Private Practices

Patient fears push rapid evolution at a small family practice

Sara Berg, MS , News Editor

As a small private practice owner, AMA member James Milford, MD, remains focused on keeping his patients safe during the COVID-19 pandemic and beyond. With the COVID-19 landscape changing frequently, Dr. Milford implemented several new measures that allowed him to continue to provide quality care and protect patients.

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However, his ability to quickly adopt innovative ideas during a pandemic would not have been possible if he had not made the transition to private practice. Thirty years ago, Dr. Milford began his medical career as an employed physician. Fast forward to three years ago when he had hit a wall. After asking leadership for additional help—and being denied—he knew he had to make a change in his career.

“There are just so many little things like coffee stains on the carpet—we can’t replace those until the next budget cycle—or I need a printer in each exam room, but we can’t do that. It doesn’t make sense,” said Dr. Milford, a family physician and owner of Three Oaks Health in Johnson Creek, Wisconsin.

“One of the last straws was hiring a medical assistant that I would work with on a daily basis and not letting me even interview the person,” he said, adding that while he came from a position where he was the biggest revenue producer from primary care in the organization and well respected, he decided to leave. With his increased awareness of the issues surrounding being an employed physician, he wanted to take charge of his future and the quality of care provided to his patients.

“I left, put two feet up to the edge of the cliff and jumped and opened my own practice,” said Dr. Milford.

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By opening his own private practice in rural Wisconsin, he was able to set himself up for success even during the tumultuous times of COVID-19. Without having leadership deny his requests, he had the power to change his practice whenever he needed.

Here is how Dr. Milford took measures into his own hands:

“We really have gotten back to the basics of what we went to medical school for,” Dr. Milford said during a panel discussion hosted by AMA Chief Experience Officer Todd Unger. The AMA is providing daily COVID-19 video updates featuring interviews with a wide range of physicians and experts from the AMA and elsewhere who provide real-time insight on the challenge of the pandemic.



“Right away we asked our whole team, are you on board with this, do you want to move forward with this, how can we make you feel safe so that our patients can feel safe?” he said. “There isn’t a roadmap to any of this so you had to go back to the basic studies and really look at what you needed to do to keep your practice going and you had to innovate as you went along and we’ve done some of that.”

Dr. Milford met with his son, who is his business manager, to look at how they should move forward. He emphasized, “whatever solutions we put in place are not short-term solutions. It has to be long-term solutions to put in place, something like the UV investment.”

The idea of UV light for decontamination and reuse of N95 masks came up when concerns about personal protective equipment (PPE) shortages first emerged. With this idea on his mind, Dr. Milford worked with his son to build a box to house the UVC light. Because UVC intensity is inversely proportional to distance, they decided that a box would do the trick.

While disposable filtering facepiece respirators (FFRs), like N95s, are not approved for routine decontamination, FFR decontamination and reuse may be needed during times of shortage. Guidance from the Centers for Disease Control and Prevention shows the most promise as potential methods to decontaminate FFRs.

Built in his basement, Dr. Milford lined the box with aluminum foil and added the UVC bulbs. After PPE is used, each member of the team places their mask in the box and turns the light on for sterilization. This allows for each mask to be reused several times.

“It is also asking your patients, ‘what is it that makes you feel safe?’” said Dr. Milford, adding that one patient noted not feeling safe opening the door.  

“We installed automatic doors so that they don’t have to touch the doors,” he said. “We instituted different touch points and direct rooming so that patients can come directly in without going to the waiting room, and we are very verbal about that. They have that expectation ahead of time. We realized that in order to get people through our doors and to feel comfortable, we have to make them feel safe and be truthful about it.”

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Since March 11, telehealth has accounted for about 40% of the patient visits. And while in-person visits have decreased by 10%, revenue has increased compared to a year ago.

“We purchased a couple iPads and different experiments with techniques to be able to communicate,” said Dr. Milford. “Luckily, we have a young staff that has allowed us to do that and we’re small, so the IT part we can just figure it out.”

“We did the social distancing amongst ourselves within our office too, so unfortunately now I do telehealth in a closet,” he said. “That part is the only downside to the telehealth for me.”

Otherwise, the team was able to switch “out a visit for a telehealth visit,” said Dr. Milford. “It just flowed right into the mainstream.”

“We’ve realized, obviously, a lot of health care can be provided through telemedicine,” he said, adding that about 50% of their patients don’t need to be seen in person. While there is a lot of evidence providing guidance for telehealth and how to care for patients remotely, there is still the question of, “For a patient with hypertension, how often do you listen to the heart? For a prevention exam, does an exam really make a difference?”

“We don’t have evidence to guide us on where the safety boundary is on telehealth, but we’re doing our best and taking our best guess right now,” he said. “It’s sort of obvious to keep them out of the clinic from the COVID standpoint, but there’s going to be a long-term answer that we need regarding boundaries on physical examination.”

“As we move forward here, we’re going to have the attitude of keeping people who are sick that don’t need to be seen, out of the office,” said Dr. Milford. “The future is ahead of us and our attitude is telehealth is going to stay.”

The AMA has created a step-by-step physician practice guide to reopening. This guide builds on the AMA’s ongoing efforts to ensure physicians and other health professionals have the most up-to-date information and resources necessary to navigate the rapidly changing landscape of the COVID-19 pandemic. 

Stay up to speed with the AMA’s quick guide to telemedicine in practice and track the fast-moving pandemic with the AMA's COVID-19 resource center, which offers a library of the most up-to-date resources from JAMA Network™, the Centers for Disease Control and Prevention, and the World Health Organization.

The AMA also created a physician’s guide to COVID-19, which features resources on how to optimize the supply of PPE.