1 Doctor, 0 Staff

When patients arrive at James Ochi’s office in San Diego, they flip a light switch in the waiting room to announce their arrival. When he’s ready to see them, the solo pediatric otolaryngologist greets them himself and leads them into the exam room. While this provides a nice personal touch to Ochi’s practice, it’s also a necessity — because he really is solo.

Ochi has no receptionist, no nurse, and no front or back office staff. Instead, he does nearly everything himself. Between patients, he sterilizes his instruments, changes the exam table paper, and checks his messages. At the end of each day he straightens up the waiting room, empties the wastebaskets, and puts out the trash. “My colleagues think I’m nuts,” he admits. “But for me, this is the only way to run a practice.”

Ochi didn’t start out practicing like this. After medical school, residency, and a fellowship in England, he joined a pediatric ENT group in San Diego. But in 1992, after less than two years with the group, he decided to go out on his own. “The trouble with many groups,” Ochi explains, “is that there’s often more pressure to serve the needs of the group than the needs of the patients.”

Ochi’s new practice was fairly traditional at first, with two full-time employees. But as managed care became more of a force in the area, he felt pressured to see more patients. “I knew I couldn’t keep up that pace because I wasn’t happy, and my patients weren’t happy,” he recalls. “My colleagues faced the same pressure. Some of them were seeing 50 to 60 patients a day, but their incomes were still dropping due to high overhead and lower reimbursements. Doctors lost control of their practices.”

It was on a medical mission trip to Mexico that Ochi got the inspiration to simplify his practice. “I was sitting there working in a hut that’s smaller than my garage, with no office, no receptionist, and few resources,” he recalls. “I was treating people who had the same problems my patients have back here, and getting the same results. There were dogs and cats running around, and dozens of patients waiting for hours in the hot sun. But despite those conditions, they were happy because someone actually spent time with them. So I began wondering, ‘Why can’t I do that back home?’”

When he returned, Ochi began cutting his overhead so that he wouldn’t feel pressured to see so many patients. The transition took nearly two years and included dropping one full-time staffer. “As my overhead dropped,” says Ochi, “I found I could afford to drop the managed care contracts that weren’t worth the hassle.”

The Secret: Lots of Technology

Ochi’s first big step in automating his practice was converting to electronic records in 1997. That enabled him to let his other full-time employee go, saving $48,000 in salary, benefits, and payroll taxes. And, instead of having a transcriptionist type his dictated chart notes, he uses voice-recognition software that converts them directly into computerized records.

To manage the records, Ochi uses a software program called PaperPort that allows him to pull up charts on his laptop whenever he needs them at the office or at home. He updates and stores the records twice a week on backup DVDs. “Having instant access to medical records is a great advantage,” he says, “particularly for this kind of practice.”

The next step in Ochi’s automation process was online scheduling, for which he uses Microsoft Appointment Manager. Parents now book their children’s appointments on his website, which he designed himself and maintains for only $300 a year. The website at ENT4MyKids.com includes online registration and medical history forms for new patients, which parents fill out and bring with them, along with a referral if necessary.

Ochi checks each day’s online schedule on his laptop and prints out a copy. Some new patients are nervous about making appointments online, but once they arrive they’re struck by the amount of time and personal attention they get from Ochi. As one mother commented after a recent visit, “My husband and I came out of there and wondered, ‘Did we just go into some other time zone?’”

One thing Ochi struggled with in computerizing his practice was trying to choose a single integrated software package that would provide all the services he needed. “Most docs do that because it seems simpler,” he says, “but I think that’s a mistake because none of the integrated packages is good at everything.” Instead, he combined the most useful features from several software packages to create his own system. All the programs he uses are off-the-shelf and available at any computer store.

One reason for Ochi’s success at automating his practice is his obvious comfort with computer technology. “With today’s improved computer performance, compatibility, and reliability, it’s relatively easy to do what I’ve done,” he says. “I could help someone set up this kind of system in an afternoon. In fact, many doctors could do this themselves if they’re fairly proficient. You don’t have to be a computer whiz.”

There are some office jobs that Ochi hasn’t computerized, however, like billing. He now uses an outside service that costs him $27,000 a year — about half what he used to pay the employee who formerly handled the task. And, instead of a receptionist, patients who call the office now get voicemail. It offers an array of options, including a chance to leave messages, which Ochi checks several times a day. “Usually, I call back quickly,” he says, “which patients really appreciate. If they ask a question about their treatment or medication, I can check their chart because I always have my computer with me.”

With no one to share call coverage, Ochi uses a nurse triage service on nights and weekends. If someone calls the office with an urgent problem, the voicemail system routes the call to the triage service, which can contact him if it’s a real emergency.

Less Money, but More Peace of Mind

In 1997, the year Ochi switched to electronic records, his gross income remained pretty much unchanged — a little over $400,000. But because of his reduced overhead, his net actually jumped from $200,000 to $250,000. “I was making more money with less effort,” he notes proudly.

“Once I realized I didn’t have to push myself so hard in order to make a decent living, I started cutting back on my practice,” says Ochi. Instead of seeing 40 to 50 patients a day, he now sees only 10 to 12, and spends at least a half hour with each one. (He also does about 10 surgeries a week at a nearby hospital, and serves as an assistant clinical professor at the UCSD Medical Center.)

Simplifying his practice also made it easier for Ochi to deal with managed care plans. “Many HMO and Medicaid plans pay so little that it wasn’t worth treating their patients,” he explains. “But now it is. Thanks to my lower overhead, I’m one of the few doctors who can afford to see them. And they really appreciate that I give them so much attention, instead of being shuttled through the office like cattle.”

Another advantage of spending more time with his patients is that Ochi is less afraid of a malpractice suit. “That’s not because I’m a gifted clinician,” he explains. “It’s because my patients are getting more attention. As a result, they’re more likely to be forgiving if things don’t turn out as well as they expected.”

As a result of his lower patient volume, Ochi’s gross and net have dropped significantly. But as he insists, “That’s okay with me, because I see it as the price of simplifying my practice. I’m not making as much money, but that doesn’t bother me the way it would if I had higher living expenses, like most of my colleagues. Most of them are very good at making money, but they’re awfully good at spending it, too. The trouble is, that lifestyle keeps you locked in to the high-pressure, high-volume practice that’s required to support it.”

To avoid that trap, Ochi keeps his overhead low at home, as well as at work. At 47, he’s already paid off his home mortgage, saved enough for his children’s college expenses, and is well on the way to funding his retirement. He spends little on vacations or entertainment; he drove his last car for 13 years, and hopes to do the same with his current one.

According to Ochi, his current low-volume practice is not only better for his patients, it’s better for his own peace of mind because it allows him to spend more time with his family and more time on his medical missionary work. Instead of spending just a few days each year working at a mission just across the border in Mexico, he was able to spend two weeks last year serving in Thailand and Cambodia.

A “Nut,” or a Model for His Colleagues?

Since articles about Ochi’s novel practice have appeared in local newspapers, reactions from his colleagues have varied sharply. “Some of them think I’m nuts,” he admits, “and some don’t believe what I’ve done. But I’ve gotten calls from doctors who want to know how I do it. In fact, it’s the primary care doctors who are most interested because they’re being hurt most by the managed care crunch.

“When I’m invited to give talks to medical groups about my practice, I feel like I’m walking around with this great secret. I describe it as a return to the ‘golden age of medicine,’ when you had time to form real relationships with your patients because you knew and trusted them, and they knew and trusted you. The younger doctors often can’t understand what I’m trying to say, but the older ones generally do. In fact, some of them actually tear up when they remember what it was once like.

“I try to explain that there’s no reason for doctors to pedal so hard and so fast if their patients don’t get the attention they need. That’s why I feel happier now when I leave the office each day: I don’t have that great burden of overhead weighing me down, and I know I’m providing my patients with better medical care. Best of all, I’ve got more control over my practice and my life.”