The downside(s) of a small private family practice

[Reality Check 2]

Looking for feedback from those in small practices, practice owners or those who have been in admin.

 

​I joined a solo private family doc when the 2 older doc partners retired. It became one doc and 2 PAs serving a 30+ year old practice with over 10,000 patient registrations and about 5500 active patients.

 

Most docs don't have an MBA much less a business degree and were never trained in owning or running a business. Some still use the adage - well, we always did it this way.....

 

My issue is with the office manager. 

 

A medical office manager can make or break a practice through many avenues - staff choices, personality, skills or lack thereof.

 

Unfortunately, many docs become dependent - much too dependent - on an office manager who then gains a sense of power or control and the doc is essentially hostage to this person.

 

Our office manager has been there 5 years - me 1 ½ years. 

 

She had ZERO medical practice experience prior to this job. NO ONE knows why she was hired. The manager who was retiring voted against hiring her but the older docs basically said "get someone in here" and - voila - a nightmare hatched.

 

She is the only one who knows the bank now, the payroll system, the insurance etc and won't allow anyone else to help and she won't delegate any duties. 

 

She is inept in my opinion. Not tech savvy, barely able to handle the computer much less a mediocre EHR. NO KNOWLEDGE of OSHA, codes, standards and certifications. Can barely fill out a credentialing application much less a state license application. Doesn't know SQUAT about meaningful use, MACRA or anything else. 

 

She is flustered easily, brusk, inappropriate with staff, unprofessional, unkempt and avoids any and all active positive interactions - PERIOD. Won't even deal with rude or inappropriate patients in the office or on the phone. The last business she ran - went bankrupt. 

 

I am a threat to her. I have a business degree and 25 years of experience with active working knowledge of everything above that she can't do, won't do and won't delegate or aspire to. When I encounter a problem in the EHR and she won't deal with it - I call them and get it fixed. I call the lab when she won't. I call the vendor when she won't. I find the supply we need when she won't. 

 

And somehow that makes me a bad person.

 

My doc is totally trapped by her, over dependent and absolutely unable to fathom change in the office. 

 

I said I had an issue with her and needed to discuss it. His response - "Be careful. She is invaluable to me......"

 

Well, so am I. Can she see patients and bill out over $750K a year working 4 days a week? 

 

The office is paralyzed by her. Nothing can or will change or progress as long as she is there. She has him hostage even with her limited capacity. 

 

He doesn't know what he doesn't know. He won't even discuss suggestions or changes. 

 

I have twice the years of experience as my doc. I have experienced multiple office managers, styles, systems and can see so much we could improve or change and even come up to code on and avoid fines and citations....... 

 

No go. He won't go there.

 

What to do? There are issues I cannot overlook. I am a strong personality with a lot of skills and I am a do-er - fix shit. Get it done. Do it right. Do it right the next time. 

 

Unbelievably frustrating.

 

 

[UGoLong]

I also work in a solo practice -- I have for 10 years -- with an office manager. Actually we've had several. I only had problems (and then not too many) with the first one we had. I have 40 years plus working at many levels in many places as well.  

 

If your boss won't deal with your office manager, it's a safe bet that you won't be able to either. 

 

I doubt that railing about her lack of qualifications is going to have any effect; it's her performance that is the issue (lack of qualifications are a likely cause, not an effect). Your choices to me are:

 

1. Putting up with things as they are and learning to deal with it (that sucks)

2. Recognizing that you are, in the end, an employee, so just do your job and stop trying to do her's too. If the EMR needs fixing, tell her and your boss. If she doesn't deal with the lab, tell her and your boss. Not as a snitch, but to say that you are doing your job and can't do what your boss expects unless someone gets the problem that is not your responsibility taken care of.

3. Get your boss to counsel, train, or replace her.

4. Leave and find a better place.

 

I personally would have a hard time with 1 or 2. You've already proven that you can't get your boss to replace her. 3 doesn't seem to work, but maybe there is a less confrontational, more creative way to do it.

 

Simply bitching some more about her to him might end costing you your job. Option 4 is looking better all the time.

 

Good luck!

[south]

Pretty much agree with the options above.  You can either choose your time to be the ship deserting this sinking rat, or kind of suck it up and learn to ignore it and be happy.  

 

The latter sounds like a negative connotation when you read it, but possibly the biggest mistake I ever made - which straight up ruined my life - was based on my getting all righteous and up in arms about stuff that just didn't matter at all.  Had I applied a little bit of "really not my concern", I would have retired comfortably about right now.

 

Take that for whatever it's worth.  If I find myself in a great situation like that again, watch me ignore stuff!

 

It is , of course, really fun to think about going to your boss and putting a plan in front of him to (1) hire a temp PA, then (2) curb this toxic dumbass as you take over (half time) until someone else gets hired and up to speed, then (3) going back full time and (4) make a decision to keep the new PA or not (sounds like they need one).  Six months of work or so to improve things dramatically.

 

Won't work though - he's too passive.  Doesn't seem to care about the lack of efficiency costing him money and business.  I don't think you can fix that, man.  Most of us know several of these docs.  Feel for ya.

[TWR]

RC 2 I have worked family medicine for 31 tears. Now retired. The first 18 were the best. I owned my own practice and called all the shots. Had staff of 4. The same 4 for my entire tenure in NYC. I see two choices for you, suck it up and put blinders on. This is not you! Over the course of time and following your response to many posts, this just is not your personality! Therefore you must leave the practice as professionally as you can. The situation will not change. I find very suspicious the fact that the om controls everything.

ps are you originally from NY or around there?

[Reality Check 2]

RC 2 I have worked family medicine for 31 tears. Now retired. The first 18 were the best. I owned my own practice and called all the shots. Had staff of 4. The same 4 for my entire tenure in NYC. I see two choices for you, suck it up and put blinders on. This is not you! Over the course of time and following your response to many posts, this just is not your personality! Therefore you must leave the practice as professionally as you can. The situation will not change. I find very suspicious the fact that the om controls everything.

ps are you originally from NY or around there?

 

 

I am a Texas girl, born and bred. Moved to Washington a long time ago.

My mom taught us an independence thing that seems to be pretty loud sometimes.

[sk732]

Violence therapy?

[Reality Check 2]

This practice has only employed PAs in a support role in the past and now 2 of us ARE the panel providers for a large number of patients.

 

The office manager doesn't really get it that we ARE providers - not owners - but still vital decision driving forces within a practice. The doc doesn't quite grasp that yet either.

 

And that is a major influence in my desire to have PAs with certain levels of experience be eligible for independent practice and autonomy.

 

I am not a cog. I am not a drone. I do NOT answer to the office manager on any level except scheduling my vacations and doing payroll etc. She is NOT my boss. I am not a subordinate.

 

That ideation is so hard to overcome. 

 

This particular manager is old enough and of a generation that she would never refer to the doc as anything but "DOCTOR" even when he wants his first name used in the office. It is a deference based on perceived position and power. It is highly outdated.

 

I don't see a future here. It makes me sad. It makes me want to open a hardware store again or a doggy day care and say goodbye to medicine. But, I can't - locked into a needed income for now.

[overthehorizen]

What I am about to say won't be of great help to Reality Check 2 but her experience can be helpful to others. I would say that it is imperative to understand the practice dynamics and operations prior to joining. When offered a job, respond with contract specifics that prevent you as a PA from being marginalized and cheated.  I interviewed with a practice recently that converted from private ownership to a third party ownership by a group that owns multiple practices in the state. The practice manager who was designated to represent the firm in all dealings tried to sell me something I wouldn't buy. So I wrote back with requirements for a contract. The firm never responded. The practice manager has a degree from a community college and the practice calls her the Chief Executive Officer. Something there doesn't match up. I sensed problems from the start. I gave them a chance to make a presentation. In the end, I realized there are many practices where Physicians win and PAs lose. They don't want to operate in any other manner.

[probasestealer]

I'm in solo practice I've found everything to be much more complicated with extra hoops to jump through at every turn (IT, prior-auths, EMR, etc). Can't beat the other perks of a small office.

 

Your situation sounds like a nightmare. I think you really have 2 choices, leave or learn to deal with the chaos. I would certainly STOP doing her job for her, but I realize that your personality problem won't allow you to not do things the right way...

[Reality Check 2]

Today I received a handwritten apology note from the office manager about her recent outburst and poor handling of a situation with my MA.

 

So, the doc had to have said something - or another staff member - and she was held to a standard of behavior.

 

A first step, a baby step.....

 

A small bit of hope.

[rev ronin]

Consider that she may be stealing--robbing the practice blind.  No one person should be allowed to have sole financial control of anything, anywhere.  If the doc wants it that way, he's sufficiently naive to financial reality and human nature that I would not want my financial future tied to his.

[ventana]

challenges abound as a PA gets long in the tooth....

 

in this situation - I believe you have to prove you are the invaluable one in the practice not some schmo....

 

So start taking on little things, learn the banking, payroll, staffing

 

hold her to a professional standard in all dealings with you - and treat her like a professional as well (to easy to try to sabotage her, but that is bad)

 

Take credit for what you do, show that you are the leader and the practice will not run with out you....

 

 

should work, BUT some don's never see the light, and an office manager is ZERO threat to the doc, a PA who also knows the business is a huge threat (not really but they make it so sometimes)

 

 

 

 

BTW I have 15 years experience, two business degrees, and lots of real world business experience including opening and running my own practice and yet I still have to do the above in my current job....  and even yesterday had to remind them of this......

[south]

Consider that she may be stealing--robbing the practice blind

You know, this is a good point.  If you want to get away with something like this, make it painful to deal with you and people's natural inclination is to leave you to your own devices.  

 

An office manager could probably get a PA (or a doc) in a lot of trouble if they were to really put their mind to it...ranging all the way from you making some sort of mistake to...your signature is right there for the forging... food for thought

[mgriffiths]

As I've said elsewhere my father is a FM doc.  He is one of around 12-13 owner physicians in the practice.  Two other physicians are in the process of trying to buy in after they were robbed of approximately $1 million.  Their office manager had control of the books, payroll, bank accounts, etc. and nothing can be proved because the paper trail is gone, but the office manager literally fell of the face of the earth one day, along with said paper trail.  Probably down in the Caribbean for a nice vacation before coming back to try and do it to someone else!

 

Those two docs are now a little over $1 million in debt with no way to continue their own practice so had to become employees in my father's practice to raise the capital to buy in.

[jwells78]

There may be another option, but it may not be something youre willing to do.

 

 

"Keep your friends close,

Your enemies closer"

 

I would consider myself more of a hammer than a nail, but in my experience-- making "friends" with people I secretly loathe and appealing to them has worked in situations like this.

 

Ive seen leaders like this; instead of collaborating and building a cohesive team, they find a way to put their thumb on those they perceive as threats, typically by being nasty and vindictive.

 

BUT, what if she thought of you as her buddy and not a threat? Your influence may just change the entire climate of the practice indirectly.

 

Or you could just bounce... ????

[Reality Check 2]

Whatever happened to make her write me a handwritten apology has shifted the balance.

 

I am obviously regarded - most likely for income ability - and now she has to shift her tactics or get smarter. Found out she has no college education...... 

 

I don't want her job but am highly qualified to do most of it. I am a provider, not a manager. My point to the doc was that she honestly doesn't know what she is doing a lot of the time and that can hurt him immensely.

 

I do fear her making horrible mistakes with finances or legal issues and tanking this practice. I do see her mismanaging funds either stupidly or intentionally and tanking this practice.

 

The doc is just so blind to what he doesn't know.

 

We need an independent auditor to look at the practice and tell the doc what is what and set a base standard for yearly, quarterly, whatever kind of reviews.

 

I just do what has to be done to make sure patients get what they need in a professional manner and in the best medical method. 

 

Not sure what the future holds. Two major corporate monsters hold the monopolies on our town and employers are hard to come by.

 

So, again, staged independent practice rights for PAs with certain amount of experience and give us autonomy so we can bargain for employment or business ownership with more tools and support.

 

And, buy some lottery tickets every now and then.....

[UGoLong]

The big deal to help prevent fraud seems to be for one person to be responsible for accounts receivable and another person for accounts payable. If both are in one person's hands, danger!

[Reality Check 2]

The big deal to help prevent fraud seems to be for one person to be responsible for accounts receivable and another person for accounts payable. If both are in one person's hands, danger!

 

 

The bigger deal is to hire someone who actually knows accounting principles and some knowledge of medical billing or use a good outside service. Outsource payroll for some accountability if possible. Use double signatures on all checks over XX$$ and some other super basic business stuff that I don't see happening. 

 

Seems pretty basic but I bet we would all be shocked by the number of old practices being run by the seat of the pants.

[Houstonian]

Small practices tend to be run like "Mom-and-Pop" shops, not like Fortune 500 corporations.

 

You should do your own job, but if you need to contact EHR, lab, or other outside parties in order to do your job, then you should do so and not rely on an incompetent office manager who has no clue as to why you need these things done.

 

In the meantime, look for a more suitable job situation.

 

It is not likely that you will get this situation satisfactorily resolved. HUGE risk of financial mismanagement/incompetence by current office manager.

[rpackelly]

The worst is when the spouse runs the office and there is a divorce or affair. I have seen this. Second worse, which I have also exp rienced, is when the doc dies unexpectedly. Third, and pretty common, is when the doc sells the practice but does not include the PA, or the doc sells the practice to an awful group. In general larger organizations are more secure.

[DizzyJ]

I'm in an office where the "executive director" is the doc's wife......NEVER EVER AGAIN.  She does a bad job and he at one point tried to get her out of the office, but she refused to turn over information (logins, account info, passwords) to the office manager to take over her duties.  So...she is still here.  

[Reality Check 2]

I'm in an office where the "executive director" is the doc's wife......NEVER EVER AGAIN.  She does a bad job and he at one point tried to get her out of the office, but she refused to turn over information (logins, account info, passwords) to the office manager to take over her duties.  So...she is still here.  

 

Our office manager thought it was no big deal for US to give HER our passwords for certain things so she could "take care of things". I have NEVER given her a single login of mine for anything - and I never will.

My license, my professional integrity, etc. She will NEVER have access to my professional access points that could result in a decision with my name, title and license number on them.

 

However, she hasn't given anyone any of the office data. 

So, worst case scenario - she gets hit by a bus --- WHO is going to do payroll? WHO is going to pay the bills, do insurance, pay taxes, deal with licenses, etc?

 

Very different issues, indeed.

 

My doc just doesn't get it - she WILL retire someday, she could get hit by a bus, she could abscond to Bermuda..... He needs a back up plan and a safe scenario. It doesn't exist. He doesn't get the checks and balances thing.

[DizzyJ]

Our office manager thought it was no big deal for US to give HER our passwords for certain things so she could "take care of things". I have NEVER given her a single login of mine for anything - and I never will.

My license, my professional integrity, etc. She will NEVER have access to my professional access points that could result in a decision with my name, title and license number on them.

 

However, she hasn't given anyone any of the office data. 

So, worst case scenario - she gets hit by a bus --- WHO is going to do payroll? WHO is going to pay the bills, do insurance, pay taxes, deal with licenses, etc?

 

Very different issues, indeed.

 

My doc just doesn't get it - she WILL retire someday, she could get hit by a bus, she could abscond to Bermuda..... He needs a back up plan and a safe scenario. It doesn't exist. He doesn't get the checks and balances thing.

She doesn't have any of my logins/passwords, but has them all for the admin aspect of our EHR, email set up, scheduling program.  She has master admin control and refused to even let the office manager have access to comcast voicemail log in.  it is her job security to keep all this to herself.  She as well can get hit by a bus and then the office will fall apart with no back up plan in place.  

[Guest Paula]

RC. You need to buy the practice.

[Reality Check 2]

RC. You need to buy the practice.

I would rather buy a hardware store.....

But, good idea.