Summer Nagano Gray:You have been a successful practice management consultant for nearly three decades. You have assisted more than 720 physicians across the country, set up more than 250 practices, presented hundreds of speeches and seminars, and authored three books on the business of medicine as well as innumerable articles. How did you begin your career?

Yvonne Mart Fox: In 1972, I was a single parent with a 3-year-old child. I found I couldn't have a full-time job because I knew I couldn't be primary in two places-as a mother and as a career woman. So I took temporary jobs and then decided to work for a temporary agency.

As a temp, I worked in more than 70 medical offices. On one of my first assignments, the agency sent me to Cedars-Sinai Medical Center, and then they kept sending me back. It was great because I was able to work hours that fit around my son's school schedule.

Not long afterward, I was having dinner with one of the residents who said he was opening a private practice. I said something technical to him about billing and he said, “Huh?”

The lightbulb went off in my head, and I realized I had knowledge. These doctors didn't know anything about business, and I could help them set up their offices.

I decided to make a living giving seminars on how to set up a practice. But at my first seminar in November 1978, only seven doctors showed up.

Around the same time, I received a call from a physician who said, “I'm starting a practice and I need this, this, and this. Can you do it?” I said, “Yes I can. But the next seminar is on such and such a date.” He said, “I don't want to go to a seminar. I want you to help me.” I said, “I guess that makes me a consultant.” And he said, “Well, I guess it does.” I said, “I don't know how much to charge you.” He said, “Well, figure it out and be here at 9.”

SNG: What exactly is a Practice Management Consultant?

YMF: I teach physicians how to establish their practices and run them efficiently. One of my clients refers to me as “The doctor for the doctor's office.”

I teach physicians the business side of medicine: what to do, when to do it, how to do it, where to get it and how much time it takes. I teach them how to avoid the pitfalls in their business ventures, whether it's finding an office, building an office, hiring staff, setting up a bookkeeping system, improving efficiency, expanding a practice, consolidating a practice, merging a practice, joining a practice or selling a practice.

SNG: You are one of the pioneers of practice management consulting who is still consulting. To what do you attribute your longevity?

YMF: I love what I do, and I really enjoy my clients. Each one is special to me.

My clients realize that no one's more interested in their success than I because my reputation rides on their success. They come to me in times when they're in tremendous transition and they're scared. And I think that I understand their fears and don't negate them.

One of the rules I've had throughout my career is that if I didn't know something, I wouldn't charge for learning it. All the doctors I worked for, if they didn't know something, they went to the library or called a colleague. They never charged their patients for learning; they charged their patients for knowing. That's what I decided to do.

I have a home-based office-I've always been ahead of the curve. I say that with a smile on my face because when I first started, I had a young child and I could not afford to be anywhere but in my home. As time went on, I found my clients were either residents who didn't have control over their time and had to meet after hours or established physicians who didn't have control of their time because they were running a practice or working for someone else and had to meet on weekends or in the evenings. So my home-based office worked well for them because they weren't inconveniencing me by having evening meetings. I like to say, “If it's good enough for the White House, it's good enough for me.”

SNG: During your many years in practice, you've always specialized in the solo physician. Why haven't you diversified through the years?

YMF: A number of reasons. First, solo physicians are the largest portion of physicians in the United States-approximately 56%. Second, the majority of my experience-back to my early days of temp work-has been working in solo physician offices. As a result, I really understand them and their needs. I have always called myself “The small guy for the small guy.”

I feel so strongly about solo physicians that in 1994, I founded the Coalition for Solo Physicians around the need to represent the more than 200,000 solo physicians in the United States. I felt that someone needed to champion the concerns of these doctors and thought “Why not me?” so I did.

I made several trips to Washington DC and spoke with senators and representatives about such issues as managed care and the need for Any Willing Provider laws. I told them that we have nothing against managed care as long as it is physicians who are managing the care.

SNG: After consulting for so many years, you must know all of this by heart.

YMF: Each client and situation is different so no consult is ever the same. I learn something new every time, and I always strive to keep learning.

A couple of years ago, I realized that I had set up many computerized offices, but I had never worked in one or in an office that had managed care contracts.

So I decided to go back to “school.” I went to a medical temp agency and asked to be placed for a week in a private practice with managed care contracts. I felt I could go in undercover. Although my cover was blown the minute I walked in the door-the doctor recognized me from a seminar I gave-it was an incredible week. I learned so much.

I found out a lot of the intricacies of managed care that I never could have seen as a consultant. I told the doctor that 90% of what I learned I could have absorbed just by observing, but it was that 10% that required experiential learning.

One of the other important things I've learned is that a practice management consultant has to know his or her boundaries. It's important not to exceed your scope of practice. It's kind of like being a family physician and knowing when to call in other experts.

The best of us always work with an attorney and a CPA. I may have reviewed more employment contracts than some attorneys who specialize in healthcare law, but that doesn't make me an attorney. I can look at a financial statement and understand it fairly well, but that doesn't make me a CPA.

SNG: What is your most gratifying consult?

YMF: I really enjoy helping physicians start up practices. When they come to me, I always ask them to give me a wish list: “If we had no monetary restrictions or other boundaries, what would your practice be like?” They're really practical people so their wish lists are easily doable.

It's very gratifying for me to be able to come in at the end of the very long process of becoming a physician and having to make top grades to get into and stay in medical school, get the best residencies and get the best training and be like the fairy godmother who helps make their dream come true. It's wonderful.

SNG: Why did you decide to write your books and what has been the response to them?

YMF: Originally, I was going to write my practice management trilogy in this order: How to Start a Private Practice, How to Join, Buy or Merge a Physician's Practice, and How to Manage the Business Called Private Practice.

I began writing a column for Resident & Staff Physician in 1983. Soon after, I started getting questions and phone calls from physicians saying, “I've read your articles about how to set up a practice. Well, I set it up, now how do I run this thing?” So I found that I had to write the last book first because that was the demand. So How to Manage the Business Called Private Practice was the first book published. The American Medical Association distributed it.

The second book, How to Join, Buy or Merge a Physician's Practice, published by Mosby in 1998 was written with one of my clients because I wanted the perspective of a Fellow.

My third book, How to Start a Private Practice, is a compilation of articles that I've written through the years.

All three books are available through my web site.

SNG: What is it like to work with physicians all day?

YMF: I love it. Doctors are the most demanding clients, but they only want from me what they give to their patients. They want me when they want me. They don't know one day from the other. Evenings and weekends can seem to be appropriate times for meetings, just as they're an appropriate time for a baby to be born or a heart to be transplanted.

I honor their profession and recognize that some of the foibles that may make them difficult clients are the very attributes that make them excellent physicians.

I feel privileged to help them a little because of the miracles that they perform. And actually, in May 1997, I was one of those miracles, which is not exactly something you want to become.

SNG: How did you become a medical miracle?

YMF: I had a very, very unusual diagnosis. As far as I know, I'm the first patient ever to have survived. I had thromboses of the portal vein, of the major mesenteric system, and of the splenic vein, which means that blood was not flowing correctly to any of my vital organs except my heart and lungs. This is usually discovered at the autopsy because the patients die. Saving my life took most of the facilities of Cedars-Sinai and about 100 very dedicated doctors who weren't going to lose me.

It was a wonderful experience. I know that sounds ridiculous because I was so ill, but the physicians were so caring. They held my hand and always treated me as if I was cogent. If they couldn't hold a hand, they'd hold a toe. If they needed to examine me, they would ask or tell me. And the nurses were so kind. It was an incredible experience to be that ill a patient and to see what doctors really do and the compassion they have for their patients. We're all stunned that I'm alive, and we're amazed that I'm well.

I always liked physicians before, but now I feel that this experience cemented my resolve to continue helping physicians. It has made me even more adamant about trying to save our medical system. And I also have another reason, a selfish reason: I'm afraid if we don't change the course we're on, these doctors won't be there when I'm old and sick because the best and the brightest will leave medicine and do something else. If they're smart enough to be doctors, they're smart enough to be anything else and be successful.

SNG: What are your goals for the future?

YMF: One of the surprises is that almost 200 of my clients have hired me multiple times, mostly whenever they're making a major change.

When I was a temp and when I first started my practice, so many doctors asked if I would work for them continuously. I have just started a new service, Consulting Administrator, so I can. This allows me to provide on-site or on-call advice on all issues, as well as answers to basic and complex questions.

The first physician using this service has been a client off and on for 20 years. Her offices in Florida were devastated by the hurricanes and tropical storms. I not only helped her get her practice up and running but also to collect the insurance monies to which she is entitled.

Another goal is to create a course for Residents and Fellows on practice management so that physicians won't be frightened during transitional periods.

I plan to continue episodic consulting, speaking, and writing to teach doctors the business side of medicine.

Since I am a medical miracle, I will continue campaigning to enable physicians to practice medicine as they want. I really admire them. Doctors are truly lifesavers.

Summer Nagano Gray is a Los Angeles-based writer and editor who specializes in healthcare issues.