The E-Myth Physician: Chapter One

by Michael Gerber

The Story of Keith and Susan

Mind and heart are only different aspects of us.
--"The Dancing Wu Li Masters"
Gary Zukav

Despite what most Doctors think, every business is a family business. To ignore this truth is to court disaster.

This is true whether or not family members actually work in the business. Whatever their relationship with the business, every member of a Doctor's family will be greatly affected by the decisions a Doctor makes about the business.

Unfortunately, Doctors tend to compartmentalize their lives unless some family members are actively involved in their practice. Doctors see their practice as separate from their family. They see their practice as a profession--what they do--and therefore none of their family's business.

"This doesn't concern you," says the Doctor to the spouse.

"I leave business at the office and my family at home," says the Doctor, with blind conviction.

And with equal conviction, I say, "Not true!"

In actuality, your family and practice are inextricably linked to one another. What's happening in your medical practice is also happening at home. Consider the following and ask yourself if each is true:

  • If you're angry at work, you're also angry at home.
  • If you're out of control in your medical practice, you're equally out of control at home.
  • If you're having trouble with money in your medical practice, you're also having trouble with money at home.
  • If you have communication problems in your practice, you're also having communication problems at home.
  • If you don't trust in your practice, you don't trust at home.
  • If you're secretive in your practice, you're equally secretive at home.

And you're paying a huge price for it!

The truth is that your practice and your family are one--and you're the link. Or you should be. Because if you try to keep your practice and your family apart, if you try to keep your practice and your family strangers, you will effectively create two worlds that can never wholeheartedly serve each other. Two worlds that split each other apart.

Let me tell you the story of Keith and Susan.

Keith Roberts and Susan Boga met in college. Participants in an anti-Vietnam sit-in in the chancellor's office, they sat next to each other and talked for hours. Though not a leader of the movement, Keith was one of its fiery orators. Susan thought he was the most dynamic man she had ever met, and soon they were living together.

Though Keith's father, now deceased, had been a doctor, Keith rejected everything his father stood for; rigid discipline, small-town thinking, and medicine. Instead, after graduation he became a landscaper. He loved getting his hands dirty and being his own boss. Still, Susan sensed that something was missing in Keith's life.

Every Christmas, Keith and Susan flew to Iowa to visit Keith's mother. Keith could hardly walk outside without someone approaching him with essentially the same message: "Your father was such a good man. He helped so many people. You must be so proud."

Keith and his father had never been close, so pride was not the first emotion that came to mind. Anger? His father rarely spoke to him except to criticize. Resentment? His father was rarely home.

At his mother's house, Keith was drawn to a photo on the mantle. It was a picture of his father, black bag in one hand, bending over to kiss a little boy who was wearing a leg brace. Though that picture had been there for years, he had never really looked at it. Now he stared at it as though for the first time.

Two nights later, Keith announced that he wanted to go to medical school. Convinced that her husband was meant for great things, Susan readily agreed, promising her support. Through four years of medical school and two years of residency, she worked various jobs to keep them afloat.

Right out of school, Keith--Dr. Roberts--went to work for a medium-size medical practice near Sacramento, California. Soon afterward, Keith and Susan had a daughter. Those were good years. They dearly loved each other, were active members in their church, participated in community organizations, and spend quality time together. All in all, they considered themselves one of the most fortunate families they knew.

But work became troublesome. Dr. Roberts grew increasingly frustrated with the way the practice was run. "I want to go into business for myself," he announced one night. "I want to start my own practice."

Keith and Susan spend many nights talking about the move. Was it something they could afford? Did Keith really have the skills necessary to make a medical practice a success? Were there enough patients to go around? What impact would such a move have on their lifestyle, on their daughter, on their relationship? They asked all the questions they needed to answer before going into business for themselves.

Finally, tired of talking and confident that he could handle whatever he might face, Keith committed to starting his own practice. Because she loved Keith and did not want to stand in his way, Susan went along, offering her own commitment to help.

Thus began the practice of Dr. Roberts. He quit his job, took out a second mortgage on their home, and leased a small office.

In the beginning, it went well. A building boom had hit town, and new families were pouring into the area. Dr. Roberts had no trouble getting new patients. His practice expanded, quickly outgrowing his waiting room.

Within a year, the practice employed an office manager, a receptionist, and a bookkeeper to take care of the money. Keith was ecstatic with the progress his young practice had made. He celebrated by buying a new Mercedes and joining a country club.

Of course, managing a practice was more complicated and time-consuming than working for someone else. Dr. Roberts not only supervised all the jobs his people did but was forever looking for work to keep them busy. In his spare time, he spoke with insurance companies, went to the bank, and waded through piles of paperwork. Dr. Roberts also found himself spending more time on the telephone, mostly dealing with patient complaints and nurturing relationships.

As the months went by and more and more patients came through the door, Dr. Roberts had to spend even more time just trying to keep his head above water.

By the end of its second year, the practice, now employing four full-time and two part-time people, had moved to a larger office downtown. The demands on Dr. Roberts's time had grown with the practice.

The Doctor began leaving home earlier in the morning, returning home later at night. He drank more. He rarely saw his daughter anymore. For the most part, he was resigned to the problem. He saw the hard work as essential to building the "sweat equity" he had long heard about.

Money was also becoming a problem for Dr. Roberts. Although the practice was growing like crazy, money always seemed scarce when it was really needed. He had discovered that insurance companies were often slow to pay.

When Dr. Roberts had worked for someone else, he had been paid twice a month; in his own practice, he often had to wait, sometimes for months. He was still owed money on billings he has submitted more than 90 days before.

When he complained to late-paying insurers, it fell on deaf ears. They would shrug, smile, and promise to do their best, adding, "But you know how business is."

Of course, no matter how slowly Dr. Roberts got paid, he still had to pay his people. This became a relentless problem. Keith often felt like a juggler dancing on a tightrope. A fire burned in his stomach day and night.

Making it worse, Keith began to feel that Susan was insensitive to his troubles. Not that he often talked to his wife about the practice. "Business is business" was Keith's mantra. "It's my responsibility to handle things and Susan's responsibility to take care of our daughter, the house, and me."

Susan's seeming lack of understanding rankled Keith. Didn't she see that he had a practice to take care of? That he was doing it all for his family? Apparently not.

As time went on, Dr. Roberts became more consumed and frustrated by his practice. When he went off on his own, he remembered saying, "I don't like people telling me what to do." But people were still telling him what to do. Just yesterday, his office had to get an insurance authorization for a $6 blood test. It required a long-distance call and several minutes on hold.

Not surprisingly, Susan grew more and more frustrated by her husband's lack of communication, his seeming lack of interest in her and her daughter. She persisted in quizzing him about what was going on at work, why he always looked so stressed. She pressed him to spend more time with his family.

The bookkeeper, Devin, was also becoming a problem. Devin never seemed to have the financial information Dr. Roberts needed to make decisions about payroll and general operating expenses, let alone how much money was available for Keith and Susan's living expenses.

When questioned, Devin would shift his gaze to his feet and say, "Listen, Doctor, I've got a lot more to do around here than you can imagine. It'll take a little more time. Just don't press me, okay?"

Overwhelmed by his own work, Dr. Roberts usually backed off. The last thing he wanted was to upset Devin and have to do the books himself. He could also empathize with what Devin was going through, given their growth over the past year.

Late at night in his office, Dr. Roberts would sometimes recall his first years out of medical school. He missed the simple life. Then, as quickly as the thoughts came, they would vanish. He had work to do and no time for daydreaming. "Having my own medical practice is a great thing," he would remind himself. I simply have to apply myself, as I did in school, and get on with the job. I have to work as hard as I always have when something needed to get done."

Dr. Roberts began to live most of his life inside his head. He began to distrust his people. They never seemed to work hard enough or care about his practice as much as he did. If he wanted to get something done, he usually had to do it himself.

Then one day, the office manager, Karen, quit in a huff, frustrated by the amount of work he was demanding of her. Dr. Roberts was left with a desk full of papers, a waiting room full of patients, and a telephone that wouldn't stop ringing.

Clueless about the work Karen had done, Dr. Roberts was overwhelmed by having to pick up the pieces of a job he didn't understand. His world was turned upside down. He felt like a stranger in his own practice.

Why had he been such a fool? Why hadn't he taken the time to learn what Karen did in the office? Why had he waited until now? Ever the trooper, Dr. Roberts plowed into Karen's job with everything he could muster. What he found shocked him. Karen's work space was a disaster area! Her desk drawers were a jumble of papers, pens, pencils, erasers, rubber bands, envelopes, business cards, and candy.

"What was she thinking?" the Doctor raged.

When he got home that night, even later than usual, he got into a shouting match with Susan. He settled it by storming out of the house to get a drink. Didn't anybody understand him? Didn't anybody care what he was going through?

He returned home only when he was sure Susan was asleep. He slept on the couch. He left early in the morning before anyone was awake. He was in no mood for questions or arguments.

When Dr. Roberts got to the office, he immediately headed for the medicine cabinet

What lessons can we draw from Keith and Susan's story? As I've already empathically said, every business is a family business. Every business profoundly touches every family member, even those not working in the business. Every business either gives to the family or takes from the family, just as individual family members do.

If the business takes, the family is always the first to pay the price.

In order for Dr. Roberts to free himself from his prison, he first had to admit his vulnerability. He had to confess to himself and his family that he really didn't know enough about his own practice and how to grow it.

Dr. Roberts had tried to do it all himself. Had he succeeded, had the practice supported his family in the style he imagined, he would have burst with pride. Instead, he had unwittingly isolated himself, thereby achieving the exact opposite of what he sought.

He destroyed his life--and his family's life along with it.

Repeat after me: "Every business is a family business."

Are you like Dr. Roberts? I believe all Doctors share a common soul with him. You must learn that a business is only a business. It is not your life. But it is also true that your business can have a profoundly negative impact on your life unless you learn how to do it differently than most Doctors do it. Differently than Dr. Roberts did it.

Dr. Roberts's practice could have served his and his family's life. But for that to happen, the Doctor would have had to learn how to master his practice.

Instead, Dr. Roberts's practice consumed him. Lacking a true understanding of the essential strategic thinking that would have allowed him to create something unique, Dr. Roberts and his family were doomed before he even opened his doors.

This book contains the secrets that Dr. Roberts should have known.

Let's start with the subject of money.

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