From One Room to Three Dermatology Clinics

Dr Diane Madfes started her own dermatology practice about twenty five years ago, wanting more flexibility as a mother of two young children. What she had not anticipated was that every system her previous employers and hospitals had quietly handled for her would dissolve overnight. She describes herself as clueless at that point, and is unbothered by it: sometimes it is better to be clueless, because then you hit the ground running. She began with an office manager and one medical assistant, on call around the clock, because in the early years you are there whenever the patients can come. Twenty five years later the practice is six physicians and roughly twenty support staff across an office in New York, a second in Greenwich and a satellite in Florida. This episode is hosted by Sally from Coherent rather than Jared, recorded in New York.

The operating philosophy running underneath it is unusually explicit, and in places deliberately old fashioned. Call during office hours and a person picks up, because a person who knows the schedule and the procedures can ask what your downtime is and suggest you come in at the end of your trip. New hires take about three months to train and are tested with secret callers, and she would rather they understood how the practice works than memorised a script. New technology goes to a doctors-only huddle first, where the studies get read, before it reaches the front desk or a patient. There are no physician assistants and no nurse practitioners, which she names as one of the pillars holding the standard of care. And she is candid that the hardest thing to automate is triage: a text reading "I am healing from that infection I had three months ago and now I just want my body check" still gets flagged as an active infection, so people sort the messages instead.

On growth she is refreshingly concrete. She knew it was time for more space when staff were bumping into the lasers and patients were being asked to wait in the park until a room freed up, so rather than move she knocked on her neighbour's door and asked whether he might bring his retirement forward a little. Greenwich opened after 9/11, when her patients were afraid to travel into the city; the Florida satellite appeared because snowbirds kept coming back with problems that had gone unattended. She sublets Greenwich on the days she is not there and vets who shares the space, on the grounds that a patient walking into that office is still forming a view of her brand. She is blunt about text fatigue, and about the difference between contacting a patient and asking a patient to do something for you. And she turns down private equity, which approaches every day, because she reckons she can already do what they would do.