Peeling Back The Curtains On The Startup: A Case Study


By:  DMKashmer, MD MBA MBB



We discuss numerous techniques on the blog for startup companies.  In this series of entries, we will discuss a case study of a startup as it unfolds in order to highlight some of the different tools and techniques we’ve used.


Intro To The Young Startup

Allow me to introduce Provider Lifestyle Experts (PLE).  Provider Lifestyle Experts ( is an idea that relieves a pain point that many physicians, especially surgeons, have:  multiple administrative tasks exist which we have little time to complete.  Things like licensure, credentialing, scheduling, planning, and other associated tasks often take more time than we have in our busy practice and lives.  They help bury us under paperwork hurdles that are hard to surmount.


Personal assistants are some options we can use so that we can better focus on taking care of patients and ourselves.  I have previously tried a virtual personal assistant team based on the advice of colleagues and a book called The 4 Hour Work Week.  These two sources led me to have an interest in virtual personal assistants and non-virtual personal assistants.  At some point I realized I was spending a significant amount each month on a personal assistant.


Unique Value Proposition

For that reason, I thought it maybe worth while to start a virtual personal assistant team which is focused on the special needs of physicians and surgeons.  Perhaps not surprisingly, the paperwork tasks and special needs for healthcare providers were VERY difficult for existing virtual assistants (often offshore) to understand.  That fact lead to errors, re-work, and many hours spent performing tasks that should not have taken so long.


In short, the tasks I required often needed special expertise beyond that normally seen in virtual personal assistants.  Existing virtual personal assistant services often fell short for what I needed as a healthcare provider.  There was a special value proposition required to be an excellent personal assistant for the jobs I needed done….and it’s not just paperwork.  The virtual assistant who specialized in healthcare could do literature searches, maintain all my documents in the cloud, and let me know about CME issues and times when I need to focus on recertifications.  These and other specialized tasks made me value the idea very highly.


Validated That Many In Healthcare Share Same Pain

I “got out of the office” and asked colleagues the jobs they needed done to decide if this admin paperwork was just a problem I had or if it was a problem that many healthcare providers had.  It turns out, perhaps expectedly, that the issues I saw were shared by colleagues including nurses, prehospital staff, physicians, and respiratory therapists.  So, I decided to take the money I spent every month on my own personal assistant and try to role out a scalable, virtual assistant service that satisfied this unique need.


Realization I Couldn’t Follow Through, & Passed Idea Off To A Startup Team

Unfortunately I lacked time and ability given my other endeavors to really have this service take off.  As we’ve discussed before, a team of 3 to 4 people is significantly associated in some series with startup success, and, when asked about startup team size, some say there’s no set number…but you should be able to feed the entire startup team with a box or two of pizza.  I lacked time to follow through on this idea and, on review, didn’t have all the skills required to make it go.


For that reason I passed off my idea and allowed a team of my colleagues to take it and run.  Isn’t it better to see the idea developed than not?  I continue to pay a monthly fee as a customer for this new company but I was no longer the person to run the company.


Next Up:  Team Building & Business Model Canvas

This series of blog entries, now, follows the lifecycle of this young startup.  I am very excited owing to the team that has picked up this idea and I can’t wait to watch as it is developed and grows.  Please enjoy, as I will, seeing this unique, valuable service expand.  We will be applying the tools and techniques of startups and we will describe how these are leveraged in designing and maintaining the startup.


Basic questions like:  what does a valuable value proposition look like?  Perhaps most importantly, what does a good team look like?  How can I determine how much capital I should use to get started with my idea?  Other old friends, such as Lean startup principles & the business model canvas, will appear early and often.


Next time, how to pick a team and the business model canvas as applied to PLE.  By the way, special thanks to the PLE team for letting me write about their endeavor.  It takes a lot to pull back the curtain a la reality TV on your startup, so I thank them for the all-access pass.

Top 4 Important Things About Paramedic – Physician Communication




By:  The Musing Medic


Unique Relationship Between Paramedics And Physicians


Physicians and paramedics have a unique relationship.  In the grand scheme, the physician is in charge even if they are not present in the pre-hospital setting.  But the physician also trusts the paramedic to use their own clinical judgment and diagnostic skills to properly assess and treat a patient.  That requires trust from the physician and humility from the paramedic.  But the only way both groups can come together and form a great working relationship, perhaps even friendship, is by constantly working on communication.  So here are some musings (get it, the musing medic–yeah, I know) on key communication points between physicians and pre-hospital staff.


The Top 4 Most Important Things

1. Medicine is a hierarchy whether we like it or not.

Physicians are at the top of the food chain.  This is not because they possess some other-worldly quality.  It is because of their training.  Undergraduate, medical school, residency, and sometimes fellowship…that is a lot of time spent to honing their craft.  Paramedics should realize that when a physician commends or rebukes, it is because their training has developed them into providers that attempt to collate massive amounts of data and information and form an objective stance.  If they provide you with advice or criticism on a patient, take it and run.  They are not trying to lead you astray.


2. Knowledge is not limited to one specific group of people.

As a paramedic, I stay in the loop with current literature–and not just the EMS trade magazines.  If you could see the books on my shelf like Harrison’s and Rosen’s, both of which are well worn from reading, you would know I am serious about my field.  Sometimes we are even more knowledgeable about current practices than other staff.  I urge you to read up on the studies regarding supplemental oxygen use on an Acute MI or the effectiveness of Trendelenberg position.  (Both are considered ineffective and outdated yet some physicians still cling to these age-old practices.) Just like anyone else, physicians can (and do) become complacent.  The moral of the story is:  don’t assume the paramedic you are talking with is uneducated or lacking in knowledge.  Treat us as a colleague and watch your relationship evolve.


3. Medical command calls should be two professionals working together.

Rarely should the physician just say “No” without hearing the paramedic’s thought process.  Help them consider alternatives or other avenues, but never shut them down immediately or without an alternate option (this does not apply to paramedic’s whose actions will likely harm the patient, that is a time for a forceful response). And to the paramedics, formulate a plan before you call in.  You are on the front lines in the field, not the physician.  They are counting on you.  If you can provide sound, logical reasoning for a treatment, they most likely will agree.  But don’t be afraid to get a second opinion, physicians are there to help.


4. And finally, be open to doing a post-run discussion or debriefing.

Physicians, you should be going over an interesting patient with the paramedics.  Learning opportunities abound but are rarely capitalized on.  And paramedics, seek out the physician, ask them for a moment of their time, and work through the call together.  If you don’t know, ask.  The only way to advance is by constantly improving yourself.


If I Had Just One Word To Sum It Up


So there you have it.  Just a few tidbits that have been on my mind lately.  I think if I had to highlight one single point of this whole thing it is the concept of humility.  Not one person can do it all or know it all.  Both sides must work together.  Paramedics and physicians need to remain open to input from one another.  Bill Nye once said “everyone you will ever meet knows something you don’t.”


I think this is a great way to approach medicine and life in general.



Till next time,
The Musing Medic

Coming Soon: The Generation Y Surgeon, The Musing Medic, & Blogging A Book


Hello All,


This coming week on the blog, we hear from the Generation Y Surgeon with more opinion pieces about the culture of Surgery.


The Musing Medic shares an interesting take on common prehospital issues with us.


And we explore the business canvas technique as applied to a startup company along with lessons learned by the startup team.


See You Soon On The Blog



Duty Hours As A Weapon Part 2


By:  The Generation Y Surgeon (@GenYSurgeon)


Using the Duty Hours as a Weapon Part II: The Devaluation of Residency

In my last post I highlighted how residents have learned to use the duty hours as a weapon against their program, peers and attendings.  I also pointed out that this is NOT professional (one of our core competencies!); however, residents aren’t the only offenders.  In this post I’m looking at the other edge of the sword–how senior physicians use the hours against residents.


We have all heard the stories of the olden days….when surgeons were lucky to walk to the hospital uphill both ways because that meant they were allowed to leave.  When residents were called residents because the actually resided in the hospital.  When doctors worked 1000 hours a week and were treated like gods by nurses and patients alike…


Those days are over.


The 80 Hours Is A Double Edged Sword For Residents

Ever since the start of the 80-hour workweek, residents have found themselves in the middle of a no-win situation.  If you log violations or get caught lying your program could get shut down.  If you go home like you’re supposed to, attendings are annoyed that you’re unavailable.  Making the schedules for case coverage, rounding and calls has turned from a chore into a nightmare.  And at the end of the week, you’ve still only worked 80 hours.  Eighty hours is a long time–it keeps you from having a social life, from your family, and from your significant others…but to the people you work for it means next to nothing.


The constant backhanded insults from senior physicians regarding duty hours are demeaning and they strip all the pride out of being a general surgery resident.  No matter how hard you work (or not), at the end of the week someone tells you that there’s no way you’ll live up to their standards, match their commitment or otherwise end residency as a fully trained surgeon.  It’s demotivating and demeaning.  No wonder residents do their best to get out of the hospital.  When you take away the pride associated with working hard and sacrificing your personal life for your work, what’s left?


As Millenials, Our Generation Didn’t Cause This…But We Take The Brunt Of It

Using the duty hours as a psychological weapon against the residents is unfair because the current generation had nothing to do with WHY they were instituted in the first place.  We were all in diapers when our profession let training standards dip to the low point where patients were endangered or where the public thought they were endangered.  A profession is a self-governing and autonomous group, and part of that means that we create a sustainable culture and work force that is safe for us and for our patients alike.  You can accuse the government or media all you want of spinning the issue, but regardless of why or how people felt physicians working 120+ hours a week was anything but safe and sustainable.  The profession had not self-regulated prior to the storm breaking.


Unfortunately it took a highly publicized patient issue (not to mention many others that were not publicized!) to establish the hours restrictions.  We should be ashamed of ourselves as surgeons and physicians that we let things get to that point in the first place.  A profession, by the true definition of the word, would have had the foresight and discipline to institute effective changes before these disasters occurred.


It Wasn’t The Younger Generation That Failed 

So when you when you find yourself using the duty hours as a weapon, whether on purpose or inadvertently, remember that it wasn’t the younger generation that failed.  How we got to the need for resident work hours was a failure of Surgery as a profession in its entirety.  Don’t just complain about the work hours–help to build and develop them.  We as surgeons, and as professionals, need to evolve and adapt or we too will go the way of the dinosaur.


Any feedback?  Let me know beneath!


Is Ultrasound Useful For Your Friendly Neighborhood Paramedic?


By:  The Musing Medic (@TheMusingMedic)



Ultrasound Is Everywhere In Medicine, Should it Be In Our EMS Hands?

Ultrasound (US) has become a ubiquitous diagnostic tool used by a number of physicians from family medicine to trauma surgery to OB/GYN.  The modern US has become sleek and portable and reasonably priced.  There are even handheld US available for around $8,000.  Every physician practicing could have US capability in the palm of their hand.


So with US being so common, is it reasonable to think that US would be practical in the hands of your friendly neighborhood paramedics and medical flight crews?


The Big Two:  Training & Transport Time


According to the article Use of ultrasound by emergency medical services: a review, studies previously completed internationally and domestically show support for the use of US in select settings and situations.  Two of the major factors they touched on were training and transport time.  Training would be the least of the concerns in my mind.  With enough instruction, both didactic and clinical, most emergency responders should be able to accurately identify vital structures and anatomical regions in their normal state and identify varying pathologies when illness or injury occurs.  Really, it is knowing when and why to perform an US examination.


Access to definitive care for acute illness or injury is dictated by location. The idea of the “golden hour”in trauma or “time is muscle” in an Acute MI applies to many patients, whether they are five minutes or five hours from the nearest medical center


Does Urban Versus Rural Matter?

Ultrasound makes sense for both both urban/suburban responders and rural responders, but in different scenarios.  US examinations would be appropriate in both setting for detecting cardiac activity in cardiac arrests, evaluation of potential aortic aneurysms, pneumothorax or hemothorax in trauma patients as well as a FAST exam to check for internal hemorrhage.


But the urban/suburban setting allows for faster transport times.  That means that the US examination should not delay transport to the nearest appropriate medical center.  Regardless of how talented or skillful the emergency providers are, they simply do not possess all the necessary resources to manage an actively exsanguinating patient.  The onus is on the provider to make the appropriate judgment whether or not to perform an US examination.


Longer Transport Time Allows Easier US Examination

Practicing in the rural setting, more time during the transport can be dedicated to US examination and aiding in the formation of a differential diagnosis and treatment plan.  It should be mentioned that many emergency responders in rural settings have additional training and resources that urban/suburban providers do not, such as the ability to place chest tubes and administer blood products.  In these instances, immediate intervention is indicated in the field due to the time it would take to reach definitive care.


In The End It’s:  Location, Location, Location

What this entire topic comes down to is the same thing that real estate agents have been saying for years: “location, location, location”.  US has a place in the pre-hospital setting but a more limited utility in the urban or suburban setting.  Training has been developed and rolled out for pre-hospital providers so that is a good start.


I’m certainly in favor of US in the prehospital setting in theory, but more research is needed before I am willing to give this practice my full support.


Thoughts or comments?  Let me know beneath.

The Generation Y Surgeon Warns Us About Duty Hours As A Weapon


By:  The Generation Y Surgeon (@GenYSurgeon)


Using the Duty Hours as a Weapon Part 1 of 2:

Gaming The System


I have a huge beef with most physicians’ interpretations of professionalism.  I’ve been called unprofessional for wearing the wrong thing, defending the wrong side of an argument, taking a stand against the majority or doing poorly on an exam–that’s probably all par for the course in surgical residency at what I call “yelling programs”.  Like other trainees, I may have been accused of many things, but I am NOT unprofessional.  Fun to tell stories of crazy accusations tossed at us as residents over a glass of wine or a beer–but NOT fun for much else.  A profession, by a great definition I found and hold dear, is a self-regulated, autonomous group with a shared skill set and body of knowledge.  I have many opinions on how surgeons (and physicians in general) should and should not interpret (and display) professionalism.  Of course, an issue that seems to be in direct conflict with these guidelines is the issue of duty hour compliance.



Setting The Stage For A Charged Discussion On Duty Hours


Unless you’re brain dead you’ve heard plenty about resident duty hours.  No doubt it was negative in nature.  The hours were instituted as a means to protect patients and providers alike (well residents anyways–our attendings are still working horrendous and frequently unsafe numbers of hours).  Yes, you may feel that the hours restrictions were in response to minimal data and maximum sensationalism whether you admit that publicly or not.  However, one thing we may agree on is that there have been many unintended consequences.  One example of these unintended consequences is when residents use the duty hours restrictions as a weapon against their program directors, attendings, and even their own co-residents to get what they want–what I call “duty hours as a weapon”.



Do You Realize How Much 80 Hours Is?

Let me preface this discussion with a few realities:

1. Eighty hours is a really long time.  It’s twice what most people work in a week.

2. It’s normal to want to work less and go home.


The problem is not with the hours themselves, but how the restrictions are twisted to be self-serving.  Violation of duty hour regulations carries stiff consequences including probation and closure of your program!  Yet, knowing this, residents continue to gamble with these hours as a means to getting time off or to get out of work.


As A Chief Resident I Have To Fight The Duty Hour War…Against Other Residents!

As a senior resident I find myself in the middle of the duty hour war.  As team leaders, senior residents are responsible for educating the juniors on the rules and mitigating the work schedules along with ensuring adequate case coverage and resident availability.  I mean, who else would do it?  Not the attendings or program administration.  They basically say “Guys you need to take care of this!” The hellfire rains down from the program director when violations are logged, yet the most painful battle is dealing with junior residents who “fight” with the hours as a weapon.


Here’s How The Weapon Gets Used

Listen, residents have learned to play the duty hours to maximize their time off and ensure they have time to do what they please.  I understand wanting to leave on time, to have a predictable schedule, to go home to your family/gym/friends/etc, but I don’t understand why residents do so in such a non-constructive way.  There have been too many times where an unfavorable call or rounding schedule has been met with threats to log violations.  It’s infuriating and makes no sense!  If we all log violations in duty hour restrictions then we may find ourselves with way too much time on our hands while we try to find another program at which to train!  This threat is maladaptive to say the least and instead of being a legitimate issue it’s now just a study in brinksmanship.


Why Do Hours Get Used As A Weapon?

Why do residents do this?  Well I think we may not be tired enough.  Idle hands are the devil’s tools.  (And yes, I think if the intern is writing a page long note then we probably aren’t busy enough.) In the “olden days,” prior to hours restrictions, residents worked such long hours that they just succumbed to the torture and forgot what it was like to be “free”.  Some feel they were trained to literally do what we do now “in their sleep” and that they really were “residents” of the hospital.  Right or wrong?  I don’t know. And of course I think most who completed training “the old way” have Stockholm syndrome.


Maybe Now They’re Rested Enough To Have Some Fight In Them

Today, although we still work twice as many hours as most, we are rested enough to realize that there’s more to life than just residency…and we want to go live it.  Pair that with the lifestyle-based decision-making typical of Millenials and you get a group of residents who are willing to do anything to get out of the hospital.


Stop Using The Hours As A Weapon And Be A Professional

Residents, we need to find a better way to protect our time and maintain our professional standards.  Using the hours as a weapon is unacceptable.  Part of being a professional is learning how to be a self-sustaining and self-governed association….not a self destructive one.  Maybe you feel that we shouldn’t bother being a profession anymore, because sometimes it seems like we no longer regulate ourselves but others regulate us.  Maybe, but that’s another entry.  The focus here is on the fact that duty hour restrictions are here to stay so it’s up to us to use them as a safety measure, not as a weapon…it’s part of becoming as much of a professional as we can be in the current healthcare system.


Disagree?  I’m interested to hear what you think.  Write me beneath in the comments field.

Coming Soon: Prehospital Ultrasound, Duty Hours As A Weapon, & Lean Six Sigma is 90% People


Hello All,


Interesting week in store on the blog:  The Generation Y Surgeon adds to the “As-A-Weapon” series and talks about issues seen when staff use their duty hour restrictions as a weapon.


In other headlines, The Musing Medic gives us the prehospital provider’s take on ultrasound “in the field”.


We also continue our series on Sharing The Secret of Lean & Six Sigma For Healthcare with an update on how the program is actually 90% about the people involved and only 20% about the statistics involved–yes, that’s 110% because Lean & Six Sigma always gives 110% to the organization…


See you this week on the blog!



Let’s Welcome The Musing Medic





Hello Folks,


Seeing as this is my first entry for, a brief introduction sounds like a good idea…


My medical career started ten years ago right out of high school, and I began as an EMT-Basic.  Later, I earned my Paramedic certification.  I’ve worked both pre-hospital and in the Emergency Department of a trauma center.  My undergraduate degree is in Natural Sciences and I’m currently in the medical school application process.


My interests include evidence based medicine (EBM) with a specific focus on pre-hospital care as well as EMS education.


The posts you see from me will focus on issues ranging from technology in EMS to educational issues with rants, raves, and other random thoughts.  You’ll recognize posts from me and they’ll have the symbol above.


Let’s get started shall we?


–The Musing Medic (@TheMusingMedic)

Coming Soon: The Musing Medic

Editor’s Note:


Hello All,


As you know, we’re searching for original voices and we appreciate all the interest so far!  In the next few weeks, you’ll meet some of our colleagues who are looking to share their unique voices.


We continue to feature original voices from the front lines of medicine because the unique issues they see tell us in which directions to innovate.


Our colleague, The Musing Medic, focuses us on unique, evidence-based prehospital care and related issues.


We think you’ll enjoy our colleague’s take on things as much as we do.  Enjoy the read.