Doctor

Doctor's micro practice makes almost perfect

Doctors communicate by e-mail

Sunday, February 11, 2007

By James T. Mulder

Staff writer

Dr. John Callahan became disillusioned after working for eight years in a busy primary care practice in Watertown.

He said he was seeing too many patients and rushing their visits.

The internal medicine doctor felt like a slave to an archaic, inefficient paper filing system that often left him in an exam room with the right patient and the wrong chart.

So when he opened a solo practice in Fayetteville last month, the Syracuse native was determined to buck the status quo.

He set up Adult Primary Care of Fayetteville as a "micro practice," an approach pioneered by a Rochester-area doctor that uses high technology and minimal staff to break down the barriers between doctor and patient.

The office, which opened last month, is paperless. A computer system stores patient records electronically, manages patient flow and even sends patient prescriptions electronically to the pharmacy. Callahan said the technology lets him keep his office staff small a receptionist, a nurse and a part-time office manager. With low overhead costs, Callahan said he can afford to see fewer patients. He spends 60 minutes with new patients and about 30 minutes on follow-up visits.

The 10-minute visit, a necessity in some practices with high overhead costs, tends to leave patients unhappy and doctors unfulfilled, Callahan said.

"I don't think I want to be that kind of doctor practicing in that vein," Callahan said. "If you have a small office you won't make as much money, but if all you're about is chasing money then your heart is probably in the wrong place."

Dr. L. Gordon Moore, a family physician in the Rochester suburb of Brighton, pioneered the micro practice approach in 2001 after practicing in a large group left him dissatisfied.

"I felt like I was on a treadmill," Moore said. "There was a growing gap between what I hoped to deliver in terms of superb care and what was actually possible in the paradigm of the current system."

Moore started his practice with no staff, using computers to handle as many administrative tasks as possible, answering the phone himself and personally greeting patients when they arrived. He eventually hired a nurse, but still answers his own office phone.

Moore wrote about his experience in a journal and got such an overwhelming response from other doctors he started a Web site (idealmicropractice.org) with practical, how-to advice.

More than 100 doctors nationwide have copied Moore's approach to running a medical practice, which he calls "Norman Rockwell with a 21st century backbone."

"We have very high-tech, high-touch, very personal practices, we spend more time with people and we get people in for same-day appointments with no 'mother, may I,' " Moore said.

The "micro practice" approach has its share of skeptics.

"More time may be good for the patient, but it isn't necessarily more income for the physician," said George Chapman, a physician practice management consultant in Syracuse. It's the intensity of the service a doctor provides that determines how much he or she will be paid, he said.

Moore, however, maintains the "micro practice" formula can be more profitable than the traditional approach for some doctors. Moore said he was able to make 30 percent more money seeing 12 patients a day in his micro practice than he earned when he was employed in a large practice seeing 25 to 30 patients a day.

Between 60 percent and 70 percent of a traditional practice's revenue goes to pay overhead, and staff costs account for about 71 percent of that overhead expense, according to Moore. "I took that down to zero initially by using computers," he said.

Moore saidhe and some micro practitioners also communicate with patients regularly by e-mail.

He said he interacted with one patient last year 26 times by e-mail and phone, even though she came to the office for only one visit.

Doctors, however, don't get reimbursed for e-mail consultations.

"We need reimbursement reform," Moore said. "Our current payment model does not support the ideal care we could be delivering. The current model says, 'Bring them in and churn them through.' "

Callahan is adopting a less radical version of the micro practice approach.

He's not doing e-mail consultations because he fears it could trigger lawsuits from patients who try unsuccessfully to reach him via e-mail.

He also hopes to get another like-minded doctor to join his practice.

"If you're the sole man on the iceberg, I don't think it would be intellectually stimulating," he said.

Callahan, however, is sticking closely with the micro practice script when it comes to lower patient volume, longer visits and same-day appointments.

"Doctors who see 35 to 50 patients a day, they get burned out," he said. "After awhile, you are going in there and rubber stamping the encounter. It really doesn't make for a healthy relationship. You can do it, but you are going to make mistakes and miss things."

James T. Mulder can be reached at 470-2245 or jmulder@syracuse.com