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June 30, 2020

Probabilistic Permission

Regroup, restart, reinvigorate, recalibrate, rethink, reinvent.

Sounds like some weird game of Scrabble.

These ‘re’ things are what we are all up to, but I want to come back to the one we discussed earlier this week – rethinking, particularly when life now requires us to question something that we’ve long held to be true.

There are several reasons why this is hard for us.

Ego is one.  Admitting that we need to rethink that means we might have been wrong.  You might have been wrong, but me? Noooo.

Success is another.  The more our past thinking worked well, the harder it is to change it now.  This is why generals keep fighting the last war.  Today’s generals were the successful colonels and majors in the last war, and they did not get promoted because they died.  They won.

Another is the sheer magnitude of the work that comes with a change in thinking.  Everything was built on the old idea.  Alter that and we have a heavy lift to redo everything that is now obsolete.  Let’s keep believing the world is flat and just go get lunch.

There are other social and psychological forces for the inertia of beliefs – peer pressure, culture, reputation, the fact that we got everyone T-shirts emblazoned with the old mantra.

But there is one unique thing that we should get on the table, one we don’t think about but an idea that might make changing our mind easier.

Most of us, most of the time, tend to hold our truths in black or white fashion.  Something is true or it is not.  Our brains operate in binary mode – on or off.

Consequently, if we are asked to rethink something we held to be true – say a patient’s loyalty to their personal physician or how we think about different types of patient visits – and our only option is a complete rejection of what we believe, we are going to work really hard to defend the status quo.  All the reasons above kick in together.

Viva la resistance!

How do we overcome this?

One way is to work instead to think – and communicate with one another – more probabilistically.  Instead of ‘yes/no’ we frame our position in terms of ranges, levels of confidence, or percent of a chance.

If I ask you if your patient volumes in October will be back to last year’s level and your only options are ‘Yes’ or ‘No,’ once you take a position, it is harder to change.

But if I ask you, ‘What is the likelihood that patient volumes will get back to our baseline this fall?’ and you say ‘75% – plus or minus 5%,’  then it is a lot easier – cognitively, psychologically – to revise your estimate up or down later as new data arrives to inform the question.

We are guessing at a lot of things right now. If we admit that, and use language accordingly with ourselves and our colleagues, we will be able to rethink, learn and grow much faster.

Tim Coan
Tim Coan

CEO and founder

Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
June 23, 2020

Are You Sure?

The older I get, the less I know.

I am not sure if that statement is an indication of humility delivered by being wrong a lot; the effect of having teenagers who tell you what a cultural dolt you are; or the natural aging process that wipes out thousands of neurons everyday literally reducing what you know.

I’ll claim all the above and gladly admit that I know less than I used to know.  Granted, at one point I was a know-it-all, so had nowhere to go but down.

Life seems to work that way.  We amass a little learning; a little experience and we end up with a long list of things we just know to be true.  We build our world around those ideas. We are confident.

Then life – people mostly – happens and things don’t behave like we believe they should.

Growth comes when we step in a pile of knowledge failure.  What we were so sure of didn’t survive contact with reality.  Anyone who doubts this doesn’t have kids.  Or a dog.

That is not entirely true.  Many people have experiences that don’t jive with what they ‘know’ and they double down to protect their erroneous belief, offering more and more elaborate rationalizations, amendments and denials in order to explain away the facts so they can hold on to their truth.  This does not lead to growth, unless we are measuring the thickness of the skull.

But when what we held to be true, not up for debate even, runs into more than just an odd anomaly we are given a moment in which we have the opportunity to learn, change and grow.

One thread that ran through my reading during the quarantine related to decision making in the face of uncertainty.  From poker bets to earthquake predictions to political polls to economic forecasts, we constantly face situations that require us to form an opinion from less that complete facts and then decide.  The problem is that we quickly forget that we didn’t really know for sure.  Our hypothesis, often pulled out of our ear or another bodily orifice, becomes a factual given in our mind very quickly.

We are confident, but not humble.

Then COVID comes along and blows up many things we thought we knew for sure.  We could make a long list of things we knew in February that are not so sure about in June, but the ones that matter for our discussion here relate to healthcare and physician practices and the mindset of patients.  That list alone is long.

As we get started recreating, the first question is about how we deal with the knowns that have now been challenged.

Will we construct complex arguments to keep us from having to do the hard work of changing our mind, and all that goes with that?

Or will we ask the hard question – Is what I thought I knew to be certain no longer true?

The future of our businesses depends on our answer.

Tim Coan
Tim Coan

CEO and founder

Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
June 18, 2020

Obsolete Maps

[Part Three in a series.  Click here for Part One and Part Two.]

As I have been reflecting on my great-grandfather’s losing battle with the rising Arkansas River in 1943, I realized that as a now ‘city boy’ (according to my redneck brother) I don’t naturally think in acres.  Blocks, neighborhoods, interstate exits – these are my geographic frames of reference.  Acres are not as natural for me as they should be for someone with farming roots.

In that flood, 450 acres forever disappeared underwater as the river changed course.  My 24-home typical suburban neighborhood sits on about 10 acres, so 45 of those.  A square mile covers 640 acres, so about 70% of that.



Here is where we get to the really hard part of the coronavirus reality.  Not the part about short-term pain or inconvenience or the challenges in restarting, but the part where we stare hard at the situation and ask, ‘Is it gone forever?’

Last weekend I was happy to plop down in the booth at our favorite Mexican restaurant for an enchilada and a margarita. But in about 30 seconds you realize that despite their best efforts, the math just doesn’t work.

I flew for the first time yesterday and while I enjoyed having a row, or seven, to myself with room to spread out, the same math was easy to do.  As it was at the hotel. And many other places you see.

Many just won’t make it.

Their business is, or is sliding toward, the bottom of the river.

Surely this can’t happen to physician practices, right?  I mean, we’re talking doctors here, superheroes in white lab coats.  Wasn’t there some implied and unspoken promise for surviving med school?

Devastating floods and microscopic killers are indiscriminate.

The prognostications on physician practices that will close shop, particularly small practices and especially primary care, are blaring everywhere.  That has not yet happened at a doomsday level and maybe the soothsayers got a little carried away.  Or maybe PPP loans and Medicare advance payments propped up some dead practices that just haven’t fallen over yet.

I recently spoke with some folks who work with a lot of small practices and they are optimistic.  Maybe it was their unique market, maybe it was more hope than realism.  I’ll hang on to their take as we all want some good news.

But the math of business applies to physician practices, too.  Take enough volume out for long enough and it ends up under 25 feet of water.

Well, that was cheery, wasn’t it?

Dan Dan might tell us there are two options: quit farming and move on, or you better work the land you have and maybe go find some more.

This is where we’ll be focusing in the weeks to come.  You’re going to hear things you’ve heard from me before, only with more urgency.  You’ll hear some new thoughts based on our new reality.  But I assume you still want to keep farming, keep practicing medicine and taking care of patients.

So, let’s get after it.

Tim Coan
Tim Coan

CEO and founder

Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
June 9, 2020

When the Water Recedes

[Part Two in a series.  Click here for Part One.]

I have wondered what went through my great grandfather’s mind in that moment when he had to acknowledge defeat.  The river, the rains, the flood won.  Dan Dan and his bootlegged bulldozer hadn’t so much as surrendered as been engulfed, literally and figuratively.

I am sure he and the other farmers did what we do when there is a natural disaster, what we’ve all been doing as we try to process the coronavirus – we stand and marvel at the destruction, looking for a new anecdote or factoid to help drive home the magnitude.  Today, we steal memes and quips from social media as we try to drop a new one in conversation with the neighbors.  The internet is no match for the colorful euphemisms that a bunch of redneck farmers would share at the feed store to describe a generational flood.

What we are really doing as we share these tidbits is just buying time until we can get back to work cleaning up, restarting.  If you have perpetual dirt under your fingernails, a little downtime is nice, but you are only really happy when you are working, doing what you were made to do.

I imagine that Dan Dan was out even before the water had fully receded trying to make the best of the situation, rolling up his sleeves to plant the next round of crops.  He was on my paternal side, but my mom came from the same farmer stock.  A tough lady, she would only allow about three minutes of moping after something bad happened before she was in your face and saying, ‘You can’t change that, so now what are you going to do?’

Pick yourself up, get to work.

That is where we are now.

Getting back at it is weird and sluggish.  No part of your practice was designed to work with all these barriers – patients in masks and distance and video screens.  Patient care is, by its very definition, close and intimate and personal.  Heck, often it involves some awkward level of nudity.

I was talking to one of our clients, a pediatrician, and asked how telemedicine was going.  She was happy to have it, but her frustration was obvious.  If you become a pediatrician, you love and value contact with kids.  It is one of your most important tools.  Even my orthopedic surgeon, who is about as cuddly as a radiator, wants to grab and twist my shoulder.

We’ll get it rolling, we’ll figure it out.  Hey, we’ve (mostly…somewhat…OK, a little) figured out the dang EMR, so we can probably manage having patients text that they are in the parking lot.

Here’s the hard news…

You need to get this restart thing figured out quickly because there is a much bigger task in front of you.  Remember, there is a good chance that part of your business, maybe a meaningful part, is now in the middle of the river and never coming back.  What are you going to do about that?

We’ll go there next time.

Tim Coan
Tim Coan

CEO and founder

Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
June 2, 2020

Dan Dan and the River

I never met my great grandfather, but the stories are legendary.  Some are apocryphal I am sure, some enhanced with a little entertaining hyperbole, some details grown a little fuzzy over time.

Dan Dan, a hardscrabble Scottish farmer, settled into the Indian Territory not long before Oklahoma became the 46th state.  His land was nestled there where the Arkansas River turns north a bit before leaving Oklahoma and heading across its namesake state to join the Mississippi.

He was notable for his interminable will, penchant for the alcohol of his ancestry, and a fiery temper that was probably inflamed by the Scotch. He went to town and bought his Buicks two at a time.  He’d drive one like a bat of hell across the fields and when it would finally conk out, a hired hand would haul it back to the dealer for repair as he hopped in the second one without slowing down.

He parked his car astraddle the railroad tracks one day, forcing the engineer to slam on the brakes to bring the train to a screeching stop.  The day before the train took too long switching over and it blocked his driveway, delaying him by 15 minutes from getting back to work after lunch. In his view, Kansas City Southern would have to wait the same amount of time to square things up. Yes, he pulled a pistol from under the seat of the Buick when the engineer approached the car and ordered him to move.  It was persuasive.   The train waited.

He may or may not have killed a man. Some guy over in Arkansas was abusing his wife, a sin that Dan Dan would not tolerate. A strongly worded conversation led to some form of frontier justice; the details of the punishment are a little fuzzy, but the judge appreciated the matter being handled directly and swiftly, dismissing the charges in a matter of minutes.

I share those stories to share this one.

As I mentioned, Dan Dan’s farm was low against the river.  Regular floods were a good thing, but 1943 was different.  In mid-May, the river crested at 38 feet above normal, wrecking devastation across both Oklahoma and Arkansas.

One field was right on the river.  Somehow Dan Dan had secured one of the few bulldozers that was not in Europe supporting the war.  He had used the dozer to build a levy around the perimeter of the field.  There were crops in the field and crops were cash.

As the river continued to rise, the levy was threatened. Frantically, a worker used the dozer to shore up the levy.  Inevitably, the river broke through and water begin to pour into the field.  My great grandfather ordered the man to drive the dozer into the crumbling hole in a desperate attempt to save the field.  Hesitation at the command brought out the aforementioned pistol and the dozer was plunged into gap, of course to no avail.  38 feet of river would not be held back, even by a determined farmer with a bulldozer and a gun.

The crops in field were lost in that flood.  But that was not the biggest loss.  The field itself disappeared, even when the water receded.  The flood changed the flow of the river and that 450 acres of dirt was, and still is, out in the middle of the river somewhere.

The flood brought short-term loss, massive clean-up, long-term loss and property boundaries changed forever.

Sound familiar?  Next time let’s start unpacking the parallels.

Tim Coan
Tim Coan

CEO and founder

Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
May 27, 2020

The Halting Restart

Is it safe?  What are the new rules?  Are special signs needed?

And these are just questions about relaunching a blog…what about real life?

Sit six feet from your screen as you read this and maybe you should wipe emails from me down with hand sanitizer and toilet paper.  That is probably wise advice, regardless.

Remember when, oh it seems like about six years ago, that this whole thing was about toilet paper?  Man, those were the days, way back there in late March when our biggest worry was the Proctor & Gamble supply chain.

Seriously, I am not even entirely sure how to restart this blog so how the heck do we do that with – well, with everything?

Maybe I just weave every COVID-related cliché together in this post and get those out of the way, like the socially awkward middle dude who has no idea how to talk to the girl he likes, so he just repeats the funny things he read on Instagram.

Maybe I should deliver an overly somber ‘we are here for you in this difficult time’ email, just like the millions you’ve received from every vendor who has your email address.  Once I found out the CEO of the plumbing supply company where I bought a gasket online three years ago was doing everything he could to keep me safe, then I was at peace.  The Johns Hopkins tracker site should count these silly things.

Maybe I should compile a list of links to every government website that you already reading twice a week.  Like you had not figured out that information about the Small Business Administration could be found on the website of the Small Business Administration.

Maybe I should just make up stuff that I know nothing about and repeat it as the truth.  No, you’ve got plenty of that.

I could tell you to hang in there, that this will pass and that it will all be OK, but you and I both know that is more Hallmark card than an honest sentiment right now.  We will persevere and the important stuff like your loved ones and the Amazon delivery truck will be there, but beyond that there are still a lot of questions, aren’t there?

Back when we thought this was going to be like a really long snow day, with everything canceled for a bit while we huddled up to play board games with the kids, I assumed my first post would be about how some things would permanently change.  Wow – talk about an understatement.

That is still probably the direction we should head out on this restart journey, probably the line of questions where I can, I hope, prod your thinking a bit in the coming months.

To do that, I need to first tell you a story about Dan Dan, but be warned that this full-blown extrovert has been cooped up, too, so this one might take a bit.  We’ll do that next time.

Be safe.

Tim Coan
Tim Coan

CEO and founder

Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.