Between the Blinks #011

Blink Exercise of the Week.

Of Mites and Marriage.

NuLids has been a treatment that Ada and I have both used for years, and for me it has become a workhorse when it comes to patient care. There are plenty of situations where I use it, but a patient I saw a couple of weeks ago was a particularly good reminder of why I like having it available.

She came in as a new patient with significant discomfort, and her symptoms matched up pretty well with her most obvious clinical finding: Demodex blepharitis. For me, Xdemvy is the foundational treatment for Demodex blepharitis. If I'm diagnosing the condition, I want to actually treat the underlying problem rather than simply clean up what I'm seeing at the slit lamp. There was just one issue with relying on Xdemvy alone in this particular case. Her wedding was less than 10 days away, and she was hurting now.

This wasn't mild irritation that happened to be bothering her a little before an important event. While we were talking about how her eyes were feeling and the fact that her wedding was coming up, she became tearful multiple times during the exam. I explained that I still wanted her to start Xdemvy because that was going to be the foundation of our treatment plan, but I also didn't love the idea of sending her home and simply telling her to wait for it to work. We had less than 10 days, and I wanted to do what I could to get her moving in the right direction as quickly as possible.

We discussed adding an in-office NuLids treatment to help jumpstart the process. She agreed, we performed the treatment that day, and she went home with the plan to continue treating the Demodex blepharitis with Xdemvy. The next day, I had my staff call her to see how she was doing. The message that came back to me was, "Patient says she is really happy with our office, and that she is feeling good today."

Obviously, a next-day phone call doesn't tell me that her Demodex blepharitis has been resolved, nor was that the expectation. What it reinforced for me was the value of thinking about what we can do for the patient in front of us while our foundational treatment has time to work. We tell these patients they have mites living around their eyelashes, prescribe a medication, and then explain that treatment is going to take weeks. For some patients, especially those who are significantly symptomatic, offering something that can help get the lids cleaner and start improving how they feel sooner can be an important part of the conversation.

I don't look at NuLids as a replacement for Xdemvy in Demodex blepharitis. In my practice, they serve different purposes. Xdemvy remains my go-to foundational treatment for the disease, while NuLids gives me another tool when I want to address what's sitting on those lids and lashes right now. Sometimes treating the disease and helping the patient get through the next 10 days can be part of the same plan.

Practice Notes.

Financial Rollercoasters.

One of the biggest adjustments I've had to make during my first year of practice ownership has been getting comfortable with the fact that my income doesn't look anything like it used to. As an associate, I got a paycheck every two weeks. I knew when it was coming, and I knew almost exactly how much would be on it. If the practice had a slow week, that wasn't really my problem. If the office needed a new piece of equipment or had a big expense come up, that didn't change the number hitting my bank account.

For now, that game has completely changed. Dry Eye Center of Arizona is operating as a sole proprietorship, so the practice's income and my income are essentially tied together. That's a pretty great feeling when revenue is strong. It's a little less exciting when you're the person paying the rent, the business loan, payroll, vendors, supplies, equipment expenses, and everything else that comes with keeping the doors open. Instead of watching a paycheck reliably appear every two weeks, I now watch the practice bank account move up and down throughout the month.

The beginning of each month is probably the best example. Before I've seen a single patient, thousands of dollars are already going out the door between rent and my business loan, along with all of the other expenses that happen whether the schedule is full or empty. I've started to think of each month as its own little game. I begin in the red and watch to see how long it takes the practice to climb back to break even. Once I get there, the next question becomes how far past it we can go before the calendar flips over and we start again.

That can become a dangerous game if you watch it too closely. Early on, I was checking revenue at a frequency that was probably closer to every 30 minutes than I'd like to admit. A cancellation suddenly felt much more significant when I could immediately translate that empty slot into lost revenue. A great treatment day could make me feel fantastic, while a slow afternoon could have me wondering why nobody had called the office in the last two hours. If you stare at the numbers closely enough, you can find a reason to be anxious almost every day.

Being the only doctor in the practice adds another interesting layer. If I'm away for a week attending Academy or another conference, there isn't another doctor seeing patients and generating revenue while I'm gone. The practice still has expenses during that week, but the exam rooms aren't producing anything. That can make an otherwise completely normal month look very different depending on how much I'm traveling, how many clinic days I actually had, or even where weekends and holidays happened to fall.

I've had to learn how far in and out to zoom. I still look at daily revenue because I think it's useful to keep my finger on the pulse of the practice. I want to know when we have a particularly strong day and understand what happened. I also want to notice when things are slower and ask whether there's actually a reason. But I don't want to let one Tuesday convince me that the practice is thriving or failing. When I really want to understand how we're doing, I look at the month as a whole and compare it with what came before it.

I'm still figuring out the right balance. There will be great months, and there will be months where I'm traveling, expenses pile up, or the schedule simply isn't as busy as I'd like. I'm learning that neither one necessarily tells the entire story. The numbers matter, and ignoring them would probably be just as unhealthy as refreshing them every 30 minutes. Somewhere between those two extremes is enough information to understand how the practice is doing without letting every deposit and expense dictate how I'm feeling that day.

I definitely miss knowing exactly what was going to be on my paycheck every other Friday. But I'm also starting to appreciate what those fluctuations represent. For better or worse, I'm no longer watching somebody else's practice go up and down. I'm watching mine.

Life Between the Blinks.

Keeping it Local.

Now that I'm a little more settled into the office, I've finally had some time to think about things beyond simply keeping the practice running. The first several months of ownership felt like there was always something more urgent that needed my attention. Lately, I've been able to focus a little more on the personality of the practice and what I want it to feel like, and one thing I've started making a conscious effort to do is support some of the other small businesses around me.

A small doughnut shop recently opened nearby, and I've started going there when I want to bring something in for my staff. In the past, I probably would have defaulted to a popular chain without thinking twice about it. Now I'll grab coffee and doughnuts from the shop down the road instead. It's a small change and certainly isn't keeping anyone in business on its own, but I like knowing that some of the money I'm spending to treat my staff is going to another person trying to build something of their own.

I've started thinking the same way about the office itself. I'm still figuring out what I want the space to look and feel like, and recently I had a wall that needed something on it. I have another large piece of art in the office that I bought online, and it gets compliments all the time, so I easily could have done the same thing again. Instead, I found a local artist and bought a piece from them. I ended up being even happier with the result. I get something unique for the office, the practice gets a little more personality, and there's something nice about knowing the person who created it is part of the same community where I'm trying to build my own business.

Owning a small business has definitely changed the way I look at other small businesses. It's much easier now to appreciate what might be behind the coffee shop, restaurant, store, or artist you're buying from. There are leases to pay, slow days to get through, employees to take care of, and probably someone sitting at home wondering whether this whole thing is going to work. I know that feeling pretty well at this point.

When I opened Dry Eye Center of Arizona, I was understandably focused on what was happening inside my four walls. Now that things are starting to feel a little more settled, I'm realizing that opening a business isn't an isolated experience. You don't just sign a lease and become part of a medical plaza. You're joining a community of other people who took their own version of the same leap.

I'm still going to order things online, and I'm definitely not giving up on national chains forever. But when there's an opportunity to support someone nearby who's building something of their own, I've found myself wanting to take it. I'm proud of the little business I'm building here, and it's been nice to start feeling like it's becoming part of something bigger than just the office itself.

One Last Blink.

Sometimes the long-term treatment plan is only half the job. Don’t forget to ask what your patient needs from you today, especially when there’s a wedding in 10 days and a few thousand uninvited guests didn’t RSVP.

See you next week.

Andrew Zagelbaum, OD.

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