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I spent last week at a medical conference, fully expecting to hear the usual story from practices – they need more patients, and I did hear that story. What caught me off guard was the second group, the practices that told me, with a look I can only describe as slightly haunted, that they had more patients than they could possibly handle.
“Too many patients” sounds like the kind of problem most practices would happily trade for.
So I got curious and kept asking why they felt they couldn’t keep up, and the answers came fast, and a similar pattern started to emerge. Nearly every physician’s calendar was full, the team was shoving extra appointments in wherever they could find a gap, and they’d invested in new technology that was supposed to smooth things out. One person told me their practice runs 4 different EHR systems, and none of them talk to each other (I’ll come back to that one a little later in the episode).
When demand stops being the problem
An orthopedic practice I spoke with has 9 physicians who are running all day and into the night, and the administrator told me they can’t even get their doctors to take a vacation because everyone is too busy. A primary care office that opened just 3 years ago is growing like gangbusters and is already feeling the pain of processes and tools that simply don’t exist yet for the pace they’re growing.
If you’re one of those practices where demand isn’t really your problem anymore, you’re not alone. If you’re not there yet, stay with me anyway, because the chances are pretty high you will be, and it’s a lot easier to prepare than to catch up.
Once patients are lined up at the door, the question stops being “how do we get more patients?” and becomes “how do we take care of everyone who’s coming to us without wrecking the reputation we worked so hard to build?” An endless supply of patients sounds wonderful until it shows up as long wait times, phones nobody has time to answer, and physician schedules booked out for months when the patient needed to be seen sooner rather than later.
Behind the scenes, staff stays late, authorizations pile up because everyone is managing the day’s fire drills, and patients wait for a callback to confirm their authorization went through while nobody has had a minute to make that call. Then a surgeon extends a case because it turned out to be more involved than expected, the whole day shifts, and somehow the doctor ends up being blamed for everything that goes wrong. Rarely does anyone stop to ask whether the system itself needs redesigning, because frankly, everyone is too busy keeping the current one afloat.
What practices usually try (and why it only works for a little while)
When a practice can’t keep up, it usually reaches for one or more of the same solutions to fix the problem. They hire another employee or bring on a PA or NP; maybe they temporarily extend clinic hours. Chances are high they buy software that promises to solve everything, only to find it doesn’t talk to anything else they own, or nobody knows how to use it. They may try to automate a piece of the workflow, or bring in a consultant who looks at one slice of the process without ever looking at how it affects the whole practice. Other solutions include outsourcing billing or phones, adding appointment slots so physicians don’t even have time to chart between patients, or quietly asking the team to take on “just a little bit more.”
Some of these help for a while, but none of them last, because adding more people or more technology on top of a problem doesn’t touch the thing that created the problem in the first place, which is usually a lack of processes, or processes that no longer fit the size and complexity of the practice.
Take the PA, for example; if the scheduling team doesn’t know which appointments belong with the PA and which need the physician, they’ll do the sensible, cautious thing and book everyone with the doctor. The PA’s schedule sits half empty, the physician’s schedule is still overflowing, and the practice has added cost and complexity without adding a single open appointment time.
Extending practice hours can face the same issue. The workflow doesn’t change; people just stay in the building longer, it starts eating into their personal and family lives, and the practice becomes a harder place to stay, opening an entirely different can of worms when it comes to retention.
And then there’s the practice with 4 EHRs, where each physician brought their own system when they joined; none of those systems talk to scheduling or billing, and no single place lets anyone see the whole picture. Somebody on that team manually bridges every one of those systems so everyone else can do their jobs, and I’d bet that person is overworked, overwhelmed, and already has one foot out the door.
The process lives in somebody’s head
I walked into that conference with a hypothesis that most of a practice’s critical processes live in someone’s head, whether it’s the person running the front desk or the person processing every claim in billing. So I started asking, and the conversations went something like this:
“Do you have your processes written down?” “We do.” “When were they last updated?” “Not since I’ve been there.” “How long have you been there?” “15 years.”
What are the chances a practice has changed in 15 years? Pretty darn high. Look at the last 2 years alone, with AI showing up in nearly every corner of how we work, and you can see how quickly the ground shifts.
Then I’d ask who their best scheduler was. “Oh, that’s Sally; she’s been here 12 years.” And what would happen if Sally won the lottery and never came back? “We would be so screwed. Nobody knows how she does her job.”
I heard some version of that in nearly every conversation with administrators and executives. “Mary is the only one who knows how to get authorizations through.” “Jennifer knows which referral coordinator to call when something is stuck.” “The practice manager is the only person who can rebuild a physician’s schedule around a vacation.” In one practice, time-off requests went into a stack of sticky notes, which meant a physician’s vacation request got missed and an entire day of patients had to be rescheduled.
One physician I met with moved to a concierge model 3 years ago, and when I asked when he’d last updated his practice’s processes, he said, “Oh, about 10 years ago.” He doesn’t even run the same type of business anymore. He’s just been through major staff turnover and hopes to sell his practice within 5 years so he can retire, and without documented, efficient processes, that sale will be a lot harder than it needs to be.
When the doctor becomes the backup plan
When Mary is on vacation, it’s awfully tempting for a physician to decide it’s faster to just do whatever task they need done now themselves. Depending on how far removed they’ve been from that process, that can turn into an “oh shiitake” moment pretty quickly, because either the task doesn’t get done well or it eats the hours that should have gone to patients. That’s how an 8-hour day turns into an 11-, 12-, or even 15-hour day nobody signed up for.
This is also why onboarding is so hard, you can have a new hire shadow the person who’s leaving, but if that person is only around for 2 or 3 days and the new hire is still just trying to sink or swim, very little information transfers. Whatever does transfer can also bring along all the bad habits with the good ones. If Jennifer’s shortcut is going over someone’s head to get a faster answer, her replacement tries the same move without the relationships or seniority to pull it off; you now have friction in both the process and the practice.
What growth does to a process built for 2 physicians
What may have worked beautifully with 1 or 2 physicians can become a catastrophe with 12, 13, or 14. If you have 2 physicians, that means 2 schedules to manage. When you grow to 14 physicians, that means 14 schedules, each with different modalities, different clinic and surgery days, and different time off. When you add the team supporting those physicians, you’re easily managing 28 to 36 schedules.
If your scheduling process was built for 2 people and you’re now asking it to manage 36, you can imagine how that feels to the person holding it together. That process is now spread across 14 physicians and 3 locations, and it gets worse. While the original process owner sits in the main office, the people running it in the other two offices, who only shadowed her for a couple of days, and are now expected to make an outdated process work in their locations. The practice grew because you added physicians, but the operational playbook never grew with it, and that’s why everyone is running around with their hair on fire.
What this is really costing your practice
In most episodes, we talk about what a broken process costs in revenue. This time I want to talk about a cost that’s harder to put on a spreadsheet and, honestly, more important, which is what it’s costing the people who own and run the practice.
Let’s start with Jennifer, who has been refining her process for the last 15 years while working at the practice. She’s developed roughly 780 weeks of workarounds, relationships, and hard-won shortcuts. Suddenly she gives 2 weeks’ notice, and you’re asking her to hand over 780 weeks of know-how in 2 weeks. Essentially, you’re trying to get her to compress about 390 weeks of experience into each week she has left. It isn’t going to happen; it’s humanly impossible. What exacerbates this situation is if someone leaves unhappy and doesn’t give you notice at all.
This doesn’t even take into account the impact on physicians. Doctors didn’t go to medical school to fix staffing schedules, figure out why the phones aren’t being answered, chase down where referrals went, troubleshoot software, find the stuck authorization, or explain the same process for the 50th time. When a scheduled 8-hour day routinely stretches into 11 to 15 hours, that’s 3 to 7 extra hours every day stolen from sleep, health, family, and the relationships that exist outside of medicine.
The last cost I cover in the show is the people rescuing broken systems all day; these are the same people who eventually burn out, and when they leave, they tend to leave in clusters, which leaves you guessing at what they did, how they did it, and how to pick up the pieces.
The PE Playbook You Can Borrow To Keep Your Independence
Large groups and consolidated organizations do one thing exceptionally well – they write down how work gets done, test it, and keep refining it, and that playbook is a big part of what they bring to the table when they approach an independent practice. There’s nothing magical about it; it’s discipline, and you can build discipline yourself without handing over your autonomy to practice medicine the way you believe it should be practiced.
Building your own playbook is one of the best ways for you to stay independent, stay efficient, keep patients happy, and create a place your team wants to stay because it helps them thrive instead of just survive.
Your 3-Step Action Plan:
You don’t have to fix the entire system at once, but you can take action in the right direction.
Take a 1-week inventory of where things get stuck.
Recruit help and, for 1 week only, write down every place work stalls. Don’t fix anything yet. Look for:
- Spots where someone consistently has to step in because part of the process is broken, like a staff member outside the authorization team chasing an authorization
- Where people are waiting for answers, how long they wait, and what a reasonable wait would be
- Where work piles up that nobody gets to
- Every situation where the doctor becomes the final say or the fix, which is one of the clearest indicators of why your physicians feel burned out
- Every time someone says “only Sarah knows how to do that” (fill in your own Sarah)
At the end of the week, choose the single biggest bottleneck, the one with the bright red box around it that kept showing up, and only that one.
Compare the written process to what actually happens.
If a process exists for that task, pull it out and ask:
- When was it created, who actually follows it, and how much of it?
- Does it match your current software and the roles you have today?
- Could a new employee join tomorrow and follow it to do the job?
- Does everyone complete the task the same way, and if not, what’s different?
- Does it spell out who owns what and when something gets escalated, including to the physician?
- Could the practice keep running if the person doing it today got promoted or left?
The gap between what’s written and what’s real tells you exactly which pages of the playbook are missing.
Rebuild that one process as a living playbook.
Involve the people who actually do the work and gather their insight in a way that respects their expertise and makes them part of the solution. You can use AI to help draft the update, but don’t treat whatever it spits out as gospel; review it with your team. Make it a living document the team can update when compliance, technology, or roles change; clarify who owns it; then implement it and test whether it’s working. One process, one frustration, one bottleneck at a time.
A word of caution: don’t walk into a team meeting and announce that you’re reinventing every process in the practice, because I can promise you they will revolt. Start with one, and let the results do the persuading.
Almost none of this needs to fall on the physician. Let your team create, modify, and test the process, and have them bring you only the challenges they couldn’t solve themselves. You should still review the process so you understand it, and as a bonus, you’ll quickly see who on your team is excelling and genuinely invested in the practice’s success. There’s a second bonus, too: a practice with documented, current processes is far easier to transition, grow into new locations, or sell when the time comes.
If you’re reading this and thinking, “We have no idea where to start, and I don’t even have time to figure out which process to start with,” that’s exactly why I created the Growth Review Call. We’ll talk through the biggest challenge in your practice before you invest in more software, more marketing, or another consultant. You can book your Growth Review call with the link below.
Find Out Where Your Practice Growth Is Stuck
If you don’t have an outside perspective on your practice, that is exactly what I provide during a free 20-minute Growth Review. Together, we will identify your practice’s biggest growth challenge so you know where to focus your energy to eliminate it.
Do the Math for Your Practice
Download the free worksheet that walks you through exactly how to find these numbers, calculate your referral completion rate, and see the revenue impact specific to your practice. The free worksheet takes about five minutes to complete.
About the Author
Alisa Conner is a Strategic Growth Advisor who helps independent medical practices and professional service organizations find where their growth is stuck and empower their teams to run efficiently, so owners can focus on serving the people they want to serve. She hosts The Profit Loop, a weekly podcast and YouTube series, and is based in Boulder, Colorado.
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Frequently Asked Questions
Why do practices with plenty of patients still struggle to grow?
Because demand isn’t the constraint anymore; capacity is. When processes were built for a smaller practice, more patients turn into longer waits, unanswered phones, piled-up authorizations, and overworked physicians, which eventually pushes patients to go elsewhere.
Will hiring more staff or adding a PA fix an overwhelmed practice?
Usually only for a while. Without a clear process, new people handle work their own way, and schedulers who don’t know which patients can see a PA will default to booking the physician, leaving the PA underused and the physician still overbooked.
What does it mean when a process "lives in someone's head"?
It means the practice depends on one person’s undocumented knowledge to get something done, like authorizations, referral follow-up, or physician schedule changes. If that person is out sick, on vacation, or leaves, the process breaks and the knowledge leaves with them.
How do I start documenting processes without overwhelming my team?
Pick one process, not all of them. Spend a week inventorying where work gets stuck, compare the written process to what really happens, and rebuild that single process with the people who do it as a living document they can update. Twenty minutes at a time is enough to make progress.
Should physicians be the ones redesigning practice processes?
No. Physicians should review and understand the process, but the team doing the work should create, test, and refine it, bringing only the unresolved challenges to the physician. That protects physician time and gives the team real ownership.