For many years now, pharmaceutical companies have relied on drug representatives to persuade doctors to prescribe their products. Why? Because it worked. In 2007 there were 102,000 drug reps in the field, buying lunch, delivering samples and angling for five minutes of face time with a doctor. But, as industry rules for gift exchange have changed and doctors’ time has become even more limited, this marketing model has begun to fall apart and big pharma is retrenching. Industry watchers expect a 25% reduction in the number of drug reps in circulation; recent layoffs in most of the major pharmaceutical companies are validating this projection.

But, that still leaves 75,000 or so eager young men and women idling in your waiting room, if you choose to see drug representatives. (About one in four doctors do not see reps.) What should you do?

There are plenty of reasons to simply say no to drug reps. First, they can take up your clinical time and drive your office staff a bit crazy, even if they are willing to cart in donuts, sandwiches and chef salads to grease the wheels. But perhaps more importantly and insidiously, drug reps are master sales people, shined up with a veneer of useful clinical information. Rest assured that before any drug representative sets foot in your office, she or he has studied an enormous amount of data about your prescribing patterns, including how much influence sample acceptance has on your willingness to favor their company’s drugs. The drug rep knows exactly what you may need to hear to be persuaded to increase your use of their preferred products, based on both prescribing data and field testing. Plus, the rep has been meticulously trained in how to maximize the utility of their drugs and downplay any potentially negative issues surrounding them as well.

In the face of this roundly negative information, why anyone would entertain the notion of dealing with drug reps? Because they also bring some positives to your practice. The samples they supply can make a real difference in some practices. You can try out a medication without asking the patient to invest in a prescription. You can box up a prescription’s worth of the medication for that patient who simply can’t afford it otherwise or who will probably not get around to getting the prescription filled but may be willing to take medication that you place in their hands.

Although drug reps are trained to shine the best light on their products, they can also provide useful information that saves you time learning about the products. They keep you apprised of what’s in the pipeline, why their drug is better than a competitor and how doctors are using and evaluating effectiveness.

Should you or shouldn’t you make yourself available to drug reps?

Here are some suggestions for structuring the relationship to your benefit.
1. See representatives by appointment only. Frankly, you are doing them a favor. It’s a terrible waste of time to hang around hoping to get a few minutes of your time. Everybody wins if you guarantee five minutes at a time that’s convenient for you.
2. Recognize that some of what they say to you is crafted by their knowledge of your prescribing patterns. Ask them to share that knowledge with you; you’ll at least learn something about yourself.
3. Listen to the spiel and the info with the awareness that their first job is to persuade you to use their product. Use their information as a stepping stone to gathering your own information.
4. Accept samples if they will help your patients but be aware that the drug company is trying to make you feel obligated to favor their products. Don’t think of samples as gifts that must somehow be reciprocated; they’re sales tools, pure and simple.
5. Don’t accept the lunches and other freebies; it appears inappropriate even if you are not actually swayed by these tactics.

Above all, pay attention to your own prescribing habits. Are they in fact habits or are you keeping up with the literature and adapting based on clinical evidence and patient need? Be sure you know more than the drug rep knows about how and why you prescribe.

Susan Brissette
SB Cass Associates
East Nassau, New York

1. O’Reilly, Kevin, “Doctors increasingly close doors to drug reps while pharma cuts ranks”, March 23, 2009, American Medical News, http://www.ama-assn.org/amednews/2009/03/23/prl10323.htm
2. Ibid.

If the thought of hiring a practice manager makes you anxious, your reaction is perfectly reasonable. Your practice manager is an incredibly important person in your life. You will not only spend significant amounts of time working with that person, you will trust him or her with the financial underpinnings of your livelihood. It’s smart to recognize the importance of this hire and give the search process the attention it needs.

So, then, how do you go about selecting the right person for the job? One good approach is to look for three “Cs”, chemistry, competence and craftsmanship (managerial craftsmanship that is).

Chemistry

Whether you like it or not, you will spend a lot of time with your practice manager. You will need to help her understand the goals of your practice, the financial structure you are using, how you (and your partners if you have them) need the practice’s operation to support your work and how you would like your patients’ issues (clinical, administrative, financial) to be handled. She needs to “get in sync” with you quickly and effectively so that you can let go of the day to day administration, feeling confident that your practice is operating the way that works for you.

You and your administrator don’t need to be best buddies but you need to like each other and respect each other enough to be stunningly frank about important issues. She may need to tell you that your favorite nurse is not salvageable or that unless you change your work schedule, the money that you expect to have is not going to be there. You need to be able to challenge each other’s thinking and work out solutions while remaining colleagues.

Chemistry is a hard concept to evaluate but here are some ways to get at it when you’re looking for a practice manager:

• Do you like the person? Does she seem like someone you’d be willing to spend time around?
• Talk about values with manager candidates. If your values are in sync, you have a very good start on a relationship of trust and respect.
• Ask her to describe her previous physician employer’s strengths and weaknesses. Are you comfortable with the way she discusses that relationship?

Competence

There’s no point in hiring a practice manager if she’s not competent. Competence can be judged in several ways. Look for someone who has a bachelor’s or master’s degree in healthcare administration. You’ll know that she’s made a commitment to the field and has been trained in the basics. Look for experience in another healthcare setting. A person who has been second in command in a larger or same size practice or manager of a smaller practice often makes a good fit in terms of experience and career move. Look for someone who belongs to a practice management association and/or has earned a practice management credential. (There are several available.) That connection shows that she recognizes the need to keep learning.

Don’t worry about matching your specialty to the person’s experience. While it would be terrific to find someone who worked in an orthopedic practice to run your orthopedic practice, you’re better off selecting someone with the general experience and/or educational background; she will learn the nuances of your specialty quickly because she has the background to do so.

Managerial Craftsmanship

Nothing destroys an office’s productivity faster than personnel problems. If your staff or your partners aren’t happy, you and your patients and your bank balance will suffer. Your practice administrator needs to be deft in handling personnel issues. She must be able to adjust her managerial style to help each person in the practice do the best possible job while demonstrating a consistency and even handedness that allows everyone to feel confident that they are in a stable and fair working environment.

This skill is also difficult to “test for” in an interview process. However, one way to learn about managerial style is to ask questions such as: “Tell me about one of the most challenging personnel issues you have handled and how you handled it.” Don’t ask hypotheticals. Inevitably, you can’t really give someone enough information to get a reasonable answer. Instead, spend time listening to candidates describe their experiences and decide if you feel comfortable with their approaches.

Bottom Line
If you can find a competent practice manager with a managerial style you like and values you can respect, you’ve probably got the right person.

Susan Brissette
President of SB Cass Associates
East Nassau, New York

1. For simplicity’s sake, we’ll plan on a female administrator so that we can dispense with “he or she” and “him or her”.

Depending on the nature of your specialty, a large amount of supplies may be consumed by your medical practice. These items range from tongue depressors and table paper, to medications such as lidocaine and Penicillin for IM injection. Then there are the special purchases such as the flu vaccine, tetanus shots and the myriad of immunizations that pediatricians and family practitioners need to administer on a regular basis.. Unless you have a “paperless office”, many common office supplies are consumed in large quantities such as copy paper and pens, as well as soap and tissue paper for the office bathrooms and exam rooms that seem to constantly need replacement. These items can often be bought in bulk at discount warehouses or office supply stores for a significant savings.

Private practices need all the services any business needs such as local and long distance phone (and pager) service, regular office cleaning and maintenance, and possibly lawn care in the warm months and snow plowing of the parking lot during the winter. Plus there are services unique to medical practice including medical waste removal, answering service, and possibly transcription support. Computer support by experts in healthcare information technology is also critical, and will become a bigger need soon as more practices convert to electronic medical records.

Equipment purchases usually get much more consideration before the practice commits, but the small recurring charges can often accrue to amounts well above the cost of any particular piece of equipment in your office. Managing purchasing, negotiating for discounts, and always shopping for bargains will help your cashflow and improve your bottom line at the end of the year.

This quick list of services and supplies needed by medical practices is just an overview. Like all medical office protocols and procedures, purchasing also needs to have checks and balances within your practice. A good office manager should handle these purchases for you, and you need to decide at what dollar amount you need to co-sign the checks. If you can pay for these recurring costs with a credit or charge card that rewards points, perhaps getting a trip to a nice resort once a year with those points will help ease the pain of paying for all those medical office supplies!

As you get started, and as you reassess your progress and results, you’re going to want to have standardized protocols for many of the activities in your medical office. These can be bound together and serve as the core of your employee manual which is useful for your new employees, and I believe can become the basis for evaluating staff, giving bonuses, and even firing them should you need to do that unpleasant task. The more you automate, the fewer interruptions you will get and your whole private practice team will operate as one well-oiled machine.

Many “best practices” are being developed as protocols and as we become aware of them we will post them on the PrivatePractice.MD website (probably under the “Resources” section). I list here just a few situations which call for planned actions, organized as a protocol:

1.) Patient Emergency in your office. Do you have a code cart? Is it fully stocked with necessary equipment and medications that haven’t expired? When was the last time its items were checked? Do you know which drawer holds the ambu bag? While you attend to the ill patient, did your staff call 911 for the ambulance? Is a staff member controlling the situation in the waiting room? Are other patients peering out of their exam rooms in response to the ruckus? Obviously you need to think through such a possibility well before such a situation arises, and run a “mock code” in your office just like you did in residency.

2.) What about fire drills? Does everyone know where your fire extinguishers are and if they should even attempt to use them? Do you smoke detectors have fresh batteries placed in them every six months? How will you get your old or very young patients out of the office to safety if there is a fire? You need to practice a fire drill once in a while also.

3.) How do you handle patients who might have TB, or chicken pox, or some other highly contagious disease as they come through your office? Do you meet them outside and put a mask on them before they enter your office? Does your staff know how you want them to guide these patients through their visit with you?

4.) The front desk personnel have their own full set of issues to handle, and protocols would be wisely prepared and practiced. What happens if a dangerous person shows up in the waiting room, perhaps an irate ex-spouse who just heard his child is there for an “emergency”? How do they process phone calls to you from other doctors? Are those calls prioritized, so that you’re interrupted or paged when a doctor calls to speak with you? How are faxes and mail handled? Who keeps the waiting room and bathrooms for patient’s use clean and tidy during the day? How are urgent appointments scheduled? Are they squeezed in or are there “acute slots” available?

The list of situations needing protocols is a pretty long one and we’ll be discussing it on an on-going basis. Just be sure to think about developing protocols when starting your practice, and as a repeating exercise as you go through your private practice day. Keep thinking, “How can I automate and delegate” this task so I’m most efficient and utilize my expertise best?

It’s all about “outcomes” these days. I’m referring to all the initiatives to measure and compare the clinical care we provide against the results. Much of medicine can be measured with datapoints, but because medicine is as much an art as a science, in my opinion, these new initiatives probably miss the benefits obtained with the “soft” stuff. What I mean is that these initiatives might show that one doctor or practice has better or worse results than others, but they don’t usually show why. Can you measure the fact that one physician is an excellent communicator and educator of his patients compared to other physicians, or one surgeon is more skillful, quicker and more accurate with a procedure than another competent surgeon doing the same procedure? Their patients do “better” based on these outcomes measurements, but the explanation for the better results is not specifically explained. You’re going to be asked to track what you do, which adds time and tasks to your day and your staff’s workload, but you may not benefit. I’m sure that’s one reason electronic medical record systems are being championed by the government and managed care companies. Doctors can be tracked and graded more easily. Hopefully the patients will ultimately get a benefit too, which is a benefit they’ll share with their doctor.

Just because it’s difficult to measure something doesn’t mean you shouldn’t try because the goal is to always improve and to always provide better and better care. Running a medical practice well requires close attention to details, and monitoring details that ultimately affect patient outcomes directly benefits your practice. That’s why it’s so important to establish practical and reproducible policies, procedures and protocols based on logical goals, and rechecking the results so that appropriate modifications can be made in your practice. Every practice is a little (or a lot) different, with different physician personalities and practice styles, and different patient populations so what works in Boston may not work in Eureka.

For doctors to buy into all these new initiatives there’s going to have to be some tangible benefit for them. Less hours, better payments, more efficient use of their time. We’ll be asked to buy the equipment and pay the staff to input the data. This investment demands a reward.

Hopefully readers of PrivatePractice.MD will share good practice tips with each other here, so that we can all learn from each other. Medical practice advisors also can show us best practices used by others so we don’t re-invent the wheel constantly. No time for that!

Every doctor in private practice knows how important their Practice Manager is to the overall business vitality of their medical practice, but I’d argue that maybe the next most important person you hire is your receptionist. Your patients may love you but if they are not warmly and professionally received in your office or when they call, they will paint your whole practice as “rude” and may eventually decide to look elsewhere for their care. If you have a big office with many staff, then the person who answers the phone and schedules your patients’ visits is equally as important as your receptionists.

In most smaller offices the receptionist and scheduling person are often the same person, making the decision about who to hire even more critical. You should expect the receptionist to be top-notch in customer service and in fact, hiring someone with previous experience dealing with customers would be the best approach, in my opinion.

These front-line staff members directly bear the brunt of patients’ frustration and anger when your schedule is too tight to allow same-day service, or when they are told the lab results are still not back, and they buffer you from the noise that would increase your own blood pressure and distract you. So you need to be sure to reward them when they do a good job. Too often the front desk staff are overlooked for extra training, or get smaller bonuses than the nursing staff or office manager at the end of the year because in general their pay is much less. That’s a mistake, I believe. Treat them well and they will return the favors. You’ll have less staff turn-over and your patients will appreciate the continuity of regular staff in your office. Your receptionists and schedulers may be the most important staff you hire! Let them know that fact.