Optimizing schedule without midlevels

[drrosenrosen]

I've been at my current position for 2 years. I was already getting very busy when one of our docs announced he's leaving the practice. I am an employed doc at a private practice and eat what I kill. We were formerly 3 docs, now down to two, but another on track to join us next summer when he can leave his current gig.

My boss works with two NPs, and has long extolled the virtues of them. He sees all his new patients and procedures, they do all (80%) of his followups. I have been resistant to bringing on a midlevel to work with me, because I like seeing all of my own patients, I don't like training someone to do things exactly the way I want them done, and my patients like that they always get to see me. But between picking up a lot of the former partner's patients and my own growing practice, I'm having a little backlog.

So, people who don't have midlevels working with them, how do you do it? Any tips and tricks about optimizing schedule to maintain access while seeing all your own followups? I do 30 minute NP/RFA, 15 minute everything else. Kyphos and SCS are worked in early morning before the regular schedule opens. I'm 10 days/month at the office with the fluoro suite, 2 days month have mornings at a hospital procedure room, and the rest of the time at satellite clinic where I'm limited to clinic visits and ultrasound procedures. Procedures and clinic visits are mixed in the same schedule, which I don't love, but is the way the scheduling and staffing has historically been done here. Could I make an argument for better efficiency with blocked procedure time?

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[callmeanesthesia]

I've been at my current position for 2 years. I was already getting very busy when one of our docs announced he's leaving the practice. I am an employed doc at a private practice and eat what I kill. We were formerly 3 docs, now down to two, but another on track to join us next summer when he can leave his current gig.

My boss works with two NPs, and has long extolled the virtues of them. He sees all his new patients and procedures, they do all (80%) of his followups. I have been resistant to bringing on a midlevel to work with me, because I like seeing all of my own patients, I don't like training someone to do things exactly the way I want them done, and my patients like that they always get to see me. But between picking up a lot of the former partner's patients and my own growing practice, I'm having a little backlog.

So, people who don't have midlevels working with them, how do you do it? Any tips and tricks about optimizing schedule to maintain access while seeing all your own followups? I do 30 minute NP/RFA, 15 minute everything else. Kyphos and SCS are worked in early morning before the regular schedule opens. I'm 10 days/month at the office with the fluoro suite, 2 days month have mornings at a hospital procedure room, and the rest of the time at satellite clinic where I'm limited to clinic visits and ultrasound procedures. Procedures and clinic visits are mixed in the same schedule, which I don't love, but is the way the scheduling and staffing has historically been done here. Could I make an argument for better efficiency with blocked procedure time?

Hire a good scribe and they can room a patient and take a history for you while you’re doing a procedure. It can cut down your new patient time significantly because you don’t have to sit there asking them if they’ve tried PT and NSAIDs. I do procedure block time but occasionally have to put an urgent referral or follow up onto my procedure time.

 

[SSdoc33]

dont have extenders see MBB f/u. they always mess it up, miss some RFs that should be RFs, and miss some SIJ/ESIs that could be needed.

have the extenders see patietns you dont really like or dont really want to see. the ones that take a long time, and need extra hand-holding. also, patients who arent english speakers.

this may not be the best practice, but it makes your day more enjoyable.

extenders are good for callbacks on MRI follow ups or to work on pre-auths and denials.

also, for patietns with a flare up or an acute problem that need to get in within the next few weeks if you are booking way out.

i am very hesitant to allow them to make any real decisions re: injections or surgical referrals

 

[drrosenrosen]

dont have extenders see MBB f/u. they always mess it up, miss some RFs that should be RFs, and miss some SIJ/ESIs that could be needed.

have the extenders see patietns you dont really like or dont really want to see. the ones that take a long time, and need extra hand-holding. also, patients who arent english speakers.

this may not be the best practice, but it makes your day more enjoyable.

extenders are good for callbacks on MRI follow ups or to work on pre-auths and denials.

also, for patietns with a flare up or an acute problem that need to get in within the next few weeks if you are booking way out.

i am very hesitant to allow them to make any real decisions re: injections or surgical referrals

If I were to use a midlevel I would use them in this limited capacity. The problem is that I do opioid management, so it's very hard to justify having one but still doing all my own med refill appointments. But talk about something you don't want to trust somebody else with... Especially since here in Texas they can't prescribe meds under their own licenses so they are all on me.

 

[drrosenrosen]

Also, I do routine 2 week post-procedure followups, 4 weeks for RFA. Does anyone else do differently? A month? Anyone do no routine followup? I have a couple of old ladies who come in for an epidural twice a year who I don't make a routine followup for, just tell them to call when they need me again.

 

[DOctorJay]

Also, I do routine 2 week post-procedure followups, 4 weeks for RFA. Does anyone else do differently? A month? Anyone do no routine followup? I have a couple of old ladies who come in for an epidural twice a year who I don't make a routine followup for, just tell them to call when they need me again.

we call all patients one week after their procedure to see how they're doing. if 75% or better or pain 0-2/10 I'll tell them they can follow up on a prn basis. if they want an office visit we will still get them in but if they don't need it we don't make them come in.

our traditional follow up schedule is 4 weeks for steroid injections, 6 weeks for RFA.

 

[RoloTomassi]

I think you could do more like your boss and use more for f/u. If you see new visit / MRI f/u and have an outlined algorithm of plan A, B, C then midlevel can follow your lead and do all the explaining.

 

[Agast]

How many patient encounters a day?

I do up to 15 patient clinic visits in a half day

Up to 20 procedures in a half day

 

[Ronin1]

I’ve done it both ways. Currently have one NP who sees maybe 10 patient a day. He does medication follow ups and MBB/RFA planning mostly. I’m in the same area with him so he runs anything by me that doesn’t match. Any failed MBBs I see as well. It works well and lets me see another 20-30 people.

I would try to streamline your procedural time though. Move all procedural cases to morning or afternoon. It works well for me. There are some follow ups scheduled at the same time for the np

 

[drrosenrosen]

Usually about 25-30 a day, depending on how many new patients. Today I have 33.

 

[RoloTomassi]

lets me see another 20-30 people

How many do you see total per clinic day?

 

[Ronin1]

How many do you see total per clinic day?

Usually 35-40 max. Including procedures which I do daily

 

[Agast]

Usually about 25-30 a day, depending on how many new patients. Today I have 33.

So are you trying to consistently see more patients than 30 in a day? I know there are pain docs who do that but I personally would burn out hard trying to have high yield conversations with that many people. If another pain doctor is joining the group I would not try to bring on a midlevel, because then your new hire would be competing directly with the midlevel for overflow patients.

 

[RoloTomassi]

Usually 35-40 max. Including procedures which I do daily

That's a lot. 30+ feels like a rough day

 

[pmrmd]

I don’t have an NP/PA and don’t really want one. If I did have one I’d use for refill appointments only. I see about 30/day, half for procedures and half for newbies, meds, follow-ups. I think good MAs help you become more efficient.

 

[Ducttape]

So are you trying to consistently see more patients than 30 in a day? I know there are pain docs who do that but I personally would burn out hard trying to have high yield conversations with that many people. If another pain doctor is joining the group I would not try to bring on a midlevel, because then your new hire would be competing directly with the midlevel for overflow patients.

im not sure these would be considered "high yield conversations", but for the run of the mill radiculopathy, that is probably not necessary....


therein lies a kind of annoyance, almost a pet peeve, of mine....

a colleague will see a patient.
"the epidural help?" "yup." "its been 3 months, is your pain >6?" "yup." "okay, ill ask for auth for another injection. see you next week." bam. 99214.


i on the other hand...
patient i have not seen in 2 years 360 days returns, new knee pain for 10 days. cant hardly walk. failed prednisone. cant take indocin due to anticoag for stent placed 6 months ago, and counsel against daily steak and beer for dinner. discuss why oxy not an option. order xrays, labs, try to set up for knee aspiration. referral to ortho. cant aspirate because we ran out of sterile tubes. doesnt want aspiration anyways. order colchicine, but have to counsel regarding interactions with medications. discuss why dilaudid not an option. detour in to how he felt demerol was such a great drug, but not available now. too bad. get call from pharmacy telling me about drug interaction.

all along wondering why he didnt go see his doctor. find out PCP too busy, and never listens to him anyways.....



limp to a 99214.... but since he is medicaid, i get paid less than my colleague......

 

[clubdeac]

I don’t have an NP or PA. I see 26 clinic patients in a day. 1/2 new 1/2 f/u. 24 procedures in a day, all scheduled 15 min even though my RFs may go longer. Schedule epidural f/u in 4 weeks and RFA f/u in 6 weeks. No f/u for those that routinely get 2-3 epidurals in a year and do well

 

[Agast]

limp to a 99214.... but since he is medicaid, i get paid less than my colleague......

Ok, but this is pretty much self-inflicted

Heart of a family medicine doctor…

 

[Dr. Ice]

I can see 25 in a half day. I actually spend a lot of time with patients. So I’m not “milling it.” In fact my spine surgeon sends me the patients for an injection consult and actually tells the patient I will review the mri with them and answer any questions which I always do. You can look me up. Most of my reviews say “he spends time with me.” I can do it because my MA is a rockstar. She does my authorizations, and has been a pain MA for 15 years. She’s probably better than a lot of PAs to be honest. She almost knows what procedure to set up after a short interview while getting vitals and just talking to them. I bonus her quarterly quite well because she would be a very valued commodity anywhere. The Bain of my existence is charting. I’m up at 5am most days to chart. I’ve gotten to a point where I really only prioritize mris and procedures and everything gets a back burner for a long time. I think I have notes from December not dictated lol. Thought about a scribe but I’m stingy…

 

[callmeanesthesia]

I can see 25 in a half day. I actually spend a lot of time with patients. So I’m not “milling it.” In fact my spine surgeon sends me the patients for an injection consult and actually tells the patient I will review the mri with them and answer any questions which I always do. You can look me up. Most of my reviews say “he spends time with me.” I can do it because my MA is a rockstar. She does my authorizations, and has been a pain MA for 15 years. She’s probably better than a lot of PAs to be honest. She almost knows what procedure to set up after a short interview while getting vitals and just talking to them. I bonus her quarterly quite well because she would be a very valued commodity anywhere. The Bain of my existence is charting. I’m up at 5am most days to chart. I’ve gotten to a point where I really only prioritize mris and procedures and everything gets a back burner for a long time. I think I have notes from December not dictated lol. Thought about a scribe but I’m stingy…

What’s the point in doing all that work if you don’t bill for it? I can only see patients at a rate of about 20-30 minute new and 15 minute f/u, but all my notes and charges are done and finalized as the patient is walking out (I use scribes).

 

[lobelsteve]

I can see 25 in a half day. I actually spend a lot of time with patients.

No you do not. 4 hours is a half day. 25/4=6.25 pts per hour. If you leave the exam room to go to another exam room 24x in the morning, that is likely 12 minutes or more. If you do anything but see patients, more time off the clock. So your statement above is not accurate.

How about: I spend as long as it takes to make the patient feel like I spent 30 minutes with them. I sat, I joked, then we got down to business.

 

[Dr. Ice]

No you do not. 4 hours is a half day. 25/4=6.25 pts per hour. If you leave the exam room to go to another exam room 24x in the morning, that is likely 12 minutes or more. If you do anything but see patients, more time off the clock. So your statement above is not accurate.

How about: I spend as long as it takes to make the patient feel like I spent 30 minutes with them. I sat, I joked, then we got down to business.

You are correct..although still way more time than my surgical partners, however much time it is or isn’t

 

[buddababa]

I see max 20 a day. Clinic or procedures. I make enough. Y’all who see more than that are making a kill$$ing

 

[Dr. Ice]

I see max 20 a day. Clinic or procedures. I make enough. Y’all who see more than that are making a kill$$ing

Contracts contracts contracts

 

[drusso]

That's a lot. 30+ feels like a rough day

That's a busy morning.

 

[RoloTomassi]

That's a busy morning.

C'mon you see 60+/day?

 

[MitchLevi]

Tomorrow. Tuesdays are procedures and clinic. Most I've done is 41 and I don't like that volume for longevity sake.

I certainly COULD do more, but I'm 43 and I've got kids and a wife and I have hobbies that mean more to me than production bonuses.

PA sees clinic pts M-R full day and F half day. Several decades of experience. Ethical. Conservative.

 

[drrosenrosen]

So are you trying to consistently see more patients than 30 in a day? I know there are pain docs who do that but I personally would burn out hard trying to have high yield conversations with that many people. If another pain doctor is joining the group I would not try to bring on a midlevel, because then your new hire would be competing directly with the midlevel for overflow patients.

I'm happy w my 25-30 pts a day. I don't want to be busier than that, but I also want to be able to offer procedures in a timely way, including sometimes getting people in next day etc. I think the main thing that will help me is that one location that is currently a satellite clinic is having a full office with fluoro suite built out. That will expand my procedure availability significantly and I think decompress my schedule a lot. It's just a matter of getting through the next 6 months or so until that project is done.

 

[Pain Applicant1]

The Bain of my existence is charting. I’m up at 5am most days to chart. I’ve gotten to a point where I really only prioritize mris and procedures and everything gets a back burner for a long time. I think I have notes from December not dictated lol. Thought about a scribe but I’m stingy…

One of the best decisions I made early on in my practice was to establish a policy where all notes and billing must be completed before seeing the subsequent patient. Prior to this policy, I was up until midnight finishing up notes.

If you make this a policy, you'll be forced to abide by it and you'll figure out ways to make it work. Kind of like necessity is the mother of invention. Now my notes and billing are typically done before I see the next patient. There are a few stragglers at times but I can usually knock them out within a day or so.

 

[powermd]

I need to do this. Pearls? I just hired a guy who is doing a pretty good job scribing for me, as well as procedure and general MA duties. Currently I'm scheduling 30 min slots for most follow ups unless really easy and/or procedural- then it's 15. NPs are getting 60 min. I'm STILL struggling to finish notes on time. I think I need to get a lot more stringent on chit chat with patients.

 

[bedrock]

I need to do this. Pearls? I just hired a guy who is doing a pretty good job scribing for me, as well as procedure and general MA duties. Currently I'm scheduling 30 min slots for most follow ups unless really easy and/or procedural- then it's 15. NPs are getting 60 min. I'm STILL struggling to finish notes on time. I think I need to get a lot more stringent on chit chat with patients.

No offense, but that’s quite slow. I can understand 30 for NP (more complex patients) and 15 for follow ups, but 60 new and 30 min f/u are basically the appointment times for a university pain doc (or neurologist).

Good to be friendly, but important to get to the point of the patients visit.

 

[BobBarker]

@powermd not to be harsh but that pacing with a scribe is a path to bankruptcy. I don’t know if it is fixable as it is so far past what is normal. You are built for the university or the VA.

I can talk about the weather, their grandkid, and if the shot worked or not in 5 min.

 

[powermd]

In my former practice where I had a lot of help I could do 30/day easily, but I had a check in person, scribe, great procedure techs, and great billers. Now I'm solo, with a remote phone/EMR MA, and and in-office help two days per week. Patient flow has reached 8-12 patients per day. I think I have a 14 patient day coming up. So I'm working about as fast as the practice is getting business, but YES, I need to find ways to speed up visits.

 

[lobelsteve]

I can do 20 patients per day with just a front desk person.

 

[Pain Applicant1]

I need to do this. Pearls? I just hired a guy who is doing a pretty good job scribing for me, as well as procedure and general MA duties. Currently I'm scheduling 30 min slots for most follow ups unless really easy and/or procedural- then it's 15. NPs are getting 60 min. I'm STILL struggling to finish notes on time. I think I need to get a lot more stringent on chit chat with patients.

I agree with the two posts above but I don't agree that it's not fixable. When I started I booked 1 hour for new and 30 min for f/u. Early on I was at about 12 per day and then 16 per day. I mainly did this because I didn't know how to put everything together and I was still adjusting. I also had a salary guarantee so it didn't really matter since I had that cushion. Now, I'm at 30 min fluoro procedures and new and 10 min f/u. Most procedures and news are done within ten or fifteen so I can make up time.

You have to focus on the pertinent and ignore the rest. Physical exam and history needs to be focused. Murmur, LE edema found --> referral back to PCP or to cardiology to address and document in note. Tell front desk person to give the patient the cardiologist's number. That's not for you to look up.

Bring the patient back respectfully if they start to meander. I say I really want to hear more of what you're saying but I don't want to fall further behind because I don't want to upset the next patient. I'm sorry. Something like that.

Death in the family: I'm so sorry that happened. I know it's never easy no matter how old and I wish there was something I can do or say to make you feel better but I know there isn't. If you need anything please let us know. I'm really really sorry. Please hang in there for me. Something like that.

Kid gets awarded for something: I'm so happy to hear that. I'm really so happy for you and your family. That's such wonderful news. Thank you for sharing that with me. Something like that.

Pretty much canned responses but I keep them as sincere as possible.

I tried a scribe but it didn't work. Now I type on my laptop while speaking to the pt but I keep my eyes for the most part on the pt. Although typing, make sure you're listening to what they're saying. That's mostly what they want. To be listened to and validated. Just type your note but give them the impression that there's nothing more important to you at that moment than the words that are coming out of their mouths. They'll feel that a 3 to 4 min visit was more like 15 or 20 min. If you appear to rush, you don't sit down, etc they'll feel a 15 min visit was just a min or two.

You'll get it, just keep at it.

 

[forchinet121]

All good points

 

[powermd]

I agree with the two posts above but I don't agree that it's not fixable. When I started I booked 1 hour for new and 30 min for f/u. Early on I was at about 12 per day and then 16 per day. I mainly did this because I didn't know how to put everything together and I was still adjusting. I also had a salary guarantee so it didn't really matter since I had that cushion. Now, I'm at 30 min fluoro procedures and new and 10 min f/u. Most procedures and news are done within ten or fifteen so I can make up time.

You have to focus on the pertinent and ignore the rest. Physical exam and history needs to be focused. Murmur, LE edema found --> referral back to PCP or to cardiology to address and document in note. Tell front desk person to give the patient the cardiologist's number. That's not for you to look up.

Bring the patient back respectfully if they start to meander. I say I really want to hear more of what you're saying but I don't want to fall further behind because I don't want to upset the next patient. I'm sorry. Something like that.

Death in the family: I'm so sorry that happened. I know it's never easy no matter how old and I wish there was something I can do or say to make you feel better but I know there isn't. If you need anything please let us know. I'm really really sorry. Please hang in there for me. Something like that.

Kid gets awarded for something: I'm so happy to hear that. I'm really so happy for you and your family. That's such wonderful news. Thank you for sharing that with me. Something like that.

Pretty much canned responses but I keep them as sincere as possible.

I tried a scribe but it didn't work. Now I type on my laptop while speaking to the pt but I keep my eyes for the most part on the pt. Although typing, make sure you're listening to what they're saying. That's mostly what they want. To be listened to and validated. Just type your note but give them the impression that there's nothing more important to you at that moment than the words that are coming out of their mouths. They'll feel that a 3 to 4 min visit was more like 15 or 20 min. If you appear to rush, you don't sit down, etc they'll feel a 15 min visit was just a min or two.

You'll get it, just keep at it.

Great tips.

What I like best about the scribe is they allow me to stay 100% eyes on the patient instead of typing. This worked really well in my old practice because, once well trained, I could easily bounce from room to room doing only the most critical things and almost NEVER looking at a computer unless to view imaging. New guy is a FNG- but promising. He's premed, so well motivated. I doubt I'll keep him more than a year though. Deal with the devil.

Tell me about the layout of your office and how the physical flow works. This is important to me right now because I'm looking at switching offices to save on my absolutely ridiculous rent.

 

[Ducttape]

I need to do this. Pearls? I just hired a guy who is doing a pretty good job scribing for me, as well as procedure and general MA duties. Currently I'm scheduling 30 min slots for most follow ups unless really easy and/or procedural- then it's 15. NPs are getting 60 min. I'm STILL struggling to finish notes on time. I think I need to get a lot more stringent on chit chat with patients.

in a perfect world, thats how much time you should be spending with patients. there is a reason that time based billing 99213 is 20-30 minutes, not 5-10...

in our current healthcare model, that is too $low because what is treasured is volume.

and regardless of how we delude ourselves, patients as a whole do not feel we spend enough time with them.


i personally am horrible at staying on time. a scribe would have been a great help, but too expensive. at this point in my career, i have basically given up and my lunch hour is spent catching up. to reduce the frustration by patients, i let them know at first appt that i will always be late, except for the earliest appointments (which no one wants, anyways).

 

[BobBarker]

High rent can be a problem but the layout of the office isn’t hurting your throughput at this point.

@Pain Applicant1 script is very helpful and spot on. I mostly just talk about the weather, the parking situation, etc for one minute. If I find a joke that works, I repeat it every patient. Then down to business.

I have seen two today so far without a MA.

 

[Pain Applicant1]

Great tips.

What I like best about the scribe is they allow me to stay 100% eyes on the patient instead of typing. This worked really well in my old practice because, once well trained, I could easily bounce from room to room doing only the most critical things and almost NEVER looking at a computer unless to view imaging. New guy is a FNG- but promising. He's premed, so well motivated. I doubt I'll keep him more than a year though. Deal with the devil.

Tell me about the layout of your office and how the physical flow works. This is important to me right now because I'm looking at switching offices to save on my absolutely ridiculous rent.

Not to further complicate your life but commercial real estate may become a good investment in the very near future. Consider investing in a property. While you'll have other problems for sure paying exorbitant rent will not be one of them. If you're going to rent, cut your space to as little as possible. Think about how much space you actually need. It's not too much.

I have one employee let's call her FDP (front desk person). Pt (patient) #1 comes in and sees FDP. Pt #1 gets placed in room 1 if new or f/u or in the procedure suite for a procedure. If a room I see Pt #1 while Pt#2 comes in and sees FDP. FDP places Pt#2 in room 2 or the procedure suite while I'm seeing Pt #1. I finish Pt #1 who then checks out with FDP while I go see Pt #2. Pt #3 comes in and sees FDP and gets placed in room 1 while I'm seeing Pt #2. On and on and on.... Telemed helps facilitate this btw and has worked wonders for me.

If a procedure: Pt #1 gets set up in procedure suite and I go in and see them. I do the prepping while FDP sets up Pt #2 in a room. The front desk is left unattended while FDP comes into the fluoro suite and moves my fluoro for me (I step on the pedal, not her). A sign on the front desk window directs pts who enter the office to our lovely waiting room and informs them we will be with them within a few minutes. I finish up the procedure and go see Pt#2 while FDP rooms Pt#3. On and on and on...

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Another thing you can do is to request advice from ducttape on how to run it efficiently and then do the exact opposite, lol!!! I do not want this guy running my business. However, I do want him as my PCP.

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Heading out to the farm. Happy to answer more questions but won't be back here until next week. You'll get it, don't worry. I see big big money bags in your future. I'm rarely wrong about these things.

Speaking of farm, if anyone is interested in a whole or half cow - non-certified 100% organic, humanely raised, grass-fed, all-natural, no abx, etc HMU. Angus and Angus crossed with Hereferd. Getting ready for slaughter within the next several months. Beautiful marbleized beef. Look up the breeds. Butcher makes any cuts you want, vacuum packs and freezes it so stays fresh forever. Works out to less than store-bought.

 

[callmeanesthesia]

I’m certainly not the fastest but I prioritize not taking charting home, and pay for that luxury. EMR is very click-heavy with its templates so I can’t really document and talk at the same time (or maybe that’s just me). I use 2 scribe/MAs. One is seeing a patient with me, while the other is rooming the next patient. They capture and document pertinent details like PEG score, and most of the HPI before I enter the room. As we are finishing up, I circle diagnoses, pertinent PE findings, charges, and orders on a sheet of paper, give it to the scribe, and they complete the note, unless it’s a really complicated one in which case I use Dragon to dictate a paragraph or 2 into the plan before closing it. Before moving onto the next, I review the referral packet and their imaging (not just the report). I do certainly get slowed down by looking into their other medical issues sometimes, or get roped into dealing with multiple pain complaints in one visit, but sometimes that’s hard to avoid when they’re coming from 2-3 hours away and have poor access to even primary care. 30 minute new, 15 minute f/u visits for me, but all the routine f/u like MBBs go to my mid-levels so I’m usually seeing more complicated ones where several procedures didn’t work or the imaging doesn’t match with their symptoms.

 

[Ducttape]

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Another thing you can do is to request advice from ducttape on how to run it efficiently and then do the exact opposite, lol!!! I do not want this guy running my business. However, I do want him as my PCP.

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thank you for the compliment.

and i couldnt agree more about me not running the office.

 

[forchinet121]

thank you for the compliment.

and i couldnt agree more about me not running the office.

Yeah he’s essentially saying you’re a good physician and not a money hungry robot

 

[powermd]

I'm doing what you you suggested today and making sure notes and billing are done at the end of each encounter, so far so good- and I'm on schedule.

Here is a proposed floorplan for a 1200 sq ft office I'm looking at. The base rent is great 16-18/foot, but with the proposed buildout that balloons to $33/ft NNN for 5 years.

 

[drrosenrosen]

I've always had my notes done when I leave work at the end of the day. I can't imagine staying up late doing documentation or - even worse - leaving things undone for weeks at a time. I do a combination of templates and dragon.

In response to the advice in this thread, I think I'm going to look at my procedure followups first - more prn followups for easy q3mo epidurals, maybe stretch everything out to 4 weeks.

People who do COT, how often do you see your patients? I do monthly for schedule II, will stretch it to q3mo for tramadol or bupe.

 

[BobBarker]

That is a really small office but it looks like it would work. There isn’t any room for an autoclave to clean RF Probes. I like it though.

 

[powermd]

That is a really small office but it looks like it would work. There isn’t any room for an autoclave to clean RF Probes. I like it though.

I was going to put the autoclave on the counter in the procedure suite. The nicest thing about this office is the double exposure windows. It's on the second level, so it gets a lot of light. So many first floor spots are dingy.

The downside- no room to grow (but how much do I really need?) and at $33/ft NNN, that's a lot of rent. If the buildout costs could be separated from the base rent, and rent returns to baseline after the buildout is paid, that would be way more attractive. Have to ask about that. If I move to this spot, I'm also going to need to lease a fluoro, table, and US. GE is running a quote for me on a 9900.

 

[Agast]

Has anyone looked into the new AI scribe companies? Saw some positive buzz on Freed AI and a sample H&P. I'm wondering if it can be trained to include the boiler plate requirements needed to get procedures approved.

 

[Pain Applicant1]

I'm doing what you you suggested today and making sure notes and billing are done at the end of each encounter, so far so good- and I'm on schedule.

Here is a proposed floorplan for a 1200 sq ft office I'm looking at. The base rent is great 16-18/foot, but with the proposed buildout that balloons to $33/ft NNN for 5 years.

View attachment 374258

Here's my floor plan. I just drew it up last week. I have a new tenant coming into the building and the town made me redraw every suite in it before they agree to issue my incoming tenant their business license - this way they can update their records. Grrrr 😖 - gov overreach but I understand why.

Anyway, I designed it as best as possible with what I had and it works for me. I sublease the back of the office.

I think an ideal buildout would be to work in a circle. IOW, you move circularly from room to room while the pt exits. This way, you minimize your steps between pts and you don't have to worry about bumping into them when they're exiting. This limits additional questions that can hold you up. Also, a few extra steps can add up to an additional pt or 2 per day. I'm not sure how to work this out in your size office and I think your plan will work fine. If you have other options drawn out post them if you'd like an opinion on which may be more conducive.

You can always consider doing the buildout yourself or negotiating it. In most places, commercial landlords are hurting. I personally don't do triple N leases. I do modified gross and I always offer my properties below FMV. I'd rather have a happy tenant who knows they have a good deal than go a few months with a vacancy. I think most small commercial landlords like me would take that approach. The bigger guys can afford to be empty and wait as it benefits them in the long run and the overhead is spread out. Consider a mom-and-pop shop.

Be cautious about what you tell your zoning/planning commission and what's listed on your floor plan. They tend to have strict requirements regarding the type of business, expected customers/patient quantities, etc. They have to be sure that there are enough parking spots, it doesn't inhibit the flow of traffic, there's enough green space, etc. Do NOT lie by any means, but if an office or exam room is used as storage, better to list it as storage, etc. All regions have slightly different code regulations so you may want to verify with your architect that there is no issue with code compliance. If you had your plans drawn up by one, I'm sure you're fine but something to consider. It's not the landlord's responsibility to tell the tenant about this.

 

[powermd]

Size looks great, how many square feet is that? I'm always thinking about putting fluoro in a corner to minimize the need to lead line walls.