“Why is that America’s Best Places to Work NEVER include a Doctor’s office? You can’t afford for your staff to burnout. But, you can’t sacrifice the organization for one person … even if they do feel like family. [Concierge] Medicine is about doing something different, not doing the same things you’ve always done. If you’re too busy [in your practice] to not exercise good judgment when it concerns your staff, you will catch the shrapnel of their bad decisions. To which we say ‘as they go, you go …’ ” ~2017 CMT Concierge Medicine FORUM, Atlanta, GA USA | Oct. 27-28, 2017
By Michael Tetreault, Editor-in-Chief
In the past month alone, I’ve had several conversations with about eight to ten Physicians in Concierge Medicine that were discussions primarily centered around staff.
Whether it was a ‘thank you!’ from a Physician about a recent story we published or a question, comment or a concern, the issue of staffing is one that plagues every medical office, every business and every employer. Concierge Medicine is not exempt from these challenges as many Physician’s can attest and will relay this October in Atlanta at the 2017 Concierge Medicine FORUM (Oct. 27-28, 2017) — click here to learn more about our 2018 dates/schedule >>.
As we unpack this complicated topic you should understand that you are not alone when wrestling with these issues inside your practice. The business of medicine isn’t easy. It is interesting to note that our culture in business today … more or less shames business owners for having these struggles inside a company. ‘You didn’t know this was happening in your business?’
It is even worse for Physicians on an ongoing basis.
This article today is about revisiting an important topic and exercising good judgment on a regular basis. It is not about drawing harsh conclusions about the daily delivery and operations of a complicated healthcare practice and what it should or could look like.
“Business is tough,” says Dr. Chris Ewin of 121MD in Fort Worth, TX. “If you are doing something just for the money, you are never going to enjoy it. You will be the hardest boss you have ever had. So, find something you love and pursue it. Follow this advice and you will set yourself up for an enjoyable future in medicine.”
We recently asked [Summer 2017] our Concierge Medicine Today and DPC Journal Physician Readers the following question ‘How many business education hours [or #er of courses] did you take in medical school?’
- 70% said … Less than 5 Business Edu. courses.
- 25% said … Less than 20 hours of Business Edu.
- Less than 5% said … 30+ hours of Business Edu.
“Two notable observations we encountered throughout our entire [Top Doctors in Concierge Medicine, 2017-2018] review process was related to patient comments received prior to transition and staff issues— which seem to plague most medical offices, even those inside the four walls of a Concierge Medicine practice,” said Tetreault. “A physicians reputation in the public and online is dramatically different from the patient reviews they may receive prior to a physicians entry into Concierge Medicine vs. after the conversion. Many [physicians] go from zero to hero in the eyes of their patients in a matter of weeks or months. We have also noticed that the physicians staff and their individual attitudes towards patients still remains a sore spot among the doctor’s and patients concerns. Even post-transition, when physicians are well into managing their Concierge Medicine members … managing staff inappropriately can impact the clinic’s annual patient retention and ultimately, their bottom line. However, it is amazing what can be accomplished when Physicians walk this healthcare delivery process out and into their own communities. It is only now, that when we are able to look back and track these dramatic career moves of physicians that we see why so many patient experiences make so much sense.”
Here’s another true, anonymized example that we received this summer which I think provides a lens of clarity for our readers which is undeniable. It is a polarizing example that you may relate to and I hope many reading this, will learn from. After pondering, look inside the four walls of your own practice and see if this is happening to your patients.
“… she was going to a doctor who she loved, but did NOT like the staff as they were rude, lazy, etc. She had an appointment with her doctor and the Doctor was there [inside the office building]. But, she was sitting in her car. She just didn’t want to face or deal with the staff’s rudeness. Her doctor actually called her asking if she forgot about her appointment or was running late. She replied “I’m here, sitting in my car”. Then went on to say “I don’t want to come in because of your staff and how rude they are …” The Doctor replied “I will be right there.”
Your Staff, whether you believe it or not, influences the direction and quality of your practice and can shape the experience(s) [for better or worse] that patients have in the practice/program. Whether you have a small, family-like atmosphere with friendly staff whom you’ve known for years or multiple new hires that come and go … all of these people are all moving the direction of your practice, your reputation with specialists and ultimately, your influence with patients along a certain path. The question for you is, is this the direction you want to go?
Patients are hesitant to complete surveys they receive from medical offices, even it is labeled anonymous. They are afraid it will impact the relationship with their Physician. They are afraid it will negatively impact the care they receive in the future. And, finally, they are afraid if they speak up, it will impact their bill. It is hard to find a good Physician these days who is accepting new patients, spends the time necessary to gather all the facts and has empathy for their Patients. Patients are afraid to speak up and tell their Physician that they are having an issue with a member of the staff. They fear that it will ultimately result in the Physician’s dislike of them personally and possible termination from practice.
This is what our healthcare marketplace today feels like for millions of patients every single day. That’s why what Concierge Medicine and other healthcare delivery model variants are accomplishing with time … is so invaluable and critical to our ecosystem today. Concierge Medicine is about doing something different, not doing the same things you’ve always done.
For example, a long-time patient of a medical practice (15-years +) walks into the same office one day and learns that the dental hygienist they’ve come to enjoy seeing has moved onto another position. Now, a new member of the staff is hired and the replacement is unfriendly, direct and derogatory towards the patient.
Does the patient say something? Will it impact the relationship with the practice? Will it impact billing? Worse, could speaking up impact the future of the care they need? Remember, the patient likes the doctor but dislikes the staff.
Let’s pick up where we left and see how the story ends.
He [the Physician] went outside to her [patient] car and personally escorted her into the office/practice. When he entered the office, he terminated his staff. He said “this one patient is worth more to me than my staff – you’re fired.”
This may sound extreme. And please note, this is an example of what one Physician did. This story is not intended to provide or render a recommendation or legal advice. You as the Physician or owner of the medical practice should exercise good judgment. That may mean you first consult with your business advisors and if necessary, your own legal counsel to deal with challenging staff circumstances.
With that disclaimer, if you don’t exercise judgment when it comes to your Staff, are they moving your practice in a direction you want it to go? Can you be yourself with your staff or do you have to pretend you are someone you’re not? Do you often feel pressure to give in to vacation demands or personal issues because of the family-like, office dynamic which exists in the practice? How often do they take advantage of you, your generosity or your forgiveness? Do you have an employee in mind that you wish now you’d never met? Do they get along with your husband or wife? Are they nice to other people’s children? What do they wear to work? Is it appropriate? What are they saying about you [or your practice] online?
We don’t hear enough input from Patient’s because they are telling us that they are afraid to speak up …. actions have consequences and they are frightened that the Doctor [or worse yet, staff] will somehow penalize them for it. Sadly, this is the reality of our healthcare marketplace today.
Now, we all know it is not all bad. In fact, I can show you more healthy staff environments in healthcare than I can find bad ones. But, maybe, it’s time to establish some clear boundaries with your staff. Don’t get me wrong, Staff can be useful. Staff should be helpful. But, if you’re not exercising good judgment, you will catch the shrapnel of their bad decisions. To which we say ‘as they go, you go …’
“If I’m paying any amount of a monthly [or annual] subscription to see my doctor, you better know my name when I arrive and I sure shouldn’t have to tap on the glass when I walk-in. And please, move the phone to the back of the office so I don’t have to hear your staff calling in prescriptions or making specialist referral calls.” ~M.C., True Story, Actual Patient, (C) Concierge Medicine Today, 2017
It’s quite possible that this Physician in the story above had no idea that his staff was so rude to Patients. It is important as a Manager and Physician Owner/Operator to listen to how your staff communicate by phone or in person with Patients. If a Staff member is talking about one patient, it most likely doesn’t begin and end there. It is probably a repeated pattern of talking about other Patient’s as well.
Where your staff are heading is a good barometer of where they are leading.
We’ve receive input from real Concierge Medicine Patients each day. They share with us some of their experiences. For example, did you know that air quality inside their Doctor’s office is VERY important to them? Actually, it ranks at a whopping 4.5/5. When Physician’s were asked a similar question, they ranked the air quality in their office at a 2.3/5.
“Patients were skeptical and reluctant because of how accessible and convenient the service was. They expected to be kept waiting on hold. Some seemed puzzled by the fact that when they called I answered the phone and knew who they were. One patient even inquired as to how come they only had one form to fill out.” ~Raymond Zakhari, NP and CEO of Metro Medical Direct, New York
So what do Patients inside Concierge Medicine programs want to see from a Doctor’s staff?
One Patient writes … “Uniforms should be the same across the board and appropriate for the practice. Pediatric scrubs for Pediatric offices. Solid color for other offices. And, when it comes to Concierge Medicine offices who are more upscale, a dress code that is not wearing scrubs but uniformity is important. It communicates professionalism. Going to a Concierge Physician, is more laid back, casual and comfortable. That’s fine. But this isn’t summer vacation or a trip to Walmart. I want polished and respectful dress on staff. Who wouldn’t? Common sense. Make the effort. We’re [Patient’s] pay attention. I’d like to see a dress code at any Doctor’s office for that matter where the style of wearing dress pants and nice blouse (all uniformed) for staff is more professional, appropriate and appealing to Patients. If we’re going to refer our friends and Family to your Medical Office, impress them. Impress me. I matter. Patients are anxious when they go to the Doctor and scrubs usually are associated with unpleasant procedures such as lab draws or injections. Scrubs also give the impression that the people behind the scrubs are nurses who have a higher level of education and the reality of it is, these people are medical assistants not nurses.”
One Concierge Doctor in New Jersey said … “You either have a workload issue or a workforce issue? If you’re not committed to providing exceptional patient/customer service for your patients, your practice will never achieve its full potential.”
Patient satisfaction isn’t good enough. Your patient/customer service expectations need to be exceptional, and you need to create not just satisfied customers, but happy, loyal patients.
“Gain some customer service experience– try a service industry job as these skills are not taught in med school. Moving into Concierge Medicine is not solely about providing excellent medical care without the restraints of insurance industry mandates. You have to also appreciate the lost art of customer service so long ago forgotten when visiting a healthcare institution. Many times my clients (notice I do not use the word “Patients”) have noted why they refer their friends to my practice. It is the attention to detail, always delivering exactly what is promised and then some, and keeping their unique needs positioned first with a flexibility to offer new programs or meet needs as quickly as they are identified. This is the cornerstone of customer service.” ~ Dr. Carrie Bordinko, Consolaré, Paradise Valley, AZ
This past summer I spoke with a few Physicians in Concierge Medicine who took a moment [e.g. a week, or two] to step away from their practice, spend some quality time along and with their family and consider these questions. One Physician found that by stepping away from the business of medicine, albeit Concierge Medicine, gave her the perspective she needed to re-evaluate the direction her practice was going and how her staff were impacting that trajectory.
“If you provide anything less than exceptional patient service for your Concierge Medicine patients, you’re wasting time, creating extra work for and frustrating your patients, staff, suppliers and yourself,” says one of Texas’ most well-known Concierge Physicians in a recent radio interview. “Smart businesses outside of healthcare have customers. So do we. We put in our time, our emotion and our mental strength into our customers and it’s about time we start operating like a business. We have every advantage now that we’re free from a lot of the administrative burdens most traditional medical practices have. There’s simply no reason why we cannot make the extra effort to serve our patients now.”
The basic premise of patient [customer] service training in many medical practices, whether they’re membership-based or not, comes with the best of intentions. The doctor has a staff meeting about patient service, and the service improves for a few days or weeks and then it drops to mediocre levels again. Consistent reminders don’t come because you’re a busy doctor and you have a lot of other responsibilities on your mind.
One Concierge Physician writes … “I had a real battleaxe in the front office. She worked with our team and for me for a very long time. But, our practice has changed. That’s not what we need anymore. We went ‘Concierge’ and like it or not, we needed a softer, gentler and friendlier person in that position now. In fact, the whole position was changed. It took a few months for me to realize this … but I’m glad I did. I just hope my patients will forgive me for taking so long.”
Where your staff are heading is a good barometer of where they are leading. Meaning, if your staff aren’t careful about their health, they are not going to be careful with your patients health. Staff who are not concerned about their own reputation, are not going to be concerned about your reputation. Staff who are not concerned with their own finances [overspending when maybe they shouldn’t on a car, luxury item, etc.] won’t be careful with your office expenditures and your finances. Staff is a reflection on the doctor. If the doctor is a smart dresser, the staff needs to be dressed just as smart as the MD, fashion-wise.
“The conversion process is not an easy one,” said Jeffrey S. Gorodetsky, M.D. of Stuart, FL. “My staff and I are cognizant of the fact that we must consistently communicate the benefits of this choice in care, with the challenge to increase my [memberships] numbers and convert other patients.”
Here are a few considerations provided by Physicians, Consultants and Real, Concierge Medicine Patients that you may want to think about:
- Are your staff becoming better people because of your influence?
- Actively listen to your patients who tell you what they heard in the office.
- Actively listen to your patients on what they see and hear (e.g. Many Physician’s work in the back of the office most days. They don’t always hear staff conversations. However, the patients do!)
- Stand by your patients before your staff. Patients want only the best for their Doctor. They’re bringing something to your attention not to be a pest, but because they care about you and ultimately, the care they receive from you. Staff come and go, but Patients will stay forever [well, approx. 9 to 11 years on average — compared to traditional practice envirionments where it is common for patients to leave every five to six years | (C) Concierge Medicine Today, 2017] when their doctor listens to them.
- There is a reason why many Concierge Medicine Physician’s make staff changes within the first 18-months of their entry into the new subscription-based business model.
Pay attention to the conversations you overhear in the office.
- Don’t always think patients are complaining when expressing themselves about issues with staff. Patients observe, hear and see more than the Physician realizes. Think about a way you as the Physician, can learn from your patients. Actively listen.
- Note the verbal tone and tenor of conversations they have with patients.
- Pay attention to non-verbal communication displayed. E.g. eye rolls, laughter or comments from staff . Unfortunately as a Physician you may not always see this and staff may try to hide them from you. But, patients observe these things.
- Stop the gossip. The gossip that takes place amongst staff about patients happens all the time. We’ve learned from patients that even snide remarks are made with patients sitting right in front of them. What are you doing to develop a culture in your practice to avoid this from happening?
TRUE PATIENT STORY
A young [college age] woman was in the office to see the doctor for a lab draw. She noticed that a pharmaceutical rep came in after her and was sent to the back to visit with the Doctor right away. The young woman called her Mother and she suggested the young woman ask the receptionist how much longer and tell the staff that she has a class to go to very soon. The receptionist asked the Medical Assistant. The Medical Assistant’s comment to the receptionist was “if she let me draw her labs, she would have been done and gone.” Well, the young woman’s appointment was with the doctor not the Medical Assistant. The young woman had previously been delayed in the medical office multiple times due to the Medical Assistant’s schedule and trusted her Doctor to find her vein with one stick, something the Medical Assistant was unable to do in previous, repeated visits and attempts.
Lesson Learned: It is the Patient’s choice on who they want to receive their treatment(s), draw their labs, take their vitals, administer medication, etc. In the Patient’s opinion, that comment was uncalled for from the Medical Assistant. The tone and tenor was unbecoming of a medical office. Do comments like this and the behavior displayed portray a professional medical opinion with a remark like that?
- What are your staff saying and posting on social media?
- Photos, as well as their “likes” will tell a lot about an employee you consider hiring, providing they participate in social media.
- Social media can provide you with an enhanced background and potentially, professional or unprofessional behavior.
- Do they use profanity in posts or comments?
- Do what you can to always have secure, compliant and direct communication with your patient, whether it be email, text or a phone call.
- Just because staff are allowed to relay messages to your Patient, does not mean they should hear this [e.g. medical results] and information from your staff. Patients want to talk with their Doctor. Particularly if they have follow-up questions about what was communicated to them. Let’s remember, Patients are afraid to ask for the Doctor to call them. The Doctor assumes it’s okay for their staff to contact patients with results. Concierge Medicine changes all that. Staff contacting Patients with results is rarely okay. Remember, Concierge Medicine is about doing something different, not doing the same things you’ve always done.
- Physicians may not know how or are afraid to terminate employees. Many employees are simply given multiple warnings and yet, still remain employed at the office long, long after they should be. You as the Physician or owner of the medical practice should exercise good judgment. That may mean you first consult with your business advisors and if necessary, your own legal counsel to deal with challenging staff circumstances.
- Physicians who have any type of retainer or subscription fee, reduction in patients, etc., will most likely also experience a reduction in staff, post-transition when entering or starting a Concierge Medicine practice or Direct Primary Care program. Many offices will keep staff small and intimate, averaging 2.5 employees according to Concierge Medicine Today (CMT) polling results received by these offices in the past decade.
“Concierge Medicine Physicians who reduce the amount of Patients, should try for a month seeing and communicating with eight to maybe 10 patients in one day,” says Barb, a Concierge Medicine Patient and CMT Reader. “In between Patient’s, Physician’s can and should call Patient’s back, call specialist’s, etc. What about calling the specialist’s while the Patient is in the room with you? I’ll wait. It’s not a waste of time for me. I want to know my Doctor cares. Show me. Do you have any idea what kind of superstar you will be in your Patient’s eyes? That kind of personal attention is invaluable. You’ve just made your patient feel cared for and most importantly, that they matter to you … enough to call the specialist right there … even if it was only to leave a message. The Doctor can relay a better message to a specialist much better than a member of your staff can. It’s not personalized service if staff is involved. It’s only personalized when conversation is between Physician and Patient. Let’s start getting this right.”
Matt McCord Anesthesiologist at Anesthesia Associates of Ann Arbor, PLLC writes “The under-appreciated art of follow-up (and follow through) for our patients. Truly healthcare’s black-hole where transitions of care mattered little in fee-for-service healthcare. Not taking your medicines? No problem, come back in. Thankfully, this is changing.”
This is a lot to chew on. And, this is a topic that is always evolving. Concierge Medicine is in the people business and people are challenging, whether it is staff or a Patient. This important topic today is not meant to be unpacked all at one time or even resolved in one staff meeting. More than likely you won’t ever face a patient who had an experience like the one sent into us this summer. But, when it dawns on you that the trajectory of the practice is slightly awry or a course correction is needed, consider making some thoughtful changes with the right business advisors and possibly legal counsel involved.
Finally, Physicians need to have an open communication policy with patients. It is not simply enough to hear a Patient’s concerns and then never do anything to correct them. It may mean an apology. It may require a conversation with a staff member. It is important to broach the subject the next time you feel it is necessary to let the Patient know you listened and are concerned. It doesn’t mean letting your Patient’s run your business. It’s more about letting them know how much you care to listen. Let your Patient’s know you want to hear about the positive and negative things they see and hear.
“Slow and steady growth is ideal in this type of practice because it allows you to offer patients a personalized experience,” says Joel Bessmer, MD, FACP of Omaha, Nebraska’s Members.MD. “I’ve found that the word-of-mouth aspect (vs. a billboard advertising approach) has been the most consistent factor in building my practice. I consistently have patients recommending their family members and friends. Getting word of mouth referrals based on high quality care, staff service and patient satisfaction has been a much more effective tool than traditional marketing. And the slow and steady approach ensures that staff can keep up with new patients, as opposed to getting a rush of new caseloads that would be more difficult to manage all at once.”
When Concierge Medicine Doctors become committed to exceptional patient/customer service, you may stumble from time to time, but when you do, you’ll still be providing great patient/customer service. The added benefit to providing exceptional service is that when you or your staff do stumble, your patients will be much more likely to forgive you. In summary, it is natural to assume that what worked in the past will always work. But, of course, that way of thinking is lethal. And the longer it goes unchallenged, the more difficult it is to identify and eradicate. Every innovation has an expiration date.
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