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[Solution]health care Strategic management

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Why should program evaluation be used for public health and not-for-profit institutions in the development of adaptive strategies?
Explain the strategic position and action evaluation (SPACE) matrix. How may adaptive strategic alternatives be developed using SPACE?

Professional Development: 
Case Study #8: “Dr. Louis Mickael: The Physician as Strategic Manager”
Develop an environmental assessment and an internal capabilities analysis using decision support tools that have been introduced in this module (such as PLC analysis, BCG portfolio analysis, SPACE analysis and so on). Analyze alternative strategies to include pros and cons of each alternative, then conclude with a recommended strategy and brief implementation plan.
By the early 1980s, costs to provide these health care services reached epic proportions; and the ?nancial ability of employers to cover these costs was being stretched to breaking point. In addition, new government health care regulations had been enacted that have had far-reaching effects on this US industry. The most dramatic change came with the inauguration of a prospective payment system. By 1984, reimbursement shifted to a prospective system under which health care providers were paid preset fees for services rendered to patients. The procedural terminology codes that were initiated at that time designated the maximum number of billed minutes allowable for the type of procedure (service) rendered for each diagnosis. A diagnosis was identi?ed by the International Classi?cation of Diseases, Ninth Revision, Clinical Modi?cation, otherwise known as ICD-9-CM. The two types of codes, procedural and diagnosis, had to logically correlate or reimbursement was rejected. Put simply, regardless of which third-party payor insured a patient for health care, the bill for an of?ce visit was determined by the number of minutes that the regulation allowed for the visit. This was dictated by the diagnosis of the primary problem that brought the patient into the of?ce and the justi?able procedures used to treat it. These cost-cutting measures initiated through the government-mandated prospective payment regulation added to physicians’ overhead costs because more paperwork was needed to submit claims and collect fees. In addition, the length of time increased between billing and actual reimbursement, causing cash ?ow problems for medical practices unable to make the procedural changes needed to adjust. This new system had the effect of reducing income for most physicians, because the fees set by the regulation were usually lower than those physicians had previously charged. Almost all other operating costs of of?ce practice increased. These included utilities, maintenance, and insurance premiums for of?ce liability coverage, workers’ compensation, and malpractice coverage (for which costs tripled in the late 1980s and early 1990s). This changed the method by which government insurance reimbursement was provided for health care disbursed to individuals covered under the Medicare and Medicaid programs. Private insurors quickly adopted the system, and health care as an industry moved into a more competitive mode of doing business. The industry pro?le differed markedly from that of only a decade earlier. Hospitals became complex blends of for-pro?t and not-for-pro?t divisions, joint ventures, and partnerships. In addition, health care provided by individual physician practitioners had undergone change. These professionals were forced to take a new look at just who their patients were and what was the most feasible, competitively justi?able, and ethical mode of providing and dispensing care to them. For the ?rst time in his life, Dr. Mickael read about physicians who were bankrupt. In actuality, Dr. Charles, who shared of?ce space with him, was having a ?nancial struggle and was close to declaring bankruptcy.
The last patient had just left, and Dr. Lou Mickael (“Dr. Lou”) sat in his of?ce thinking about the day’s events. He had been delayed getting into work because 
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a patient telephoned him at home to talk about a problem with his son. When he arrived at the of?ce and before there was time to see any of the patients waiting for him, the hospital called to tell him that an elderly patient, Mr. Spence, admitted through the emergency room last night had taken a turn for the worse. “My days in the of?ce usually start with some sort of crisis,” he thought. “In addition to that, the national regulations for physician and hospital care reimbursement are forcing me to spend more and more time dealing with regulatory issues. The result of all this is that I’m not spending enough time with my patients. Although I could retire tomorrow and not have to worry ?nancially, that’s not an alternative for me right now. Is it possible to change the way this practice is organized, or should I change the type of practice I’m in?”
Practice Background When Dr. Lou began medical practice the northeastern city’s population was approximately 130,000 people, most of whom were blue-collar workers with diverse ethnic backgrounds. By 1994, suburban development surrounded the city, more than doubling the population base. A large representation of service industries were added, along with an extensive number of upper and middle managers and administrators typically employed by such industries.
Dr. Lou kept the same of?ce over the years. It was less than one-half mile from the main thoroughfare and located in a neighborhood of single-family dwellings. The building, constructed speci?cally for the purpose of providing space for physicians’ of?ces, was situated across the street from City General, the hospital where Dr. Lou continued to maintain staff privileges. Three physicians (including Dr. Lou) formed a corporation to purchase the building, and each doctor paid that corporation a monthly rental fee, which was based primarily on square footage occupied, with an adjustment for shared facilities such as a waiting room and rest rooms.
Of?ce Layout
One of the physicians, Dr. Salis, was an orthopedic surgeon who occupied the entire top ?oor of the building. Dr. Lou and the other physician, Dr. Charles, were housed on the ?rst ?oor. Total of?ce space for each (a small reception area, two examining rooms, and private of?ce) encompassed a 15′ × 75′ area (see Exhibit 8/1). The basement was reserved for storage and maintenance equipment. The reception area and each of the other rooms that made up the of?ce space opened on to a hallway that Dr. Lou shared with Dr. Charles. The two physicians and their respective staff members had a good rapport; and because the reception desks opened across from each other, each staff was able to provide support for the other by answering the phone or giving general information to patients when the need arose.
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The large, common waiting room was used by both physicians. After reporting to their own doctor’s reception area, patients were seated in this room, then paged for their appointment via loudspeaker. Dr. Charles was in his mid-forties and in general practice as well. His patients ranged in age from 18 to their mid-eighties, and his of?ce was open from 10:00 A.M. until 7:30 P.M. on Mondays and Thursdays, and from 9:30 A.M. until 4:30 P.M. on Tuesdays and Fridays; no of?ce hours were scheduled on Wednesday. He and Dr. Lou were familiar with each other’s patient base, and each covered the other’s practice when necessary.
Staff and Organizational Structure
Dr. Lou’s staff included one part-time bookkeeper (who doubled as of?ce manager) and two part-time assistants. The assistants’ and bookkeeper’s time during of?ce hours was organized in such a way that one individual was always at the reception desk and another was “?oating,” taking care of records, helping as needed in the examining rooms, and providing of?ce support functions. There were never more than two staff people on duty at one time, and the assistants’ job descriptions overlapped considerably (see Exhibit 8/2 for job descriptions). Each staff member could handle phone calls, schedule appointments, and usher patients to the examining rooms for their appointments. Although Dr. Lou was “only a phone call away” from patients on a 24-hour basis, patient visits were scheduled only four days a week. On two of these days (Monday and Thursday) hours were from 9:00 A.M. to 5:00 P.M. The other two were “long days” (Tuesday and Friday), when of?ce hours of?cially were extended to 7:00 P.M. in the evening, but often ran much later.
Front Desk Treatment Room 1
Treatment Room 2
Private Office
Dr. Charles’ Office Space
Front Door
Common Waiting Room
Job Description: Bookkeeper/Of?ce Manager In addition to responsibility for bookkeeping functions, ordering supplies, and reconciling the orders with supplies received, this person knows how to run the reception area, pull the ?le charts, and usher patients to treatment rooms. In addition, she can handle phone calls, schedule appointments, and enter of?ce charges into patient accounts using the computer.
Job Description: Assistant 1 The main responsibility of this position is insurance billing. Additional duties include running the reception area, pulling and ?ling charts, ushering patients to treatment rooms, answering the phone, scheduling appointments, entering of?ce charges into patient accounts, and placing supplies received into appropriate storage areas.
Job Description: Assistant 2 This is primarily a receptionist position. The duties include running the reception area, pulling and ?ling charts, ushering patients to treatment rooms, answering the phone, scheduling appointments, entering of?ce charges into patient accounts, and placing supplies received into appropriate 
The ?fth weekday (Wednesday) was reserved for meetings, which were an important part of Dr. Lou’s professional responsibilities because he was a member of several hospital committees. He was one of two physicians residing on the ten-member board of the hospital, and this, along with other committee responsibilities, often demanded attendance at a variety of scheduled sessions from 7:00 A.M. until late afternoon on “meetings” day. Wednesday was used by the staff to process patient insurance forms, enter patient data into their charts and accounts receivables, and prepare bills for processing. When paperwork began to build after the PPS regulations came into effect in the 1980s, patients had many problems dealing with the forms that were required for reimbursement of services received in a physician’s of?ce. It was the option of physicians whether to “accept assignment” (the standard fee designated by an insurance payor for a particular health care service provided in a medical of?ce). A physician who chose to not accept assignment must bill patients for health care services according to a fee schedule (“a usual charge” industry pro?le) that was preset by Medicare for Medicare patients. Most other insurances followed the same pro?le. Dr. Lou agreed to accept the standard fee, but the patient had to pay 20 percent of that fee, so the billing process became quite complicated. In 1988, Dr. Lou decided that he needed to computerize his patient information base to provide support for the billing function. He investigated the possibility of using an off-site billing service, but it lacked the ?exibility needed to deal with regulatory changes in patient insurance reporting that occurred with greater 
and greater frequency. Dr. Charles was asked if he wished to share expenses and develop a networked computer system. But the offer was declined; he preferred to take care of his own billing manually. An information systems consultant was hired to investigate the computer hardware and software systems available at that time, make recommendations for programs speci?cally developed for a practice of this type, and oversee installation of the ?nal choice. After initial setup and staff training, the consultant came to the of?ce only on an “as needed” basis, mostly to update the diagnostic and procedure codes for insurance billing. Computerization was an important addition to the record-keeping process, and the system helped increase the account collection rate. However, at times problems would arise when the regulations changed and third-party payors (insurance companies) consequently adjusted procedure or diagnosis codes. For example, there was often some lag time between such decisions and receipt of the information needed to update the computer program. Fortunately, the software chosen remained technologically sound, codes were easily adjusted, and vendor support was very good. Although the new system helped to adjust the account collection rate, ?tting this equipment into the cramped quarters of current of?ce space was a problem. To keep the computer paper and other supplies out of the way, Dr. Lou and his staff had to constantly move the heavy boxes containing this stock to and from the basement storage area.
January 8, 1994 (Morning)
On Dr. Lou’s way in that day, the bookkeeper told him that something needed to be done about accounts receivable. Lag time between billing and reimbursement was again getting out of hand, and cash ?ow was becoming a problem (see Exhibits 8/3 through 8/6 for ?nancial information concerning the practice). Cash ?ow had not been a problem prior to PPS, when billing for the health care provided by Dr. Lou was simpler, and payment was usually retrospectively reimbursed through third-party payors. However, as the regulatory agencies continued to re?ne the codes for reporting procedures, more and more pressure was being placed on physicians to use additional or extended codes in reporting the condition of a patient. Speed of reimbursement was a function of the accuracy with which codes were recorded and subsequently reported to Medicare and other insurance companies. In part, that was determined by a physician’s ability to keep current with code changes required to report illness diagnoses and of?ce procedures. Cathy, the receptionist, had a list of patients who wanted Dr. Lou to call as soon as he came in. She also wanted to know if he could squeeze in time around lunch hour to look at her husband’s arm; she believed he had a serious infection resulting from a work-related accident. The wound looked pretty nasty this morning, and Cathy thought maybe it should not wait until the ?rst available appointment at 7:00 P.M.
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Exhibit 8/3: Trial Balance at December 31
 1991 1992 1993
Debits Cash $15,994 $9,564 $8,666 Petty cash 50 100 100 Accounts receivable 19,081 25,054 28,509 Medical equipment 11,722 11,722 11,722 Furniture and ?xtures 3,925 3,925 3,361 Salaries 117,455 124,608 132,325 Professional dues and licenses 1,925 1,873 1,816 Miscellaneous professional expenses 1,228 2,246 3,232 Drugs and medical supplies 2,550 1,631 2,176 Laboratory fees 2,629 524 1,801 Meetings and seminars 2,543 838 3,880 Legal and professional fees 5,525 2,057 5,400 Rent 16,026 16,151 18,932 Of?ce supplies 4,475 3,262 4,989 Publications 1,390 406 401 Telephone 1,531 1,451 2,400 Insurance 8,876 9,629 11,760 Repairs and maintenance 3,547 4,240 5,352 Auto expense 1,009 1,487 3,932 Payroll taxes 3,107 2,998 3,780 Computer expenses 846 938 1,905 Bank charges  438 455 479 $225,872 $225,159 $256,918 Credits Professional fees $172,281 $172,472 $204,700 Interest income 992 456 210 Capital 46,122 43,137 40,117 Accumulated depreciation (furniture and ?xtures) 1,692 2,151 2,796 Accumulated depreciation (medical equipment) 4,785 6,943 9,095 $225,872 $225,159 $256,918
Exhibit 8/4: Gross Revenue and Accounts Receivable
 December 31 1979 1986
Gross revenue $116,951 $137,126 Accounts receivable 15,684 32,137
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“I’m just starting to see my patients, and I’ve already done a half-day’s work,” Dr. Lou thought when he buzzed his assistant to bring in the ?rst patient. He was 45 minutes late.
Patient Pro?le
When Dr. Lou walked into Treatment Room 1 to see the ?rst patient of the day, Doris Cantell, he was thinking about how his practice had grown over the years. His practice maintained between 800 and 900 patients in active ?les. In comparison to other solo practitioners in the area, this would be considered a fairly large patient base. “Well, how are you feeling today?” he asked the matronly woman. Doris and her husband, like many of his patients, were personal friends. In the beginning years of practice, Dr. Lou’s patients had been primarily younger people with an average age in the mid-thirties; their average income was approximately $15,000. Their families and careers were just beginning, and it was not unusual to spend all night with a new mother waiting to deliver a 
Exhibit 8/5: Statements of Income for the Years Ended December 31
 1991 1992 1993
Operating Revenues Professional fees $172,281 $172,472 $204,700 Interest income 992 456 210 Total revenues 173,273 172,928 204,910 Operating Expenses Salaries (Dr. Mickael, Staff) 117,455 124,608 132,325 Professional dues and licenses 1,925 1,873 1,816 Miscellaneous professional expenses 1,228 2,246 3,232 Drugs and medical supplies 2,550 1,631 2,176 Laboratory fees 2,629 524 1,801 Meetings and seminars 2,543 838 3,880 Legal and professional fees 5,525 2,057 5,400 Rent 16,026 16,151 18,932 Of?ce supplies 4,475 3,262 4,989 Publications 1,390 406 401 Telephone 1,531 1,451 2,400 Insurance 8,876 9,629 11,760 Repairs and maintenance 3,547 4,240 5,352 Auto expense 1,009 1,487 3,932 Payroll taxes 3,107 2,998 3,780 Computer expenses 846 938 1,905 Bank charges 438 455 479 Total operating expenses 175,100 174,794 204,560 Net Income (Loss) ($1,827) ($1,866) $350
 Exhibit 8/6: Balance Sheets at December 31
 1991 1992 1993
Assets Capital equipment Medical equipment $11,722 $11,722 $11,722 Furniture and ?xtures 3,925 3,925 3,361 Less-accumulated depreciation (6,477) (9,094) (11,891) Total capital equipment 9,170 6,553 3,192 Current assets Cash 15,994 9,564 8,666 Petty cash 50 100 100 Accounts receivable 19,081 25,054 28,509 Total current assets 35,125 34,718 37,277 Total assets $44,295 $41,271 $40,467
Liabilities Current liabilities Income taxes payable ($639) ($653) $122 Dividends payable 1,158 1,154 1,154 Total current liabilities 519 501 1,276 New income (1,188) (1,213) 228 Less dividends 1,158 1,154 1,154 Retained earnings (2,346) (2,367) (926) Capital 46,122 43,137 40,117 Total owner’s equity 43,776 40,770 39,191 Total liabilities and owner’s equity $44,295 $41,271 $40,467
 baby. Although often dead tired, he enjoyed the closeness of the professional relationships he had with his patients. He believed that much of his success as a physician came from “going that extra mile” with them. Many things had changed. Today all pregnancies were referred to specialists in the obstetrics ?eld. His patients ranged in age from 3 to 97, with an average of 58 years; their median income was $25,000. Most were blue-collar workers or recently retired, and their health care needs were quite diverse. Approximately 60 percent of Dr. Lou’s patients were subsidized by Medicare insurance, and most of the retired patients carried supplemental insurance with other third-party payors. Three types of third-party payors were involved in Dr. Lou’s practice: (1) private insurance companies, such as Blue Cross and Blue Shield; (2) government insurance (Medicare and Medicaid); and (3) preferred provider organizations. Preferred provider organizations and health maintenance organizations were forms of group insurance that emerged in response to the need to cut the costs of providing health care to patients, which resulted in the prospective payment system. Both types of organizations developed a list of physicians who would 
accept their policies and fee schedules; using the list, subscribers chose the doctor from whom they preferred to obtain health care services. Contrary to reimbursement policies of most other major medical third-party payors, PPOs and HMOs covered the cost of of?ce visits, and the patient might not be responsible for any percentage of that cost. Although the physician had to accept a fee schedule determined by the outside organization, there was an advantage to working with these agencies. A physician might be on the list of more than one organization, and a practice could maintain or expand its patient base through the exposure gained from being listed as a health service provider for such organizations. Those patients who were working usually had coverage through work bene?ts. Some were now members of a PPO. Dr. Lou was on the provider list of the Northeast Health Care PPO; only a few of his patients were enrolled in the government welfare program. “How’s your daughter doing in college?” Dr. Lou asked. He had a strong rapport with the majority of his patients, many of whom continued to travel to his of?ce for medical needs even after they moved out of the immediate area. “Are you heading south again this winter, and are you maintaining your ‘snowbird’ relationship with Dr. Jackson?” It was not unusual for patients to call from as far away as Florida and Arizona during the winter months to request his opinion about a medical problem, and Doris had called last year to ask him to recommend a physician near their winter home in the South. Because of this personal attention, once patients initiated health care with him, they tended to continue. Dr. Lou had lost very few patients to other physicians in the area since he began to practice medicine. The satisfaction experienced by his patients provided the only marketing function carried out for the practice. Any new patients (other than professional referrals) were drawn to the of?ce through word-of-mouth advertising.
Dr. Lou: Pro?le of the Physician
Dr. Lou had grown older with many of his patients. His practice spanned more than three generations; a lot of families had been with him since he opened his doors in 1961. Caring for these people, many of whom had become personal friends, was very important to him. However, as the character of the health care industry was changing, Dr. Lou was beginning to feel that he now spent entirely too much time dealing with the “system” rather than taking care of patients. Eighty-year-old Mr. Spence was a good example. Three weeks before, he was discharged from the hospital after having a pacemaker implanted. He had been living at home with his wife, and although she was wheelchair bound, they managed to maintain some semblance of independence with the assistance of part-time care. Lately, however, the man had become more and more confused. The other night he wandered into the yard, fell, and broke his hip. His reentry to the hospital so soon meant that a great deal of paperwork would be needed to justify this second hospital admission. In addition, Dr. Lou expected to receive 
calls from their children asking for information to help them determine the best alternatives for the care of both parents from now on. He had never charged a fee for such consultation, considering this to be an extension of the care he normally provided. “Things are really different now,” he thought. “Under this new system I don’t have the ?exibility I need to determine how much time I should spend with a patient. The regulations are forcing me to deal with business issues for which I have no background, and these concerns for costs and time ef?ciency are very frustrating. Medical school trained me in the art and science of treating patients, and in that respect I really feel I do a good job, but no training was provided to prepare me to deal with the business part of a health care practice. I wonder if it’s possible to maintain my standards for quality care and still keep on practicing medicine.”
Local Environment The actual number of city residents had not changed appreciably since the early 1960s, although suburban areas had grown considerably. In the mid-1970s, a four-lane expressway, originally targeted for construction only one mile from the center of the downtown area, was put in place about eight miles farther away. Within ?ve years, most of the stores followed the direction of that main highway artery and moved to a large mall situated about ?ve miles from the original center of the city. Many of the former downtown shops then became empty. Government of?ces, banking and investment ?rms, insurance and real estate of?ces, and a university occupied some of this vacated space; it was used for quite different (primarily service-oriented) business activities. Numerous residential apartments devoted to housing for the elderly and lowincome families were built near the original, downtown shopping area. Several large of?ce buildings (where much space was available for rent) and of?ces for a number of human services agencies relocated nearby. As he headed across the street to lunch in the hospital dining room, Dr. Lou was again thinking about how things had changed. At ?rst, he had been one of a few physicians in this area. Within the past ten years, however, many new physicians had moved in.
Competition Two large (500-bed) hospitals within easy access of the downtown area had been in operation for over 40 years. One was located immediately within the city limits on the north side of the city; the other was also just inside city limits on the opposite (south) side. They were approximately three miles apart and competed for a market share with City General, a 100-bed facility. This smaller hospital was only two blocks from the old business district; it was the only area hospital where Dr. Lou maintained staff privileges. Exhibit 8/7 contains a map showing the location of the hospitals and Dr. Lou’s of?ce.
The two large hospitals had begun to actively compete for staff physicians (physicians in private practice who paid fees to a hospital for the privilege of bringing their patients there for treatment). In addition, these two health care institutions offered start-up help for newly certi?ed physicians by providing low-cost of?ce space and ensuring ?nancial support for a certain period of time while they worked through the ?rst months of practice. City General recently began subsidizing physicians coming into the area by providing them with of?ces inside the hospital. Most of these physicians worked in specialty ?elds that had a strong market demand, and the hospital gave them a salary and special considerations, such as low rent for the ?rst months of practice, to entice them to stay in the area. These doctors served as consultants to hospital patients admitted by other staff physicians and could in?uence the length of time a patient remained in the hospital. This was an extremely important issue for the hospital, because under the new regulations a long length of stay could be costly to the facility. All third-party insurors reimbursed only a ?xed amount to the hospital for patient care; the payment received was based on the diagnosis under which a patient was admitted. Should a patient develop complications, a specialist could validate the extension of reimbursable time to be added to the length of stay for that patient. In the past few years, many services to patients provided by all these hospitals changed to care provided on an outpatient basis. Advancements in technology made it possible to complete in one day a number of services, including tests and some surgical procedures, which formerly required admission into the hospital and an overnight stay. Many such procedures could also be done by physicians in their of?ces, but insurance reimbursement was faster and easier if a patient had them done in a hospital. As an example of the degree of change involved, in the mid-1980s, outpatient gross revenue was only 18 percent of total gross revenue for City General. In 1992 this ?gure was projected to be approximately 30 percent.
January 8, 1994 (Lunchtime)
“May I join you?” Dr. Lou looked up from his lunch to see Jane Duncan, City General’s hospital administrator, standing across the table. “I’d like to talk with you about something.” Dr. Lou thought he knew what this was about. The hospital had been recruiting additional staff physicians (doctors who owned private practices in and around the city). A number of these individuals held family practice certi?cation, a prerequisite for staff privileges in many hospitals. The recruitment program offered ?nancial assistance to physicians who were family practice specialists wishing to move into the area, and also subsidized placement of younger physicians who had recently completed their residencies. In contrast to physicians designated as general practitioners, who had not received training beyond that received through medical school and a residency, “family practitioners” received additional training and passed state board exams written to speci?cally certify a physician in that ?eld. Last week after a hospital staff meeting, Duncan had caught him in the hall and wanted to know if Dr. Lou had thought about his retirement plans. “It’s really not too soon,” she had said. Dr. Lou knew that one of the methods used to bring in “new blood” was to provide ?nancial backing to a physician wishing to ease out of practice, helping pay the salary of a partner (usually one with family practice certi?cation) until the older physician retired. “She wants to talk to me again about retirement and taking on a partner,” he thought. “But I’m only in my late ?fties. And I’m not ready to go to pasture yet! Besides, there’s really no room to install a partner in my of?ce.”
January 8, 1994 (Afternoon)
After lunch Dr. Lou ran back to the of?ce to take a look at Cathy’s husband’s arm before regular of?ce hours started. This was a work-related case. As he treated the patient, he began thinking about industrial medicine as an alternative to full-time of?ce practice. Right then the prospect seemed quite appealing. He had investigated the idea enough to know that there were only a few schools that provided this kind of training but one was within driving distance (Exhibit 8/8 contains information on industrial medicine). As health costs rose over the past decade, manufacturing organizations began to feel the cost pinch of providing health care insurance to employees. Some larger companies in the area began to recognize the cost bene?t of maintaining a private physician on staff who was trained in the treatment of health care needs for 
industrial workers. Dr. Lou had been considering going back for postgraduate training in industrial medicine, and while wrapping the man’s arm, he began to think about working for a large corporation. “Work like that could have a lot of bene?ts; it would give me a chance to do something a little different, at least part time for now,” he thought. “The income was almost comparable to what I net for the same time in the of?ce, and some days I might even get home before 9:00 P.M.!”
End of the Day
As he was putting on his coat and getting ready to leave, Dr. Charles, the physician from across the hall, phoned to ask if Dr. Lou might be interested in buying him out. “I think you could use the space,” he said, “and my practice is going down the tubes. I can’t seem to get an upper hand with the ?nances. I’ve had to borrow every month to maintain the cash ?ow needed to pay my bills because patients can’t keep up with theirs. City General has offered me a staff position, and I’m seriously considering it. I thought I’d give you ?rst chance.” After some minutes of other “of?ce talk,” Dr. Charles said good night. “If I wanted to take on a new partner, that could work out well,” thought Dr. Lou. “It might be interesting to check into this. I wonder what his asking price would be? It could not be too much more than the value of my practice; although his patients are a bit younger and some of his equipment is a little newer. The 
Exhibit 8/8: Industrial Medicine as a New Career for Dr. Mickael “Industrial Medicine” is an emerging physician specialty. Training in this new ?eld entails postgraduate work and board certi?cation.
As yet, only a fe


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