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I'm a rural family doctor and opened my own clinic April 30, 2010. This goes against the trend of employed doctors. Here's my business update.

Two days ago it was just starting to snow as I drove to work. My son left for school before me, driving. The IT called me to ask if school was really in session. The website assured us it was. She called me 45 minutes later and said that the bus never came. By then we had a good two inches of snow. We rarely get snow here, but this is supposed to be a hard winter.

Patients arrived anyhow. We called the 80 plus year old because she lives more than two towns away. But her daughter was bringing her and they made it. Their battery died so they had to find another way home. All of our patients showed up. Everyone scheduled on Tuesday called and moved appointments.

With no one coming in, Tuesday was a snow day. I did keep the monthly meeting with the accountant/small business adviser. I have to meet with the bank in December to discuss converting the line of credit into a loan. I like my banker very much. But I don't know the language well and needed to know what reports to take to her.

We've done version four and five of the projections for next year. We have a budget and are trying to project what we will actually collect for patient visits, which has nothing to do with what we bill. And then there are all of the weird billing rules about how to charge for a level of visit.

My estimates were, of course, all wrong in the initial business plan. I thought medicare would pay less than it does, so that was good, but my estimate of how fast people would come in to the clinic was too high. We've been tracking that. The first month we averaged 1.1 per day. 1.8 in month two. 2.1 in month three. It is linear. Our medicare is approved, so we're working on billing for the last six months. All others pay cash, so our proportion of medicare patients kept rising. It was 82% in October, so version 4 of the projections had us increasing patient visits by one every other day each month, and assumed we'd be 100% medicare.

But November is not looking like that. Our proportion of medicare patients is down to 70%, to our surprise. I fill a special niche. Our advertising says "Takes time to listen, takes time to explain," which is really what I like to do. Low on procedures, good at sorting out complex pictures. I'm really comfortable with the 80+ year old who has 8 chronic diseases: diabetes, heart failure, a previous 5 vessel bypass, colon cancer six years ago, some skin cancer, moderate renal failure, atrial fibrillation and is on some old antipsychotic medicine that they've been on for 30 years and I have to look up. We are getting healthy medicare patients too. Non-medicare? Most of them are insured and most of them are VERY complicated. We are hearing over and over from patients that the hospital clinic doctors aren't allowed to spend much time with them. We are even getting people who have insurance that won't pay anything for an "out-of-network" doctor.

Two recent rare diagnoses: loin pain hematuria syndrome, which I had never heard of, and eosinophilic esophagitis. I seem to be having a special on peripheral vascular disease too, damn those cigarettes.

Version 5 of the build up estimates lowered the increase in patients per month, doesn't look quite as linear as we'd hoped. But then, November and December usually are a bit slower in clinic and then all heck breaks loose in January and February.

The accountant looked rather fierce after looking at next year's budget because we are still losing money, even at the end. He said, "Have you looked at the end result, will you be earning money to make this worth your while?"

I handed him 6 estimates, hand written. Let's see, if I work four days a week and we have all medicare patients and we subtract vacation, continuing medical education, sick leave and holidays, what would the business generate at 12 patients per day, 14 and 16? And then, if we take the projected amount earned per patient visit based on the last month, 25% non-medicare, it's higher, run those numbers. Even at the lowest estimate, once we're running at capacity, it works.

Oh, he said. He said that he sees people with business plans that he tries to talk them out of. He fails sometimes and he has business owners that running at full capacity, the owner is taking home 20K. Or nothing. Or has a loss. For the third visit in a row, he complimented us and said that he sees few few business startups that are doing the math for what full capacity looks like and is the goal reachable and will it be worth it?

I don't know the language, but I bloody well understand the math. I blinked at him and said that I had trouble imagining running things with an "I hope it'll work" attitude. It's still all estimates, because the amount of money collected per patient is a nightmare in itself, because there are all different levels of visit and then medicare keeps changing it's rules and it's payments and what they paid for this year is different from what they will pay for next year. Confusion rules.

I am tired out currently, even seeing 4-5 patients a day, when I averaged 16 for years. It's not because I have the added jobs of business owner and nurse, really. It is other, extraordinary stressors. I am tired all the time and am trying hard not to get sick. I can't estimate whether the number will be 12 or 14 or 16, because things are out of whack.

We thanked him and left, my office manager and I. Encouraged. Depending on which estimate we use, we'll be at full capacity in 2 years or a bit more.

I walked to the dentist's office in the snow and sun, 29 degrees. The IT was declared fine and we got cookies and orange juice at the store as a treat. We walked home down Lawrence Street and past the Kai Tai Lagoon, enjoying the rare snow.


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Pointless statistics for today:

  • I am in Strasbourg for the 58th time
  • I have eaten in the Italian/Indian restaurant up the road from my hotel three times this week.
  • I have been here three evenings this week.
  • This is only the 13th time I have stayed in this hotel. It feels like more.
  • For a while today, three of my writeups were in the 'Cool User Picks!' list on the front page.
  • Two of these writeups were root logs.
  • The other was far nastier than I expect most readers to notice.

I am tired, but not unpleasantly so, and I am in bed. Life is good.

Life moves slowly in Montana. I moved here July 21, 2009, and was at first expecting that I would make it a couple of months, at most. I thought that the first winter would leave me crazy to leave, as it had when I first moved here, ten years ago. I am now entering my second winter here. It is currently -13C, at the warmest time of day. This does not bother me as much as I might have guessed it would have.

There are a few secrets of how I have managed to keep my sanity. One of them is that the time since I moved here has been one of the most literary times of my life. While I have always been a reader, I have turned it up to 11 the past year, reading large parts of the canon that have so far eluded me. I've read Romance of the Three Kingdoms, War and Peace, The Brothers Karamazov, The Great Gatsby, Swann's Way, Anathem, A Confederacy of Dunces, You Can't Go Home Again, The Magicians, Flow My Tears, the Policeman Said, Fear and Trembling, Flatland, Dance Dance Dance, V For Vendetta, The Curious Incident of the Dog in the Nighttime, The Time Traveler's Wife and I even read Twilight. And those are just the familiar books, I've also read a great deal of random paperbacks. Of course, that wasn't even my point, I just got busy bragging about all the books I've read. I get that way with books.

The other way that I keep myself occupied, and the point of what I am writing about here, is that I have become much more in tuned with the natural world around me. I have always been aware of the natural world, but I am now immersed in it. The area I live has some unique qualities about it. Although a more seasoned geologist might correct me on this, I am in between two separate mountain ranges, the high, rocky, Cretaceous Bitterroot Range, and the low, rounded pre-Cambrian Sapphire Mountains. I don't know of any other place where two mountain ranges that are so diverse in geology and biology are within a dozen miles of each other. I can ride my bicycle out a dozen miles and be in a unique ecosystem. Things that may have provoked a reaction of mild interest now seem to have more immediacy --- things such as the first yellowing of the larches high in the mountains in September.

Wishing to have some record of the small, subtle changes that constantly back up the background to my life, sometime in August I started taking the same photograph every day. It showed, in the foreground, my front yard, and further away, the high peaks of the Bitterroot. I at first hoped to make a time elapse movie of these pictures. The pictures were slightly off center from one each other to make a good time elapse movie, so I instead started a flickr account to display them. And this is the lead-in to my plug of my flickr account, which can be found here:

(As an exercise to the reader, it is left to explain why flickr has the most confusing and long URLs ever.)

This is probably a niche interest, but I find it very interesting, especially when I go back over the pictures and realize certain things. Such as that even in the high days of summer, cloud cover is more extensive and more varied than I would think. And also, that the changing of leaves is not a totally gradual process: they are green for a long time, and then turn noticeably yellow in a few days. Some of these are curiosities, while some of them are a great source of meteorological and biological data. I will continue to update these pictures as the rules of flickr and as my time allow. Hopefully they will become complete enough to show an entire year's cycle of seasons.

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