Primary Care Business Owner Wants To Cut Back (2 of 3)

crispydoc Uncategorized 4 Comments

In our first installment, we determined that Dr. PBO's journey to Financial Independence (FI) needs to begin with an assessment of his starting point, his destination, and consideration of the vehicles he intends to use to arrive at FI.

Variables Largely Within Your Control

It can be surprising to realize that despite feeling stuck, many of the variables to improve our work-life balance are largely within our control.

There may be a steep initial investment of time or element of risk that make fewer of us inclined to leverage these variables, but let's review them all the same. They are not easy to change, but the outsize rewards often justify the effort.

Spend Less

I agree! You deserve a kitchen that is not equipped with vintage linoleum and the finest appliances 1965 had to offer. But you also deserve to be much happier, and you get to decide which ranks higher on your priority list.

You may decide, as we did, that you'll spend to arrange help at home and family travel but strategically reduce your car budget (as my 2009 Kia Rondo, bought used, will attest).

Or not.

The key is ensuring that your spending aligns with your values.

You may be surprised to find who else is in your corner. At one of my lowest points, during a family discussion, my elementary school-aged daughter told me that while she loved our home, she would support downsizing if I could not be happy continuing to work in medicine.

I'll leave it to you (and those affected by your decisions) to painstakingly figure out what to cut.

Remember that your cuts may not prove acceptable to your partner. You'll need to listen and negotiate cuts that work for both of you.

Earn More

Doc G from DiverseFI and the What's Up Next? podcast is a primary care doc who opened a concierge medical practice and earned a generous income doing it. He then pivoted to in-home and nursing-home based concierge work, cutting his overhead drastically while keeping his most remunerative patients. This endeared him to nursing home adminstrators and staff, ultimately leading to his position as director of a hospice program that nicely dovetailed with his existing patient population.

Where I live in LA, there are burgeoning concierge pediatric groups. Perhaps Dr. PBO could start one with a like-minded partner or a young and hungry doc, or join an existing concierge group if there is one in the area.

Alternately, Dr. PBO could identify an unmet need and innovate like Dr. Jay Parkinson, who started out with a "coffee house" practice serving a lot of young and healthy uninsured patients in Brooklyn and developed an expertise in steering those patients (who pay in cash) to affordably-priced cash medical services for further diagnostics as needed. He went on to pioneer virtual primary care practices before telemedicine was a thing, using app-based interactions that often minimize office visits.

Correct Mistakes

Life is a choose your own adventure.

A given physician can:

  1. Buy a doctor house
  2. Buy a doctor car
  3. Send the kids to private school

Notice there is no "d. All of the above."

So if you chose "d" only to find out a few years later that "d" wasn't an option, that's okay, you are in excellent company.

While difficult, you have the luxury of time and a relatively generous physician income to overcome your mistakes.

Sell the doctor house and instead rent or purchase a right-sized home, preferably in a school district where junior can attend reputable public schools.

If your spouse or partner stays at home, consider when or whether it makes sense to have them re-enter the workforce to contribute to the household income.

There's a great chapter addressing just this issue in the latest WCI book.

Buy Some Help

Charting appears to be the bane of the primary care physician's existence.

Great news, Dr. PBO! I've found a job exactly like your current one, except instead of doing your own charting, you'll have a scribe.

It pays less, but instead of coming in to chart during your entire "day off" you'll only need to spend an hour or two to catch up.

Sound appealing? Ask around to find a clinic (or emergency department) in your community using scribes, and spend a single day shadowing the most productive physician in that group. Inquire about their tips and tricks to get the best value for their dollar.

How can you justify this cost on a pediatrician's income? After all, none of your partners would willingly shoulder such an expense!

Since your current job is untenable, moving to another one where you do not have an ownership stake will inevitably reduce your income, as will leaving medicine completely due to terminal burnout.

If hiring a scribe means you can continue to work at this job 5 or more years instead of 2 or fewer, the math says that's a win. Sometimes reframing your situation can help what initially looked like the least bad option transform into the tenable option. The Happy Philosopher, a fellow physician finance blogger, took the full-time job that made him miserable and turned it into a part-time job that met his needs.

Put Yourself Under The Microscope

Another variable within your control (and I in no way seek to blame the victim) is determining if you can further improve your efficiency.

One of my metrics, door to disposition time for patients discharged from the ED, seemed to be lagging that of my peers during a busy winter when our ED was overwhelmed.

I contacted the fastest group member in this metric and asked to shadow him for an hour on a day I was off duty.

Turns out on busy days when techs were swamped, he'd personally walk patients from the waiting room to the restroom, collect urine specimens and hand them to a tech or nurse for dipping. He also personally wheeled patients unable to walk due to ankle injuries (i.e., who obviously needed x-rays) from the waiting room to radiology.

I adopted some of his techniques and my metrics improved to remain in the top third.

I subscribe to growth mindset. I haven't yet become one of my group's faster docs, but as far as I'm concerned that's attributable to insufficient practice rather than a deficiency of talent.

Perhaps your charting is already efficient and this is irrelevant, in which case I apologize.

We've offered Dr. PBO some ideas for changes he might make that are within his control. What if he's already taken these steps? What if burnout has left him needing to effect changes in the way his workplace functions? We'll explore those more difficult challenges in our final post of this series.

Comments 4

  1. In all of this one theme emerges, parsimony. In the case of the Dr House Dr Car Private schools, the physician is not parsimonious but living outside his means, a fundamentally dishonest and self destructive way to live. I’m not arguing a right to live a self destructive life, just calling a spade a spade. Living a right sized life is in fact a parsimonious life. In the case of creating a job you can survive in without burning out, the same honesty is necessary in order to achieve a right sized work load.

    In a capitalistic society it’s up to the individual to create the mechanism of survival, not the collective. The most effective ER doc understands the choke points and applies a dab of lubricant personally, not waiting for the inefficient collective to lumbar along to a one size fits all industrial conclusion. If the lubricating ER doc is rewarded for his ingenuity, suddenly all ER docs will become lubricators without need for coercion. The incentive needs to needs real, not just a ham sandwich since physicians are notorious for selling out for a ham sandwich. In the case of a scribe the incentive is a day off, presumably a paid day off since the money is likely split. So what’s the incentive? The cost of the scribe is less than the benefit of the day, therefore the scribe is the parsimonious choice. Parsimony itself can become a task master. It’s use is to right size choices to what is essential. It’s use is not to hyper maximize choices with relentless diminishing returns. It’s probably a Pareto principal subscriber where you realize 80% of the gain 20% into the change and eking out every last percent is not a parsimonious activity. Once right sized, a system will seek it’s own right sized equilibrium without force.

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  2. Great suggestions CD. The scribe one I am sure is an interesting dilemma. It obviously will come with a decent cost but as you said in the long run if it can prolong your career it may indeed be the best financial move.

    I am very fortunate on how my specialty operates. For me everything is voice recognition and done in real time while evaluating a study. I also took a lot of up front time and created an extensive list of macros which I can then verbally summon and sign off immediately or make minor alterations to fit the study.

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      Long-term gains are the key.

      The macros are a huge win. We use dragon dictation and similarly, using the same 4-5 templates, I can gain efficiency in my documentation that was formerly incredibly difficult to acheive in the ramp up period as we learned the new system.

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