2nd update to "CA license, but no board cert. How to get life back on track with a baby?"

[tofoo]

To recap: Back in November 2017, I was a new father and was desperate to get back into medicine. I thought my best bet would be to get back into residency (I was hoping to get into anesthesiology back then). In September 2018, I began what I thought was going to be a temporary work taking care of patients with wounds in nursing homes. I soon realized that I was good at closing wounds and that it was a financially sound field. In June of 2019, I started my own private practice. For more detail, I would refer you to the following posts:

First post on 11/30/17: CA license, but no board cert. How to get life back on track with a baby?
Second post on 7/15/19: Re: CA license, but no board cert. How to get life back on track with a baby?
Very last update on 8/2/19: Re: CA license, but no board cert. How to get life back on track with a baby?

A lot has happened since the last post in August.

The NP I had been training has gotten so good at taking care of the wounds. He left his old wound care company to join full time in October. A physician who used to work for a competitor joined us in December. The competitor was a primary care practice that was trying to break into the wound care market and realized they didn't know what they were doing. Now that practice is out of wound care scenery and is referring patients to us.

Our practice currently serves 22 nursing homes. Most of our referrals come from PCPs with patients whose "impossible wounds" we've closed over the past year. Some of these physicians shudder at the thought of another wound care provider taking care of their patients.

Back when I posted, I wasn't sure how reimbursement was going to turn out. That was a very stressful part of my practice, but I got really lucky with the billers who eventually figured out how to get us reimbursed by even the most difficult payor in this part of the country. As of now, the only group of patients we don't get reimbursed for are Kaiser patients.

We are truly fortunate to be able to see every patient with wound care needs without having to look at the facesheet. That "take care of patients first and worry about money later" attitude did not go unnoticed among decision makers in various nursing homes, and I think in the long run that was good for our business. We still have significant losses but I don't stress out about the money we aren't getting paid anymore. I think of it as good will we're putting out there in the world.

I bought my first home in January. I still wake up in disbelief every morning when I walk around the house.

My son is now 2 years old. He's healthy and ahead of milestones. Really makes me happy to hear him refer to the house as "my home". This was part of the reason why I decided to get back into medicine when he was just 2 months old. I'm shocked that we got here so fast. When I wrote that first post in Nov 2017, I thought it would take me a grueling 10 years of residency and struggling practice for my son to be living in our own home.

I worked hard to get here, but I've worked hard all my life. Hard work doesn't always get you there. I was lucky. And that realization makes me feel relieved.

I am pretty content these days. Yeah, there's a lot more responsibility on me as the practice grows, and I find myself doing more administrative work than clinical work. I am learning to micromanage less.

At the current pace, our practice is going to be providing surgical care to the majority of nursing homes in our metropolitan area before the end of this year. Once things are running smoothly, I plan to reach out to some of the desert communities to set up satellite practices. I know hospitals are closing in rural communities, and patients have to be transported for > 1 hour to be seen at a wound care clinic. I am hoping I can modify our practice model so that we can afford to provide a comparative level of surgical care out there. I'm really excited at the idea of traveling to these smaller towns, taking care of patients and exploring new places.

So that's it. I took a road less travelled and found a career taking care of post-acute patients with surgical needs. I grew a lot from the experience and find the work to be extremely rewarding.

Thank you for your concerns and encouragements over the past couple of years. Especially those of you reached out to me privately and cheered me on.

Thank you!

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[Oo Cipher oO]

To recap: Back in November 2017, I was a new father and was desperate to get back into medicine. I thought my best bet would be to get back into residency (I was hoping to get into anesthesiology back then). In September 2018, I began what I thought was going to be a temporary work taking care of patients with wounds in nursing homes. I soon realized that I was good at closing wounds and that it was a financially sound field. In June of 2019, I started my own private practice. For more detail, I would refer you to the following posts:

First post on 11/30/17: CA license, but no board cert. How to get life back on track with a baby?
Second post on 7/15/19: Re: CA license, but no board cert. How to get life back on track with a baby?
Very last update on 8/2/19: Re: CA license, but no board cert. How to get life back on track with a baby?

A lot has happened since the last post in August.

The NP I had been training has gotten so good at taking care of the wounds. He left his old wound care company to join full time in October. A physician who used to work for a competitor joined us in December. The competitor was a primary care practice that was trying to break into the wound care market and realized they didn't know what they were doing. Now that practice is out of wound care scenery and is referring patients to us.

Our practice currently serves 22 nursing homes. Most of our referrals come from PCPs with patients whose "impossible wounds" we've closed over the past year. Some of these physicians shudder at the thought of another wound care provider taking care of their patients.

Back when I posted, I wasn't sure how reimbursement was going to turn out. That was a very stressful part of my practice, but I got really lucky with the billers who eventually figured out how to get us reimbursed by even the most difficult payor in this part of the country. As of now, the only group of patients we don't get reimbursed for are Kaiser patients.

We are truly fortunate to be able to see every patient with wound care needs without having to look at the facesheet. That "take care of patients first and worry about money later" attitude did not go unnoticed among decision makers in various nursing homes, and I think in the long run that was good for our business. We still have significant losses but I don't stress out about the money we aren't getting paid anymore. I think of it as good will we're putting out there in the world.

I bought my first home in January. I still wake up in disbelief every morning when I walk around the house.

My son is now 2 years old. He's healthy and ahead of milestones. Really makes me happy to hear him refer to the house as "my home". This was part of the reason why I decided to get back into medicine when he was just 2 months old. I'm shocked that we got here so fast. When I wrote that first post in Nov 2017, I thought it would take me a grueling 10 years of residency and struggling practice for my son to be living in our own home.

I worked hard to get here, but I've worked hard all my life. Hard work doesn't always get you there. I was lucky. And that realization makes me feel relieved.

I am pretty content these days. Yeah, there's a lot more responsibility on me as the practice grows, and I find myself doing more administrative work than clinical work. I am learning to micromanage less.

At the current pace, our practice is going to be providing surgical care to the majority of nursing homes in our metropolitan area before the end of this year. Once things are running smoothly, I plan to reach out to some of the desert communities to set up satellite practices. I know hospitals are closing in rural communities, and patients have to be transported for > 1 hour to be seen at a wound care clinic. I am hoping I can modify our practice model so that we can afford to provide a comparative level of surgical care out there. I'm really excited at the idea of traveling to these smaller towns, taking care of patients and exploring new places.

So that's it. I took a road less travelled and found a career taking care of post-acute patients with surgical needs. I grew a lot from the experience and find the work to be extremely rewarding.

Thank you for your concerns and encouragements over the past couple of years. Especially those of you reached out to me privately and cheered me on.

Thank you!

Thanks for the update. Congratulations on your success. You seem to have a keen business sense, work ethic, and genuine care for your patients. I wish you continued good fortune for your son and your practice.

 

[Piebaldi]

To recap: Back in November 2017, I was a new father and was desperate to get back into medicine. I thought my best bet would be to get back into residency (I was hoping to get into anesthesiology back then). In September 2018, I began what I thought was going to be a temporary work taking care of patients with wounds in nursing homes. I soon realized that I was good at closing wounds and that it was a financially sound field. In June of 2019, I started my own private practice. For more detail, I would refer you to the following posts:

First post on 11/30/17: CA license, but no board cert. How to get life back on track with a baby?
Second post on 7/15/19: Re: CA license, but no board cert. How to get life back on track with a baby?
Very last update on 8/2/19: Re: CA license, but no board cert. How to get life back on track with a baby?

A lot has happened since the last post in August.

The NP I had been training has gotten so good at taking care of the wounds. He left his old wound care company to join full time in October. A physician who used to work for a competitor joined us in December. The competitor was a primary care practice that was trying to break into the wound care market and realized they didn't know what they were doing. Now that practice is out of wound care scenery and is referring patients to us.

Our practice currently serves 22 nursing homes. Most of our referrals come from PCPs with patients whose "impossible wounds" we've closed over the past year. Some of these physicians shudder at the thought of another wound care provider taking care of their patients.

Back when I posted, I wasn't sure how reimbursement was going to turn out. That was a very stressful part of my practice, but I got really lucky with the billers who eventually figured out how to get us reimbursed by even the most difficult payor in this part of the country. As of now, the only group of patients we don't get reimbursed for are Kaiser patients.

We are truly fortunate to be able to see every patient with wound care needs without having to look at the facesheet. That "take care of patients first and worry about money later" attitude did not go unnoticed among decision makers in various nursing homes, and I think in the long run that was good for our business. We still have significant losses but I don't stress out about the money we aren't getting paid anymore. I think of it as good will we're putting out there in the world.

I bought my first home in January. I still wake up in disbelief every morning when I walk around the house.

My son is now 2 years old. He's healthy and ahead of milestones. Really makes me happy to hear him refer to the house as "my home". This was part of the reason why I decided to get back into medicine when he was just 2 months old. I'm shocked that we got here so fast. When I wrote that first post in Nov 2017, I thought it would take me a grueling 10 years of residency and struggling practice for my son to be living in our own home.

I worked hard to get here, but I've worked hard all my life. Hard work doesn't always get you there. I was lucky. And that realization makes me feel relieved.

I am pretty content these days. Yeah, there's a lot more responsibility on me as the practice grows, and I find myself doing more administrative work than clinical work. I am learning to micromanage less.

At the current pace, our practice is going to be providing surgical care to the majority of nursing homes in our metropolitan area before the end of this year. Once things are running smoothly, I plan to reach out to some of the desert communities to set up satellite practices. I know hospitals are closing in rural communities, and patients have to be transported for > 1 hour to be seen at a wound care clinic. I am hoping I can modify our practice model so that we can afford to provide a comparative level of surgical care out there. I'm really excited at the idea of traveling to these smaller towns, taking care of patients and exploring new places.

So that's it. I took a road less travelled and found a career taking care of post-acute patients with surgical needs. I grew a lot from the experience and find the work to be extremely rewarding.

Thank you for your concerns and encouragements over the past couple of years. Especially those of you reached out to me privately and cheered me on.

Thank you!

Where did you get your training from in wound care?

 

[tofoo]

Where did you get your training from in wound care?

Hi, I just saw this. Don't come to SDN that often these days.

The answer to your question is long. To begin with, late Dr. Peacock as well as plastic surgery attendings (Dr. Halvorson especially) were my mentors while I was a med student at UNC. I did two years of general surgery but I cannot say that I learned much about chronic wounds at the time. I think the biggest contribution to my learning in wound care came from all of the reconstructive surgeons I spent time with while I was in South Korea. I was on the editorial board for the plastic surgery journal there (APS), and reviewed hundreds of papers. I have published handful of plastic reconstructive publications as an author, including a review paper on wounds. All of that provided a solid fund of knowledge for understanding wound and healing process.

The following really doesn't answer your question, but this is something that's been on my mind about wound care.

I think understanding of the history of wound care and reconstruction is important in managing wounds in all clinical settings (acute, post-acute, community). To be honest, what I do today resembles more of what reconstructive surgeons used to do back in pre-microsurgical era, albeit with modern instruments and equipments that they didn't have access to. I'm not doing tubed flaps or anything remotely crazy like that but the stuff I do is deeply rooted in the wound care principles and techniques found in textbooks from that era.

For instance, most plastic surgeons would tell you that denuded cortical bone will not allow for granulation without periosteum and that to close a wound like that would require either a local tissue rearrangement (advancement or rotation flap) or free tissue transfer. However, I don't know if the third option is common knowledge, which is to actually remove the cortical layer to get down to the cancellous bone, which has mesenchymal stem cells and will provide granulation bed for the wound - to either allow secondary healing or skin graft. I am not sure if this information is mentioned in Neligan; but I would be willing to bet a hundred bucks that it's not in the book as a contemporary clinical solution in non-acute settings (nursing homes, rural settings, or developing countries). The only reason I know about this is because I have a textbook from 1970s that discusses this in the chapter on bone healing. This is how I manage pressure ulcers over exposed sacral bone in patients who are not surgical candidates or who had a failed rotational flap.

Sorry about the rambling. Thanks for asking.

 

[tofoo]

Thanks for the update. Congratulations on your success. You seem to have a keen business sense, work ethic, and genuine care for your patients. I wish you continued good fortune for your son and your practice.

Thank you!!