Monday, March 06, 2006

Beginning medical practise – get off to a flying start !

The starting point of all achievement is desire. Keep this constantly in mind. Weak desires bring weak results, just as a small amount of fire makes a small amount of heat. Napoleon Hill

Starting practice can be difficult , because so many things need to be done at exactly the right time, and it’s easy to get overwhelmed. Often, it’s difficult to know what to do and when to do it, because this is the first time in your life that you will be handling a job of such complexity entirely by yourself. A little advance planning can go a long way toward giving you confidence when your clinic actually starts. It’s helpful to have a timeline and use basic project planning techniques to ensure that everything goes off smoothly. A good start will boost your chances of long-term success considerably !

When to start ?

When should you cut the umbilical cord of training and start practice ? How do you know when you are ready to start off on your own ? This depends upon lots of factors, such as your career goals and your field of specialization. Thus, while a family physician may be comfortable starting within a few months of graduating, many specialists will want to work with a senior specialist for some years before starting out on their own. Other factors such as marriage and bearing children can also play an important role in this decision.

Where to start ?

Deciding where to practise is one of the most important decisions you will need to make. Sometimes you may not have much choice in the matter - for example, married women may have to settle down where their husband chooses to locate. But if you do have a choice, then how should you go about selecting the best location for your practise ? Most new doctors mindlessly choose to settle down in large cities, because this is where the “glamour” and “action” is. However, often the competition here is intense, and you may be much better off looking for alternatives. Remember that the place where you eventually practise will, to a certain extent, determine the pattern of the practice. It may take months of research and effort before you find a town, which is not only suitable for your practice, but also optimal for your personal life and bringing up a family.

There is an axiom in business that there are three keys to success: location, location, and location. The best location for your practice is in a convenient, highly visible, and easily accessible office. The easier you make it for potential patients to find and use your services, the more quickly you will achieve the level of success you desire. After all, if you want to deliver a service to the public, then you will be most successful if you are located where the public is willing to go. Selecting a location should be done with the same care as selecting a spouse - you want a long, healthy, prosperous and happy lifetime together, so treat the decision with an eye toward the long term. Chances are that you will spend many years building and growing your practice in the location you choose, so it's important for you to consider where you would like to work and live for the long term.

You should pay attention to the following points:

* The community's need for a doctor.
How many other doctors are there in the area ? What are their specialties? Will the area support another doctor ? What is the density of the population ? Is there anticipated growth or decline in the population ?
* Your needs and those of your family
Are buildings or office premises available for purchase? Will you lease or rent? Has the property plenty of car parking space? Is there good access to public transport? What are the recreational facilities and social opportunities? Are there good schools nearby? Will they suit the ages of your children? Will the rest of the family be able to find work? Will planning permission be necessary to convert the property for medical use?
* The local medical facilities
Is there a good local hospital or health centre? What other doctor are available for consultations and referral? Are they likely to be co-operative?

Since this may be one of the most important decisions you ever make, give it enough thought and attention, and don’t just accept the first opportunity which comes your way. It might be a good idea to serve as a locum or an assistant to get a “feel” of what practice in the area is like.

Types of Private Practise

When you commence private practise , you will need to decide which form your practice will take. There are three main options:
1. Single-handed practice.
2. A partnership.
3. A group practice.

Which method you choose will depend on your own physical and mental abilities, financial circumstances and personal aspirations. All the methods have their advocates: it is up to you to determine and define your aims in order to find out what you really want. It need not be an irrevocable decision: you may decide to start working single-handed, and then meet a colleague with whom you feel you could work and form a partnership.

This is by far the most popular type, and allows you to be completely independent. You have to be dedicated and confident, because you are responsible for everything connected with the practice, including obtaining premises, fixtures and fittings, decoration, practice organization, financial planning and management; and you will have to make all the decisions. Think of yourself as being an entrepreneur starting and running a small company. Independence can prove a little daunting, particularly if you have been working in a hospital where much of the support structure is provided and the responsibility is mainly clinical. However, you do have the satisfaction of knowing that the success of the practice is all your own work and, of course, the patients are entirely yours. This type of practice is very flexible: it can be started without legal formality and the accounting requirements are fairly straightforward and simple. It gives great freedom, but it brings great responsibility. Many practitioners enjoy working on their own and have highly successful and profitable practices. You can make decisions yourself without having to waste time on committees and meetings – and you can mold your practice so that it is as efficient as possible.

The disadvantages occur when you are ill or you wish to take a holiday, for unless you close the practice or find a suitable locum, holidays become non-existent. You might also find it harder to compete with larger group practices which have greater financial muscle, so you will have to work harder to attract new patients. If you are ill and cannot practice, there is no income – effectively, you are a “daily wages” earner ! Solo practice is still the commonest form of private practice in India today.

If you want shared responsibility, a partnership with one or more colleagues may be the answer. A partnership is preferably a formal legal relationship rather than an informal agreement with no legal authority. A partnership consists of two or more people, who join together with a view to making a profit. The partnership is subject to certain legal formalities such as the sharing of profits. Each partner is personally liable for the debts of the partnership or of the individual partners if they are unable to meet their own debts. Therefore, there must be complete confidence and trust.

Partnerships have many advantages. Each partner may contribute capital and will devote time and energy to the success of the practice. Special skills and expertise may be complementary, thereby expanding the range of patients the practice can accept. Decisions, responsibilities and management of the practice will be shared. A partner may well bring in valuable referrals and contacts. In addition, an older and more experienced practitioner can be of considerable benefit to the practice. A partner is invaluable if you are ill, have an accident or if you have to give time to a family crisis. Whether you personally are at work or not, the practice will continue, the patients will be seen and you are relieved of the worry of finding a colleague to cover for you while you are absent. Partners should not only be regarded as useful for the difficult times- it is also very pleasant to share success with somebody else and to plan for the future.

A partnership is, however, a close relationship and entails a great deal of tolerance and understanding if it is to be successful. A shared decision can mean one, which is reached only through compromise and possibly argument. Disagreements are rarely over patients, but usually center on management or financial matters. Patients identify with a particular partner and there is occasionally a cross over during holidays, professional courses or sickness, so the attitudes and behavior of the partners should convey an atmosphere of stability. Take your time over entering into a partnership. It may be a good idea to work together informally for a while to see how compatible you are before signing any agreements. A partnership, whether informal or formal, is a social contract, and as in marriage, divorce can be expensive and upsetting.

Group practise is becoming increasingly popular in India now. Here, two or more practitioners' join together to share expenses such as rent, rates, electricity and water charges. In this type of practice, therefore, you would have to access to all the facilities, such as the receptionist but remain independent, responsible for your patients and with complete control of your own finances. This option has many attractions, particularly the shared responsibility for the premises and facilities and the contact and friendship of your fellow practitioners. This can be very useful for referrals, on call duties and holiday arrangements. In the US , after the advent of managed care, most doctors have turned to group practise, because they found it difficult to meet the bureaucratic hassles and paperwork demands of HMOs. Many US doctors want the protection of an established practice, with someone else running the business, so they don’t have to cope with administrative hassles, and can focus on providing good medical care to their patients.
The ideal size practice is represented by the fingers of one hand for specialists and the fingers of both hands for primary care physicians. Specialists shouldn't try to grow much beyond four or five because they start acting like employees and refusing to compromise for the good of the group. And, there's nothing to be gained by getting bigger. All the subspecialty skills can normally be covered by four or five colleagues and there are few economies of scale to be gained by further growth. The statistics are clear: the larger the practice, the higher the overhead.


There are additional options too. Many doctors now prefer to work full-time for large corporate hospitals. While this provides the prestige of being a consultant in a reputed hospital, a steady stream of patients, an established infrastructure, access to the latest medical equipment, and no administrative responsibilities, you need to pay a price for this. While the job satisfaction can be tremendous, since you are working in a “state of the art “ medical facility which attracts challenging patients from all over the country, and serves as a referral center for difficult cases, since the hospital retains the majority of the patient’s fees, your financial benefits are capped as compared to doctors in private practice. Also, most hospitals are hotbeds of petty medical politics, and the amount of backbiting and bitching which goes on amongst the medial staff can be frustrating. You also need to know how to butter up the hospital’s administration and trustees to keep them happy. Many doctors find that not only does the hospital administration retain the lion’s share of the profits, leaving them with chickenfeed, they also force them to admit a minimum number of patients and to generate a certain amount of income every year , as a result of which they lose their medical autonomy. Since competition for these hospital attachments is intense, the fear of being thrown out of the job is always present.


Many doctors find practicing in a government hospital satisfying. They do not need to worry about attracting patients or raising money to start practice. They usually have the pleasure of being able to teach the next generation of doctors, and this interaction with medical students and residents keeps them young. Job satisfaction can be considerable, since the sickest and most complex patients often end up in government hospitals. One is also on many government regulatory bodies and committees and can wield considerable power in public health, government projects, and professional medical societies. As a Professor, many doctors are leaders in their profession . However, dealing with the bureaucracy and government machinery can be a uphill task. One needs to keep the VIPs in power happy, and buying new equipment can be a frustrating exercise. Also, promotions and professional opportunities are restricted; you are forced to live with limited budgets and miles of red-tape; and many doctors find the chores associated with administering a department very unwelcome.

Key advisors you will need to help you start

When practicing medicine, you will need advisors to help you with your various business, legal and accounting needs . Rather than solicit informal advice from friends, family or others, you will be better served if you select professional advisors in the very beginning. You may want to seek recommendations from other physicians concerning these advisors. Interview each of them. Once you are convinced that they have the experience you need, determine whether you can establish a rapport with them individually, and if they can work with each other. Choose these advisors with great care and forethought – they will play a vital role in the future growth of your practice. Perhaps one of the most important characteristics to look for should be how well you can relate to him, because this relationship requires a high level of trust and understanding. Once you have found an advisor you are happy with, you can ask him to recommend another advisor in the other fields you need help. Thus, an accountant you are happy with may recommend an attorney, or vice verse.

The accountant
The accountant will be responsible for the following:
1. Setting up and monitoring financial record keeping
2. Establishing sound financial guidelines on expenditure, salaries and pensions.
3. Advising on, analysing and projecting the growth and development of the practice.
4. Preparing the annual balance sheet and income statement.
5. Dealing with all tax matters.

The lawyer
A lawyer is another necessary advisor. You must ask his advice in connection with all legal matters. Lease agreements, conveyance documents, partnership, limited company and insurance agreements must all be seen by him. A small legal practice with two or three partners is usually the best option for most doctors, to ensure that your lawyer has enough time for you.

The bank manager
A sympathetic and helpful bank manager is essential in financing the initial capital expenditure and providing you with a reserve to pay continuing expenses until the practice begins to generate some income. It is a good idea to have a talk with him before you begin looking for premises or take the first steps towards starting a private practice. He then knows what you have in mind and can advise you on a number of matters. He may even put you in touch with the other professional people who may be of help to you. Banks, on the whole, are kindly disposed towards applications for professional practice facilities, because doctors usually have a good track record in repaying their loans, and are considered to be excellent credit risks. Unless there is a serious problem, you will have no difficulty in obtaining the money you need for the practice.

There are other advisers you will need as well, and one of the most important is an insurance agent. Don’t even dream of starting practice without ensuring that you have a valid professional indemnity insurance policy to protect you from malpractise claims. You will also need to insure your clinic ; and the expensive medical equipment you buy. Other advisors may include: financial consultants, to help you manage your money as your practice grows; and marketing consultants, to help you grow your practice. In the US, medical practice management firms will often provide these services under one roof.

Getting referrals

The first few months after you start practice are usually the most difficult for most doctors. You are full of enthusiasm and your technical skills are finely honed, but you may find that attracting patients is very difficult. If you are fortunate and come from a family of doctors, this will help you immensely in getting off to a flying start – but what happens if you have no doctors in your family ? Most doctors will go through three stages in their professional life.

1. No work, no money, lots of time
2. Some work, some money, some time
3. Plenty of work , plenty of money, no time

Unfortunately, many doctors who start practice end up falling prey to the temptation of giving cuts and kickbacks to referring doctors. They are so desperate for patients, that they are willing to stoop to any depth to allow them to make ends meet. They justify their approach by saying “ Everyone does it anyway”; and are worried that if they don’t, they will starve. However, this is a very short-sighted tactic, which will end up hurting you in the long run. Not only will it reduce your self-esteem because you are behaving unethically; it will also force you to do things you are ashamed of doing ( for example, unnecessary surgery, because the referring GP insists you do it). Also, you could devote the same energy more constructively to building direct referral channels to your patients, which is far more satisfying and rewarding in the long run !

So what can you do to get more patients ? Actually, quite a lot ! Sitting and waiting for patients to come to you will not help – you are going to need to get out and let people know about your skills, so they will want to send patients to you. In order to get referrals , you need to rely on an ever-widening circle of friends, colleagues, and contacts. In order to do so, you need to learn to "network" , that intangible collection of skills that successful businesspeople seem to use effortlessly. Networking, when handled skillfully, is, more art than science , just like medicine is. Whether its simple rules are followed by either a new doctor or veteran physician, networking can produce decided benefits. You first need to start by networking with colleagues. Unfortunately, most doctors still treat colleagues as competitors. They are seen as rivals, and petty medical politics often result in rivalry and pulling each other down – energies which could have been constructively used instead to build each other up ! United we stand , divided we fall is as true today as it was centuries ago. Networking allows you to pool your skills with others, so that the sum of the parts is greater than the whole. Just like some doctors naturally acquire a polished bedside manner, others have excellent networking skills. Most of these doctors are politically very active, and their “people skills” are excellent -learn from them how to network efficiently ! Treat your colleagues well and trust them . Do not bad-mouth other doctors – word gets around ! Make it easy for them to get in touch with you and update them about their patients. If you are computer-savvy, offer to help them update their skills, so they are grateful to you. Attend medical conferences and use these as opportunities to meet as many of your colleagues as you can. At social occasions, instead of hanging out with old friends, fraternise as much as you can so you can develop new contacts.

Successful networking is about meeting people and forming relationships – you help them so that they will help you. Try to do as much good to others as you can ! If you want to increase the number of referrals to your primary-care practice, interact with potential sources of new patients. Determine who the relevant people are - you need to perpetually scan your environment and mentally tuck away the names of people and organizations that will eventually be of use to you. You also need to be able to give them good reasons as to why they would be better off sending their patients to you, rather than anyone else. They key to networking is to follow up and stay in touch. For example, sending a personal note of thanks is one task that many of us fail to do. The benefits of such a simple act are incalculable.

Networking involves honing your interpersonal skills and the following acronym will help you network more efficiently.
N: Remember their names.
E: Eye contact is key.
T: Talk less and listen more.
W: Write follow-up notes on a consistent basis.
O: Be open and ask open-ended questions.
R: Become a resource to others.
K: Knowledge is power; know people and know their work.

Your patients can be very helpful in your networking efforts. You can capitalize on their goodwill to make new contacts and explore new opportunities. Most patients are grateful towards their doctors, and are more than happy to help them ! Many doctors have made good use of their patients to build up their practice and so can you ! Learn to speak in the local language – this simple act will help to set your patients at ease, and increase your practice
manifold !

Here are simple techniques successful networkers use

1. Speak
Take every opportunity to speak about your specialty – both on a one-on-one basis, to making presentations to large groups. Be enthusiastic and willing to talk – and have ready-made presentations for those “last-minute” invitations ! Eloquent doctors are always in demand !

2. Participate
Join medical organizations. It is better to belong to fewer organizations and take an active role in them than to belong to many with superficial connections to the membership. Truly participating allows you to really get to know people and thereby supports your desire to build professional relationships with them. If there isn't an organization that fits with your objectives, create one. It can be a physical organization or a virtual one. Being the founder of the organization gives you instant credibility with your entire membership and gives you an opportunity to define and mold it.

3. Publish
Write articles ! While this can be difficult, it will get easier as time goes by – and the more you write, the more you will be asked to write ! Doctors who can express themselves clearly are always in short supply !

4. Volunteer
Volunteering is a great way to build professional relationships while giving back to the community. Take a volunteer position that allows you to use your skills and express your passion. Your network will grow along with your sense of accomplishment.

5. Socialize
Socialising is great way to build and nurture your network . It’s very useful to host an event. This can be a party at your house or a recurring event at a chosen meeting place. This will provide an informal way to get together and connect the members of your network with each other. If each member brings a member of their network, it will also help to significantly expand yours. Remember, the secret for success if often not knowhow , but know who !

As with any job, well begun is half-done, and while your first few years in private practice can involve a lot of hard work, this investment of time and energy can pay off in spades for the rest of your life. Don’t get disheartened when things don’t seem to be going well in the beginning – remember that everyone has to struggle to establish themselves !

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