Enlightened Practice Podcast
We have a special guest in this episode, Dr. Xenia Borue. She’s a child and adolescent psychiatrist who runs and works in a private practice that specialized in developmental disorders. Together with our host, Dr. Ken Braslow, they talk about groups and clinics and the complexities, the rewards, and the challenges that underlie all of that.
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Transcript of the podcast
Ken: Hi, everyone. Today we’re going to be talking about groups and clinics and the complexities, and the rewards, and the challenges that underlie all of that. Today I’m here with Dr. Xenia Borue and she is a child and adolescent psychiatrist who runs a private practice and working and specializing in developmental disorders. And outside of her training, she started out in a clinic and was a director and supervisor and is joining us today to talk about that experience and hopefully help us think through all the challenges and help us learn. So welcome, Dr. Borue.
Dr. Borue: Well, thank you for having me again.
Ken: So, you came right out of training and went into a clinic of how many clinicians were there.
Dr. Borue: So, there was one other psychiatrist and 15 therapists, as well as some auxiliary staff.
Ken: Wow. And being in a residency is being in a clinic. But there’s other people who do all the administrative side of things. And as a resident, you’re really focusing on learning and quality clinical care. I don’t recall being taught that much about administration in training. Did you have any of that knowledge?
Dr. Borue: I actually felt like we got a fair bit of that. We had a lot of people come in and talk to us about their experiences with running clinics, with running group practices, with taking on administrative rules, and we also just had a lot of mentorship from administrators in the various clinics that we ourselves participated in residency. So, I felt like actually we got pretty good exposure to the types of problems that might arise in a group setting and the types of, kind of work arounds and just approaches that you might use to address some of those things.
Ken: That’s great. That’s what we want to hear about today is the challenges and working through them. So, what attracted you to joining a clinic right out of training? Was there anything in particular?
Dr. Borue: So, coming out of residency, I wasn’t sure if I really wanted to go the clinic route or the private practice route. So, much like a lot of other aspects of my training in the past, I decided why choose one or the other, do both? That’s kind of what I did throughout all of my training in the past I did two majors. I did my PhD program, so I came out of residency going, All right, I’m going to do part time directing at a community health clinic, and I’m going to run a private practice and see which one I like more, after a trial period.
Ken: That is such a nice way to approach it. Did you feel like you had time to really dive into both of them fully?
Dr. Borue: I did. And the clinic that I chose, I had actually spent four months already on and off during my clinical rotations earlier that year, starting to work in anyway. So, I kind of knew what I would be getting into, and this was the six months that I was there was a continuation of that where I just took on a lot more responsibilities as the director.
Ken: Okay, so tell us, what did you get into once you came on as staff?
Dr. Borue: So at the time that I joined, we were in the midst of kind of trying to streamline some of our intake processes, thinking about kind of expanding the types of services that the clinic was delivering and thinking about branching into even more of coordination with primary care than we had at the time.
Ken: A lofty set.
Dr. Borue: There actually was a lot that I took on at the time. But I wanted the challenge and it was something that I appreciated getting the opportunity to try to take on
Ken: What were the challenges that the clinic had not been able to overcome or was struggling with when you first came on?
Dr. Borue: Well, a lot of the challenges that any mental health center, especially community mental health center, struggles with. I think the biggest one is how do you provide care for what is usually more marginalized population and how do you do that in a cost effective and sustainable manner? And those are really big challenges for any mental health center.
Ken: What were some of the challenges that they had overcome and where were some points that they might have been getting stuck?
Dr. Borue: So I mean, they had established themselves well in the community as the go to place for LGBT care. That was their primary objective, and they had done a great job of establishing that of expanding the clinic overall. It expanded from, I think, like seven or eight clinicians up to the 15 over the course of the previous three years. So I mean, they had done very well with growing the clinic, but the problem that they were running into was again making that clinic actually self-sustaining and the barriers to that were pretty big. They had a tremendous no-show rate. They had a lot of difficulties with the billing side of things. They didn’t have an EMR. So, there were a tremendous number of barriers that were standing in the way that we were starting to try to figure out how to address going forward.
Ken: So, were there systems in place for all of this and they weren’t working that well?
Dr. Borue: They kind of had systems, but they were not particularly effective. A lot of things fell through the cracks, and most everything still depended on paper. And when you’re depending on paper, it’s a very slow throughput system that tends to be pretty prone to error. A lot of the time and so it just it was not working very well, and there were a lot of different places where there were bottlenecks.
Ken: So from scheduling to how about charging and clinical care?
Dr. Borue: And coordination of care, especially.
Ken: Ah sure. So within the clinic, coordinating care and also outside of the clinic, or?
Dr. Borue: Both within and outside. Outside was even more challenging than within.
Ken: Okay. And then of course, payments.
Dr. Borue: And then collecting on the payments in a reasonable, timely manner. I think that’s where they struggled the most interestingly enough.
Ken: And so when you came in, you saw these issues and you thought, okay, where should we put our energies? How did you decide how to prioritize? There’s so many.
Dr. Borue: So, it was a multi-pronged approach, and initially we started with kind of the low hanging simple fruit of let’s start addressing the no show rates. And my goal was also then eventually to work towards transitioning to an EMR. But we never got kind of fully all the way to that transition.
Ken: How did you approach the no-shows?
Dr. Borue: So what we started doing was that we actually put into place a real no-show policy that we then communicated to everybody, including charging no show fees. And for folks that continued to no show, we actually followed through with discharging them, which is something that they had never done prior to me arriving at the clinic.
Ken: Wow, was there resistance to that internally?
Dr. Borue: Very much so. Yes, that was something that was really challenging for a number of therapists to kind of come to terms with because it felt too punitive and they were really concerned about kind of letting some of these people down, even though they would show up once out of every six scheduled appointments.
Ken: Oh wow. Do you think that because you came out of training and directly into a leadership role that played a role in the clinic’s internal resistance to some of this or you think that’s dependent of that?
Dr. Borue: That I’m not so sure about because that idea was already kind of being bounced around by some of the other administrators prior to even me coming into that role. And I think it’s just a challenging idea for some clinicians anyway.
Ken: Okay. So you first went about setting up a no show policy and then?
Dr. Borue: Actually past the transition period of that it worked pretty well, and our no shows started to decrease substantially over time. So, I think once the clinicians started seeing that it was working that their schedules were actually full of patients that were showing up and more engaged, I think they started kind of believing a bit more and coming on board a bit more with the whole thing.
Ken: Yeah, it’s nice to see results quickly.
Dr. Borue: Right.
Ken: So what else? You know, a lot of other fish to fry there. What did what else did you try and work on after the no shows?
Dr. Borue: So, we started with taking care of the no-shows and then we set up additional kind of in-house meetings to help aid in discussing of patients. So kind of group supervision, so to speak, for all of the therapists where we would discuss difficult cases. We would update each other on patients that we shared. And this was something that we made as a regular meeting.
Ken: How often were you meeting?
Dr. Borue: We were meeting three times a week, so we had several different kinds of supervision groups. One that was specific to gender, which was the one that was there already before I joined and then an additional psychotherapy one and an additional one for more medically challenging, medically complex patients that people were struggling to figure out what to do with.
Ken: So, sounds like clinical care would only go in the right direction with those kinds of groups. And do you feel like that also helped from an administrative side?
Dr. Borue: I feel like it actually helped me be more aware of what was going on in the clinic, even if I wasn’t directly involved. I feel like it also provided a lot more opportunities for camaraderie as well as teaching. And that’s the part that I probably miss the most about working over there is those meetings every week. I felt like I got a lot out of those.
Ken: Really interesting point that if you get burdened with administrative stuff or you’re always focused on systems, you don’t get to actually enjoy the good part.
Dr. Borue: The benefits of being in a group, which really is that collaboration.
Ken: Okay, so you worked on no-shows. You worked on building collaboration. And then what came next?
Dr. Borue: Started looking for an EMR that I could use and started the process of doing the legwork that was required to try out an EMR and then potentially talk about the next steps of transitioning to one.
Ken: And what kind of resistance did you face with that?
Dr. Borue: So, I think the biggest resistance to that came actually from the administration and not the clinicians. The clinicians were very, very eager to have an EMR because of the frustrations that are inherent with trying to maintain a paper record. The administration was very concerned about price and just the overall costs of this, the cost of training, the costs of scanning all of the paper into the EMR.
Ken: Do you think in the long run they thought it would save money, but they just didn’t have the cash on hand to invest in all of that?
Dr. Borue: That was hard for me to gauge. But I got the sense that they were skeptical that it would actually save much money, either. I think they were pretty deeply entrenched in what’s worked for 30 years should just keep working. And why should we switch to this new fangled thing?
Ken: Sure, there’s a lot of anxiety naturally around change and technology for good reason. So the EMR didn’t actually happen?
Dr. Borue: No, not while I was there. It happened about a year and a half, two years after I left under a different manager that I’ve been in touch with. So I kind of know some of the story there, but it took a lot longer than even I thought it was going to take for them to finally take that step.
Ken: Wow. So were there other big topics that you worked on or by this point where you transitioning?
Dr. Borue: So, the other one that I worked on was billing, and that was just a lot of teaching the billing staff about kind of reimbursement rates and billing and how to do some of this billing. They were stuck billing some really old, archaic codes that basically nobody billed anymore. So that all was something that we had to work a lot on in terms of changing for the billing to get better reimbursements for them. Once they realized they were getting better reimbursements, they were very, very happy with it. But it was a long transition and learning process for the billing people to actually figure out how to do the new codes.
Ken: So they were not billing professionals, per say they were just in-house staff that were doing billing?
Dr. Borue: In-house billing staff that had kind of learned it over the years and had to kind of continue to do what they were originally taught and just never really got any updated training on anything.
Ken: Yeah, codes change.
Dr. Borue: They had never even heard of complexity codes or add on codes or anything like that.
Ken: Back in the in the good old days of 90805.
Dr. Borue: Yes.
Ken: All right, so was there anything else that led you to feel like on balance, being a clinic wasn’t right for you? Or was it just how much you loved to private practice?
Dr. Borue: Honestly, for me, it was mostly that I just grew to really love my private practice and the freedom of seeing the exact subspecialty that I was the most interested in, which is developmental disorders. I got to see quite a few of patients that kind of overlapped with the population that I was seeing it for, but. It just it felt like much more my calling to devote all of my time to seeing that population. So I made the decision to kind of resign as the director and focus exclusively on my private practice, which I’ve continued over the last. Now it’s been three years that I’ve been working at it.
Ken: So, as you look back over your tenure at the group, what do you think are the things that you might have approached differently or prioritized differently or things that you would just advise a new grad who was in a similar issue to be on the lookout for?
Dr. Borue: I think one of the key things when you’re considering going into the group is the interpersonal interactions between you and the other members of that group. You should be more or less kind of on the same page about some of the broad goals that you have, and have a good sense of where you fit into that group and whether your goals fit in with the group goals. And whether your personalities kind of mesh with the personalities of the other people that you’re thinking about working with, because that’s so, so crucial that you develop those relationships with those people that’s going to make or break your experience of the group in the first place.
Ken: It’s hard to pick up on an interview.
Dr. Borue: It can be, yeah. So some of those things you do have to kind of be there for a while to really get to feel out.
Ken: So approaching it on a trial kind of basis.
Dr. Borue: If you can.
Ken: If you can, yeah.
Dr. Borue: And at the very least, if you can’t, being able to sit down one on one with multiple members of the group at multiple places, kind of in the group hierarchy. So in other words, not just sitting down with the clinical director but sitting down with the clinical director, maybe a member of the board. Definitely a therapist and definitely one of the actual secretarial staff that you’re going to be working with so that you get a better sense of who these people are and what is it like to interact with them?
Ken: Yeah, that’s such a good point about clinicians and admin staff feeling connected as well and probably more time should be spent thinking about how to build those connections. So, if you think about if you were to join a group again in a leadership position from an administrative point of view, what are the things that you would prioritize?
Dr. Borue: I think one of the things that I would very much prioritize is I would want the group to have those connections and to have evidence of those connections. I think the places where I see things going wrong is where people kind of isolate themselves in their part of care or part of the department. So the billing person kind of just stays in their office, doesn’t really coordinate with anybody, doesn’t communicate well and then nobody knows what they’re actually doing. That’s where you get into a lot of trouble. So I would want to be in an organization where people were very clearly consistently communicating with each other and had built up those relationships across parts of care.
Dr. Borue: And I would also want to be with a group where again, their goals for developing the group strongly aligned with my own goals. So in other words, if I was to join a group who cared the most about providing say, oh, I don’t know, care to pericardium women, that would probably not be a good fit for me because it doesn’t mesh with my own clinical goals.
Ken: So first, think clinically and in terms of relationships.
Dr. Borue: Well, so clinically and then relationships, they’re both really, really crucial. I think probably one is almost as crucial as the other.
Ken: Right. You need both. And then from an administrative point of view, I mean, they all seem important. You can’t run a clinic if people aren’t showing up. So, the billing side of things, the scheduling side of things, what’s your sense of where a clinic should be thinking in terms of workflows and administration?
Dr. Borue: Well, I mean, that’s just a giant question. Well, there’s just so much that goes into it. But I think that the overarching key is that it has to be streamlined and yet flexible. And that’s where a lot of the challenge comes in is that in order to streamline something, you actually have to simplify it and pair it down to the bare essentials. But you lose flexibility the more you do that. And so there’s this balance that you always have to try to negotiate between being able to handle some of the off unusual situations that come up because they always come up some way, versus having an effective, streamlined and simple system.
Ken: You have an example that comes to mind of where that balance is hard to pull off.
Dr. Borue: Oh, gosh, I mean, even just with how do you orchestrate scheduling, right? So I mean, you could have scheduling be run through just an app where patients log into that app and schedule a time, and that’s the only way that they can do it. It’s very streamlined. It’s very simple. But there are a lot of places where people can fall through the cracks and things can go wrong. People can’t set up an account, there’s just there’s so many other places. So then you start having to well, do you then back it up with phone calls? Do you back it up with other services? How do you catch all of these stragglers and stray occurrences?
Ken: It makes me think of the 80 20 rule. You probably cover 80 percent of the scenarios with 20 percent of the work, but then it’s the other 20 percent.
Dr. Borue: The other side, yes.
Ken: Well, this makes me think about the patient experience of being in a clinic. What are some things clinics can do to not just market themselves, but and of course, assuming high quality clinical care to make the patient experience more streamlined and patients feel more comfortable within a clinic from an administrative side, anything come to mind?
Dr. Borue: I think a lot of it goes towards trying to streamline and reduce the administrative burden, as well as improve the accessibility. So I think actually having some of those kind of services that are online, so patient portal for communication, for scheduling goes a long way towards improving that accessibility for people, especially in this day and age where the vast majority of people do have access to the internet, if not high speed Wi-Fi. And so having that as being kind of the place where you’re doing a lot more of the administrative throughput it’s really, really helpful for that, and then is once they get to the clinic, the experience of actually checking into the clinic of being guided through whatever additional paperwork they need to complete, whatever payments they need to complete, being taken back if they’re being seen by a nurse for vitals, wait, things like that.
That needs to be streamlined so that the patient actually feels like it’s a uniform, streamlined process that they’re kind of just being taken through without, you know, just sitting with random delays and not knowing what’s going on. I don’t know if you’ve ever had that experience as a patient where you like, show up at a clinic and you check in and like a half an hour later, you still don’t know if anyone’s actually even registered that you’re there and that eventually somehow you get taken back to a room and then you’re waiting there forever and you still don’t know what’s going on. Patients just really dislike that.
Ken: Right. Yeah, that makes sense that how well a clinic has done with all the things you talked about in terms of connections, relationships, workflows all affect that one patient experience, that moment.
Dr. Borue: And the other thing and this is actually really interesting tied back to the no show policy is this idea of actually running on time. So as part of our no show policy, we also put into place that if you were 15 minutes, more than 15 minutes late, you were counted as a no show and you were not allowed to have your appointment. And that was that hard limit that was there. And people really disliked that initially. But what it prevented was this constant tardiness of somebody would show up late and then it would throw off your entire schedule. And then everybody was just progressively more late as you went through the day and then people were waiting forty five minutes or an hour sometimes to see their therapist.
Ken: It would stack towards the end of the day.
Dr. Borue: Exactly stacked towards the end of the day. And that was happening in that clinic really, really consistently prior to this policy being put into place. And there was a lot of frustration on the part of patients when they were routinely asked to come early and then the ones that actually did come early were penalized because they would just have to wait and wait and wait. And then they would after a while, because their time wasn’t getting respected, show up late expecting that the clinician was running late, which would cause the clinician to be even more late, with the hard stop and place that actually allowed the clinic to start running much more on time. And so patients were being throughput in a way that was actually efficient and running on time. And overall, that patient experience improved a lot because of that one simple intervention just to decrease tardiness.
Ken: Oh, that’s a really interesting. Did the clinic try and send out reminders?
Dr. Borue: Yes. They sent out reminders, but it was still, people were so used to everyone running late and them being admitted after being late, like 30 minutes for their appointment, it was just completely terrible.
Ken: Right. How did you guys orient new patients to the clinic policies?
Dr. Borue: So, we had the policies there in very large letters at the front. And then it was the clinician that was going through the initial paperwork with them then would also go through, these are the expectations that we have of you as a patient in this clinic. And these are the consequences if you’re not able to meet these expectations. So it was laid out very, very clearly and concretely as a part of the intake process.
Ken: Had they been doing that before you got there?
Dr. Borue: No. That was new.
Ken: So, it was like a culture change, that all the new patients were used to the new system and they had their expectations appropriately.
Dr. Borue: And the old patients had to receive a printout of the new expectations and all of the therapists had to go through that with them.
Ken: Do you feel like you may have lost some patients because of that process?
Dr. Borue: We actually surprisingly did not lose that many people. We had to discharge I think five or six of the worst offenders for no-shows, but for the most part actually after one time of not being allowed to have their appointment because they came in 20 minutes late, most people got pissed but they came back on time, the next time.
Ken: That’s pretty powerful, just thinking about how improving systems can change clinical care and patient experience so much.
Dr. Borue: And it’s sometimes really simple interventions. But it’s simple interventions that are iterative and have a lot of downstream effects. And that also I guess, ties into both the pro and the con of working in a group. When you’re in a group setting, especially, the bigger the group gets these little things add up a lot more and can sometimes also just have these mass effects on the group.
Ken: So, things move slower typically in a group than in a private practice, but can have far more reach in terms of impact.
Dr. Borue: Right. Or, slower in terms of making changes, yes of course.
Ken: So, if a new grad asked you for any pearls of wisdom or advice upon graduating, and let’s say they’re looking at competing offers for groups or considering their own private practice. What do you think you’d tell them?
Dr. Borue: I would tell them to try to keep their options open and to try to use their first couple of years out of residency as kind of an extended period of learning. Embrace the fact that you’re going to be on yet another learning curve. So much of residency is, you get into new clinical position, a new clinic, and new role, and you are on that learning curve for learning how to navigate that role. A lot of people get tricked into thinking, hey, I graduated, I’m not going to have to do this anymore. It’s like, no, this is like the big learning curve for you now, here, doing this as your new permanent role.
Ken: Yeah. I remember finishing up fellowship and thinking I was in something like 25th grade and I was so excited to be done. And not realizing that was just the beginning. And the hard work really begins after training and you don’t realize how much your professors or your attendees are shielding you from this.
Dr. Borue: Yeah, from some of those things, which you can only learn through experience. And I think that’s the other crucial thing about this is that you can listen to other people talk about these things. You can read about them all day long, but so much of this stuff you’re only going to be able to learn through your own unique experiences with it. And you have to leave yourself open to have those experiences in the first place. So, you have to approach it with some humility of going into it not thinking you have everything figured out. And going into it with this idea that you’re going to be on another learning curve and you’re going to take this as an opportunity to really hone this set of skills and to learn this particular system and this particular approach.
Ken: That’s a really nice way to put it. Making yourself vulnerable to learning is daunting, energizing, and exciting at the same time. Okay. We’ve covered the whole world and back of coming out of training and going into groups. I really appreciate your thoughts here. I’ve learned quite a bit today that I hadn’t even thought about and this is great. Thank you so much for your time and sharing your thoughts, and I look forward to further discussions about this down the road.
Dr. Borue: Well, thank you for having me. It’s been a pleasure talking about these things. Thanks.
Ken: Okay. Take care.