HomeLearning LabsA Conversation with Dr. Melissa Gerdes

A Conversation with Dr. Melissa Gerdes

Trinity Clinic Whitehouse
Whitehouse, Texas

12-12-2006

We join Dr. Gerdes in her office. She is dressed in a maternity top and comfortable slacks and has removed her white jacket. She is 5 months pregnant and tells us she just found out yesterday the baby will be a boy. Her office is tidy with framed photos of children and family everywhere. Dr. Gerdes' demeanor is calm and rather methodical, yet she draws you in when she speaks because of her candor and clarity. She has an understated sense of humor and her eyes sparkle when she laughs. She doesn't mind talking about herself or her training, but she is modest about her accomplishments and innovations. She is, however, evidently very proud of the practice and proud of Family Medicine.

What brought you to Whitehouse, Texas?
Warm weather and family medicine brought me to Texas. I'm originally from Chicago. It wasn't until I got here that I realized Tyler was a perfect fit for me – big enough to have amenities, small enough to let me really practice a wide variety of medicine, which has always been one of the main attractions of Family Medicine for me.  I also wanted to go to a location where Family Medicine was respected and valued.

Initially, the agreement was that I would partner with the male physician who had started the practice. Unfortunately, I didn't know until about a week before I started that he was actually planning to relocate and then retire. So I was left here as a solo practitioner. That was seven years ago. In retrospect I think our ways of practicing medicine may have been in conflict, so in the end, it worked out.

In the early days, I was doing in-patient work at the hospital in addition to running the clinic –  working 70 to 80 hours a week. There was a LOT of learning in the beginning...

What sorts of things did you learn?
I learned that when you start your own practice, there's a whole lot you don't learn in med school.  And I'm not sure if it can be taught! It's just stuff that you really can't learn any other way other than doing. HR, PR, coding, billing, etc.

Did you have any kind of guide or mentor for clinical and practice management?
I received some clinical mentoring within the hospital system, when I was doing in-patient work. But I was pretty much a solo doctor trying to learn and do practice management on-the-fly. I did get some help from the hospital system. For example, if I had an HR question, I called the system HR department. They were very helpful, but still, I can't be calling them every 5 minutes, so a lot you learn just by doing. There was staff here when I started but it's all new staff today. Staff I have hired.

Your clinic has three female doctors and an all-female staff. How does that work out?
We've never had a male work here. How do three females doctors get along? I guess it's because we all have the same goal: we want to work hard while we're here, but then go home to our children and families. When we're here, we're HERE... but when we're not, we're not. It works out very well.

I am a part-time doctor. In my experience, part-time doctors don't seem to care as much about building huge panels. I think many full-time physicians have more of a sense of ownership about their patients. They don't want anyone else to see their patients. I have never thought that I am the only one or even the best one to take care of patients. I'm a better person and a better doctor if I get time away.

That's a mantra we often hear but it's hard to do in practice.
I know, and I think for doctors, it speaks to our medical training. You know, we're told in medical school that we are the ones making the big decisions, we're God, it's all on us... and I'm looking around the room at these rows and rows of doctors in training and thinking "Look at all of us!  Obviously, I am not the ONLY one!" You know, we're not God, and we're not the only doctors of our patients.

How have you found balance while still meeting needs of patients?
Well, I work 4 days a week now. When I made that decision, I had to drop down a panel size. It wouldn't be fair to make my patients wait that long to see me. So, I passed on patients to other providers here.  They are all good doctors.

How do you pass on patients gracefully?
First, we had front office staff say, "We have a new doctor, would you like to come in and see her today or tomorrow?" or something similar to indicate her availability.  We'd let patients know they didn't have to make a permanent switch, but asked them to consider it if they wanted more availability, more access. And of course, I always speak highly of the other doctors.

Do you three have similar practice styles?
We have similar practice styles in the ways that are important.

Are you production-based or on straight salary?
Right now we are production-based. We've had 6 different compensation models since I've been here, and transitions are never easy. I think the production-based system is working for us right now. There is less jealousy and in-fighting. When you're paid a flat salary, there is often a sense that "I'm working harder than so-and-so" and this is especially true with part-time providers on staff.

Do you get compensated for your administrative work?
No, I am .8 provider and that is all clinic time seeing patients.  My administrative work is basically free. I have been in conversations with the hospital and I'm negotiating some sort of stipend for my administrative work.

So just confirming– your leadership efforts for the clinic thus far have been on your own time?
Yes, I have to see patients to get paid. But if I can make things more efficient so we can see more patients and still give the best care, it will pay off. That said, a stipend will be nice.

What are some of your secrets to successful management?
I believe that you have to accept that to practice medicine these days takes more non-patient time than it used to. Maybe 100 years ago, you just practiced medicine. But these days, we have to work ON medicine, work on all the things that allow us to practice better— billing, coding, access, etc.  Rather than fight or ignore this fact, I find that it's far better to work with it.

Another thought I've had is that medicine really needs part-time physicians. Otherwise, the things we need to do to improve medicine won't get done. Serving on boards, volunteering, community projects – all these take time, and a full-time physician working 80 hours a week probably won't be able to do it.

What do you look for when you hire staff?
I stopped looking only for people like me when hiring, I've learned that hiring a bunch of "me's" is not good.  I've grown up and matured to realize that you need some diversity of personality and ideas. I base a lot of my decision on how well I think the person will fit in with the rest of the staff, that's really important. I also look for people who can multi-task easily, who can fit into a lot of different positions. Before I looked for trained people, but now our clinic is large enough that we can train them ourselves. I like that scenario best.

How do you approach managing your employees?
The female doctors here are pretty level-headed and logical.  The nurses have told me this several times. We don't throw things or throw fits. We're all pretty easy to work with. The staff is not afraid they'll lose their jobs if they screw up. I think they feel fairly comfortable talking to us about things.

The physicians and the office manager have weekly meetings on Wednesday, so we 'hold' problems that arise for the Wednesday meeting. When we notice something that needs to be addressed, we say, "Let's put that on the agenda and discuss it Wednesday."

We take an interest in the staff's personal lives, take them out to lunch... that sort of camaraderie is so important. Plus, every Thursday morning, the first 15 minutes is reserved for my staff. I don't see any patients then. We go in my office and we have a one-on-one sit down talk. I ask them how things are going at work and in the office, and how things are going in their personal lives. I might tell them some things coming up, like TransforMED changes we're implementing.  We started doing that 3 years ago and I know they really like it and it means a lot. I know because if we miss one, for whatever reason, they come up to me and say, remember, it's MY turn next Thursday. They want to make sure I don't forget.

I think it speaks volumes that every staff member here except one is also a patient.

Have you ever had an employee who didn't fit and how did you handle it?
Yes, just recently I had to deal with that. Getting rid of an employee in a big hospital system is not easy. What I finally did was say directly to her, "You're not really a good fit here, I think you should ask for a transfer."  She didn't leave right away but eventually she asked for a transfer and that really improved the work environment here.

Tell us about Trinity and its culture of change.
Trinity is very innovative, I've been pretty amazed because they really give me the autonomy to run the clinic the way I want, to make changes without roadblocks. Yet I still have the oversight and support of the big system with all the people that can help me.

Advanced Access is really tough to figure out. How did you do it?
Advanced Access was adopted gradually. We've experimenting with different models for 6 years. We keep changing it to do what works best for us and our patients at that particular point in time.

The first component is that we doctors do not 'guard' the patients. If the regular doctor is not there or can't do it, whoever is available sees the patient. Another big part of successfully implementing Advanced Access is educating your patients. Over time our patients have learned to call the day of or the day before. Right now, 75% of my scheduling is same day or next day, and I see an average of 25 to 30 patients a day, sometimes more. And there's a technology component, too. I can send a flagged messaged to have someone come in on a particular day, I can run reports to see who needs to come in for a check... I'm constantly evaluating. 

How long do you spend on patient visits?
A visit usually lasts about 15 to 20 minutes, although it depends on the patient and the problem. There are always a few patients who are real talkers.  That's just something you have to learn to handle. A few things I've done to maximize the time with the patient without running overtime:

I have asked the nurse to ask them, "What is the goal of your visit today?" That gives me a benchmark to follow and can also make a difference in how I prescribe treatment. For example, their goal might be "to get well by my band concert Friday." I may choose a different mode of treatment. Or, if they start going off on a tangent, I can say, "You said your goal for the day was such-and-such, let's get back to that. If we need to talk about this other problem, let's schedule another visit so we can focus on it more completely."

For patients who crave a lot of physician time and have the tendency to run overtime, I schedule more frequent appointments but in shorter blocks, such as weekly 15 min visits. Bottom line: It's not fair to all the other patients to be kept waiting. So I say, "I'd love to discuss this more, but we have other patients waiting and they are sick too, please call next week and come back in."

How did you develop your leadership skills? Did they just come naturally or have you actively sought to develop these skills?
Well, I have a degree in communications, and that helps. I learned early on that communication truly is important.  As a physician, I've tried to take advantage of all the leadership training that comes my way... conferences or seminar sponsored by the hospital, or the AAFP, or the Texas chapter. I'm always reading books, although it may take me a year to finish one! But yes, I think that even if people are born leaders, they have to work to develop that skill so they are effective and can reach their goals. A lot of it is training, knowing how to direct people, how to delegate.

So the stuff you learn at leadership conferences really is useful?
Some of it – yes! The idea of spending 15 minutes a week with a staff member came from a leadership conference. Not everything will work for your practice, but you have to be open.

What are your hopes for the future?
In the near future, we'll continue our TransforMED practice improvement work, i.e., some form of disease registry

In the far-off future I see us building a new clinic with more space, and hiring more doctors as we need them. Right now we have extremely low overhead – we're really maximizing our space. So I'll be nervous about a larger building and larger practice. And every time I add a new physician, I'm always hesitant, wondering how well it will work.  I do wonder what would happen if we included a full-time male doctor in the mix...

If we build a new clinic, I will feel pressure to go full-time again, and I really don't want that to happen until all my kids are older and in school [Note: Dr. Gerdes' children are 8 and 3, with another on the way.] What I'm doing now is working great for me, so I don't see any big changes while my kids are young,

And with a new clinic, what do you see yourself doing?
I envision some day not seeing patients at all. I am pretty open to whatever may happen: administration, consulting, whatever. My goal is to improve and make sure we are providing excellent care to all our patients.

Trinity Clinic Whitehouse   
Whitehouse, Texas
» Link to practice Web site

Location: Suburban
Age: 6 years old
Size: Small family medicine group practice
Ownership: Hospital-owned

Physicians:
Amy Mullins, MD
Janet Hurley, MD
Melissa S. Gerdes, MD