave them control over their schedules and we were extremely efficient. We could do 3 knee scopes and have them in recovery before the hospital could get one asleep. No call. No weekends. We controlled the flow such that staff didn’t burn out. A near turd-less life. Eventually MBA’s got involved and the process turd-ed up rapidly. First my partner quit and I was 6 months behind him. The problem with Medicine is MBA’s.

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      Gasem, you are my favorite chess player when it comes to the strategy of the business of medicine. Reading your historical playbook is like watching the 800 lb gorilla get rook rolled by the underdog.

      1. Jui -Jitsu means “soft art” and is a marshal art that redirects a hulking opponent’s momentum against himself. You just kind of encourage the self destruction. The CEO got his BS in P.E. Typical bully but not the sharpest knife in the drawer.

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    2. “The problem with medicine is MBAs”..


      To which I would only add….
      “the problem with medicine is multiplied by clinical staff that no longer want to do clinical medicine”….(think “clipboard nurses” and docs who were pretty bad at patient care who are now administrators)

  3. That is a great example of physicians not caving into the system and developing a practice that is highly desired.

    A lot of doctors living paycheck to paycheck may have caved in for fear of losing any income and not being able to pay the bills.

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