Chris Kresser: Okay, so I’ll give you Amy’s situation because Amy’s a full-time clinician at CCFM, whereas I, I’m on a more limited schedule because of my other obligations and commitments. I can tell you though how it went for me from the start after I tell you about Amy’s situation now. I should also mention at CCFM, a full-time schedule for clinicians is 24 patient hours a week, which might be less than some other places. I believe that it’s a good idea to give clinicians time to do research and plenty of time to do charting and explore some of the nonclinical aspects of care, and, of course, to have time to take care of themselves and continue getting further training, etc. So 24 hours is a full-time schedule. The way that breaks down in terms of initial consults and case reviews is, I believe, Amy is doing somewhere between seven and eight initial consults a week and then six or seven case reviews per week. The discrepancy there is that even though the number, the percentage of people who do an initial consult who didn’t go on to do a case review is very high, it’s not 100 percent. There’s some drop off people who do an initial consult and just decide that it’s not the right approach for them, or maybe the timing isn’t right, or any number of reasons.
So, during a given week, there are seven to eight initial consults, those are 30-minute appointments, and there’s six to seven case reviews, and for Amy, those are 75-minute in-person appointments, whereas for me they’re 60 minutes. Then she does a number of, the remaining hours would be established patient visits. That’s roughly how it breaks down for her. In the beginning I was, how did I overcome the gap between the initial consults and the report of findings? Actually, I think in the beginning I charged for the entire case review up front. Now I break it up where the initial consult, the patient pays for the initial consult first, and then they don’t pay for the case review until they have the case review. Initially I think I was charging for the entire service, just seeing it as one service and asking people to make the commitment up front. So from a cashflow perspective, that helped me to deal with that potential gap between the initial consult and the case review.
Another thing is that you could adjust the testing that you do in the initial consult somewhat and just focus on blood work. I think at one point I was even just focusing on blood work initially because it was, you can get the results back very quickly, and the gap between the initial consult and the case reveiw then only really has to be a couple of weeks. You can order the additional testing after that. So it’s flexible. There are a lot of different ways you can change it based on your own situation.
Then in terms of the flow of your patients, just going back to my own experience. That’s one of the trickiest things I’ve found in terms of having a practice is managing the flow of patients. There are times when, because I was only in the clinic for two or 2-½ days a week, and I was taking six new patients a week. Over time, I found that that actually would lead to too long of a wait for existing patients. If I took six new patients a week consistently, then I had the case reviews to do during my clinic hours and the initial consults. There weren’t enough spots left for established patient visits to enable people to schedule an appointment promptly—a follow-up appointment promptly. And my wait for follow-up visits started to get out to like two months or more, which I feel like is too long in order to ensure continuity of care.
That’s when I actually started to think about hiring somebody else, and I started out to train Amy, and then once Amy was ready, she started to do the initial consults. That removed three hours from my schedule because I was doing six 30-minute appointments. It opened up three more hours of follow-up appointments that I could do during the week. Then eventually, at some point, I stopped taking new patients, as many of you know. But it’s tricky sometimes to find the exact flow of the right flow. You always probably have to be making slight adjustments. At some point, you’ll start to get really full, and that’s a sign that it’s time to bring somebody else on.
But they’re all what we call champagne problems or good problems to have, and they’re all manageable. So, that’s the good news.