One Day, No Frills

Process, Not Results

Much is said about successful people, although the primary focus is on the results. As if it were the idea that mattered, or simply that the ends mattered more than the means. The way people perceive success seems very skewed. You need look no further than the questions you might ask when you hear about someone highly successful:

Likely Questions: What is their net worth? How much money do you make?

Unlikely Questions: How many hours per day do you read? What is a sacrifice you regularly make to ensure success?

The distinction I’m making here is about process vs. results. Society is far more concerned with how the hot dog tastes than how it’s made. And not enough is written on the factory that put it together.

My Process — Living A Day In My Shoes

I’m 25 years old. You’d think that writing about how crazy my work week has been would be a mix of arrogance and contain a sense of self-importance. You might be right, although I’m writing this mainly to look back on in the future. Because this week was the most brutally intense, emotionally raw, sleep-deprived, and also rewarding than perhaps any other I’ve experienced.

This is a template — the best I can provide — to indicate how I think and how you might go about leaving society’s conveyor belt behind. If you are comfortable then this blog post will be a waste of your time.

And The Alarm Goes Off

There’s that familiar headache you’ve grown accustomed to. You allowed yourself only 4.5 hours of sleep the night before because of something interesting you were reading. Cutting yourself off of something interesting was never something you were able to do, ever since preschool.

You wrestle with your mind and physically rock back and forth on your mattress, trying to will yourself vertical. Finally the floor is beneath you and you’ve taken a few steps towards the bathroom. Before you have the bathroom light on, it hits you — you have the unique privilege of running a company all day. You smile and a light turns on in your head very quickly. The headache is gone. You are already thinking about racing against the clock to setup for the first patient.

Your morning routine is about 4 minutes before you’re out the door. It’s 7AM and you have about ten minutes before the doctor shows up. You have a few patients waiting, although your operative got there at ten minutes before 7.

The clinic has a lopsided schedule because of your doctor’s availability. He works at 3 other practices in the city and you only have for a brief period of time in the morning. This was fine when you first opened, as you had plenty of time to think and discuss treatment as a team. But where we used to be stressed with 4 or 5 patients in the morning clinic, now you’re pushing through 9 or 10 over the same time period. And you haven’t added any staff in the meantime.

As the manager, you had to be at the clinic the night before to set up the best you could ahead of time. Sunday night you were at the clinic for over an hour — around 9PM — making sure all the patients had the forms they needed. The parking lot was empty at 1030PM when you headed home. It seems our healthcare system was home watching TV as premiums silently rose across the country by 30% this year.

Even with properly set up charts, there are at least ten things to keep track of during this very brief, very intense spurt of treatment that your small team is about to embark on.

You keep an eye on the lobby when you can, as a group of patients previously addicted to heroin requires it.

You help your clinical operative when a patient’s drug screen comes back positive for illicit substances. A discussion ensues about what to do next — this is not a paint by numbers decision. You look at past behavior in the chart and come to a decision together with the treatment team.

The doctor finishes with the patient he was seeing and you do the “hand off”. This is where you have ten seconds to explain what matters about the next patient and you let the doctor know about the relapse. He’s been practicing for decades and you picked up your first clinical guideline on this ten months ago. It’s his call as to what happens next. But you are part of the discussion, as you spend more time with the patient than he does.

After the hand off, you race to copy the prescription you were just handed, for the prior patient. You check their recent attendance and realize they need therapy in the next week. You quickly walk to the lobby and hand the script to the patient, explaining that to remain in the program, they’d have to come back by Friday for a session. They agree to call in later that day to schedule something.

As you walk back to the back room to repeat for the next patient, the phone rings. There’s nobody else in the clinic and you have to answer, while setting up the next patient’s chart. A patient explains that they are late but on their way. You tell them the doctor can’t wait around and they may have to come back tomorrow, but they can still try if they want. You have limited resources and unfortunately it can get in the way for your patients. This makes the patient angry, even though it’s now 730AM and the patient was supposed to be here thirty minutes prior.

The insurance company needs certain signatures from the physician to approve the payment for Suboxone. It’s an expensive medication, and also a controlled substance, and so certain documentation is required. It’s their way of inserting themselves into the clinic and their process for doing so is very inappropriate, but you have no power in that discussion. If you forget to get something signed then the patient cannot get their medication paid for, and so you make a point to not mess that up. You won’t see the physician again after he leaves for the day.

You race to the hallway and ask your operative if he needs anything. Things are running smoothly and he has everything under control. The doctor walks out of the exam he just performed and expects his next patient within 30 seconds. You are moving fast and make it happen seamlessly.

This continues for anywhere from 8–10, maybe 11 patients each morning. You are used to it but it’s also extremely intense. At the end of your clinic, everyone needs a breath. The doctor doesn’t say anything — this is likely the fastest he’ll work today. The operative sits down. Your head is spinning and all you want is some coffee.

But the phone rings. Another patient wants to know if its okay that they’re late. You explain that the doctor just left. Suddenly their faulty alarm clock is your fault. But you’ve answered the phone thousands of times since the clinic opened and you know how to handle this. The patient will go into withdrawal from the medication you prescribe — Suboxone — if they don’t have steady access to it. You want to hold them accountable for their tardiness but it would be too cruel. You tell the patient you’ll get them in tomorrow and that Suboxone is long-acting, so they won’t experience more than mild withdrawal symptoms. They’re thankful you’re here to help, because all too often, other practices aren’t so forgiving about noncompliance. But you still mark their tardiness in their chart.

You head to the Starbucks nearby. All the employees know you there — you’ve been coming here every day for the past 10 months. You grab coffee for you and your counselor — it will be the two of you the rest of the day. This ten-minute interlude allows you to decompress and process what just happened. You’ve done enough work to be satisfied with the rest of the day and it’s not 9AM yet. And so you allow yourself a moment to breathe.

You race back to the clinic and get a call on your cellphone on the way. Call forwarding may seem like a great technology service, but it shackles you to the clinic’s operations all day, even when you’re not at the clinic. You have even added new patients to the schedule as late as 11PM, which is somewhat bizarre, as they don’t expect an answer that late. You wonder why they called in the first place.

The counselor has a full day ahead — one assessment each hour until you close. These first appointments have a less than stellar attendance record as a group however. Most incoming patients blame the lack of a ride, but the real reason is fear or indifference. Seeking treatment for something so personal as substance use is never easy. You are as friendly and helpful as possible for all new callers trying to get in. But, invariably, you are hovering around 50% no show rates. And so a fully scheduled day for the counselor isn’t necessarily guaranteed to be as crazy as the schedule would suggest.

But the counselor’s schedule has very little bearing on you. Each patient he sees is a full hour, while you only have to do a few minutes of work.

The real drain is the phone. And it drains more than your time.

Your main objective to grow now is to complete the regulatory binders so that the state has no excuses when they come to survey your program next month. These are dense and require attention to detail. Do you have a grievance policy that addresses these seven items? And did you post it in your lobby? There are hundreds of these little items. But as soon as you start on one, the phone rings.

A patient can’t find your clinic and they don’t have GPS. Maybe they are wondering if you got their blood work back so they can see the doctor for the first time. Or it’s a new patient, who you either direct to another provider in the city because you only accept a limited number of insurance plans, or you take ten minutes to collect information from them.

In isolation, a phone call is a great thing. It allows you to help someone and provide excellent support to their life. But as a group, these are people who have mental health issues and need more help than your average person. And I would estimate as many as half are not sober when I talk to them, at least not the new callers. This is not a complaint — it’s simply how addiction treatment works. And it can be draining.

Enough draining and repetitive phone calls will tax even the most well rested individuals. Some patients call and accuse you of incompetence when their insurance company is to blame. Some interrupt you incessantly. Others yell or cry or threaten. You remain firm and assertive, emboldened that you are their leader. But the lack of sleep and repetitive phone calls can add up. You’re not always perfect. But you learn not to carry around mistakes with you — you don’t have the energy for it. And apologies later are better than letting a patient get away with something that hurts their odds at recovery.

This cycle repeats all day long. You might get twenty minutes to sit down and fix a treatment form for future use. But the regulatory binder gets ignored until the evening, or the weekend. That’s what will help you grow the business. But you force yourself to try mastering this stage, as brutal as it is. You won’t have to be doing this in a month or two — you’ll be training your replacement(s) soon.

All the patient phone calls receive your respect and a certain level of allowance for the difficult situation they find themselves in. That same courtesy is not extended to the insurance company or their prior authorization department. The ends justify the means — the patient is your responsibility and you are their biggest, and only, advocate. Or so you tell yourself.

The context for this fight is simple — they require paperwork to be filled out perfectly and faxed to them. Their fax machines were apparently bought at the fall of the Berlin Wall from the Soviet Union and are completely useless. You sit around waiting 24 hours for the approval, and in the meantime, the new patient cannot get their medication covered. You spend at least 2–3 hours per week explaining to your angry patients that the insurance company has a process seemingly designed by the same people who are in charge of Comcast’s customer service department. But their local pharmacist at CVS told the patient it’s your fault, and so the patient thinks they know something you don’t. This is not a fun conversation, nor does it need to happen. Alas, the incompetence is so widespread in healthcare that everyone accepts this at face value and nothing changes.

After bouncing around at high speeds all day, it’s 4PM and your counselor is so tired you hope he can drive home okay. You don’t remember what happened in your morning clinic because too much happened since. And you look ahead to the next day — it seems that there are even more scheduled then than there were today. You don’t sit down because you’ll fall asleep, so you move around and clean up the clinic from a rough day. Your counselor leaves and you have silence for the first time, only to have more phone calls come in around 5PM when people are getting off work.

The rest of your day is an attempt to exercise, eat, and have energy to work on building out the treatment programs you want to launch. What you have now is one treatment program, albeit one in high demand. You have three others that you want to launch in the next month or two. And then there is some vague thought that crosses your mind about maybe finding a date one of these days. Or the words of your mother banging around in the back of your head, something about balance…

Anecdotes From This Week Only

I’ve written enough on a typical day. This isn’t an exaggeration, but I also don’t feel like I’m in reality. That’s okay though. It’s really quite exciting and we’re helping a lot of people. What’s missing from it are the anecdotes that come with coordinating care for patients recovering from opioids. Here are the stories that I can remember from this week:

- A patient called when their medications were not being covered in that first day. I explained the fax machines from the Soviet Union and this patient kept interrupting. So I cut him off and said:
 “The longer this conversation goes, the worse it’s going to end up for you.”
 I was on my lack of sleep as usual, but it quieted the patient. I explained that we had to wait 24 hours, as I know he was instructed when he was at the clinic. I told him that there was nothing that he could do, nor that I could do, and that we had to sit and wait. His response?
 “Fuck you dude…” and hangs up on me. This is the first time I’ve heard this.
 His wife called twenty minutes later and was much more pleasant, although she didn’t comment on that prior phone call. I communicated what was needed and she understood.
 I then called the patient back the next day to let him know his medication was approved. He apologized, as did I, and he thanked me. We will have a good relationship going forward and I think he understands. I certainly do.

- A patient called after leaving the clinic, saying they saw someone shooting heroin in the parking lot. That it triggered her to see a needle. I had our counselor call later that morning to make sure she was okay. It turns out a patient’s companion was the one shooting up. This was not the first major issue from this patient and we dismissed her for the day.

- I spoke with a woman who came with one of our new patients, and she was very obviously high on opioids. She couldn’t fully form her words. I had her repeat herself twice and put just a twinge of fear in her, as it is unacceptable to have someone this high in a clinical setting. I learned later that she was in our bathroom for nearly twenty minutes and our operative dismissed her as soon as he could. But I spoke to her in between that short period. It seems the boundaries disappear when you are sick enough — this isn’t a reflection of character as much as you probably assume it to be.

- I spent the better part of two hours debating situational prescribing with one of our physicians. I haven’t been in healthcare for a year yet, but this also isn’t his primary specialty. We are debating the decisions we have to make when a patient is positive on their drug screen for different substances. If they have meth in their system, what’s the best option? How about Xanax? Or a combination of cocaine and opioids?
 The goal is safety first, but after that is covered, you want to avoid denying treatment. Even two days off of Suboxone can be incredibly difficult.

- I had a heart to heart with one of our sicker patients over the phone, hoping to encourage her to think about recovery treatment the way we do. If she isn’t getting the help she needs here, why keep forcing it? It may be what she wants, but if it’s not working, then maybe a more hands-on approach is a better start to recovery. I also told her that we don’t like having to deny prescriptions after a relapse, or remind her to call ahead of time if she can’t make an appointment. That we’re here for her and it’s not fun to have to set hard boundaries. She comes back next week and I’m hopeful it’s a productive path forward.

- I sat with a new patient’s father for twenty minutes and explained everything I’d want to know if my son was having trouble. I told him how we do things, how progress through treatment typically goes if someone is proactive, and what we look for in being able to best assist in recovery. Even after I’m gone from the day-to-day operations of a clinic, I want to encourage our employees to do the same thing, as the shift in his demeanor was palpable. He went from fear and a sense of being lost, to having some hope.

- I took three phone calls from the other large addiction providers in the city. There are only four, so having three call the same week was huge. They didn’t know about us until this week — and they all seemingly found out about us at the same time. We keep a low profile because we wanted to perfect our program before mass enrollment. Alas, it felt powerful to instill excitement in all three coordinators I spoke with. We accept insurance that nobody else does. Since those calls, we’ve already gotten a few patients as a result of my contact with the coordinators.

- We discharged a patient who was too sick to remain in treatment with us. This happens maybe once per week. It’s not something we enjoy, but sometimes it has to be done for their safety. She called back, obviously intoxicated, and threatened us: that she had secretly video recorded all our interactions and that a news team was on their way to her house. I tried suggesting contacting the hospital but she swiftly hung up.

- We received our first check from the insurance company since we opened. They dragged their feet signing us up in their computer system and we were punished by this incompetence. But we now have confirmation that we billed our services correctly and our numbers are real. We have cash flow now — something to celebrate and realize how long it took. 136 days since we opened our doors and 339 days since I first started work on making the clinic a reality.

That’s all from this past week. And only from me — my partner has an equal amount of stories from his role. I probably forgot a fair amount, as there’s too much to hold in my head after even a few days.

It may sound strange, but I know all of our active patients very well. I take all their phone calls and talk regularly to our treatment team about them. I never see them in person, except to do basic things like give them their prescriptions. But they know me from the phone calls and often ask for me by name. All of this is a really unique thing to do with your life.

Looking Ahead, And Tying It All Together

We’re getting closer to what I love the best, which is applying finance to the growth of our business. I spent years learning finance and corporate history. But this phase — the management and operation — has proven extremely rewarding. Until you are among the trees, I don’t think you really understand or appreciate the forest.

This is why I value process and the work in others. If you’re a bum on the street but can play guitar well, I think your value as a person is infinitely more than a paper pusher earning six figures at an insurance company as they approve documents with a high-90% approval rate.