Not As Easy As It Might Seem
In medicine, this stage sounds easy to achieve but it apparently is a difficult problem. Even with modern medical advances, doctors are repeating the same mistakes that have occurred for years. They earn their medical degree, specialize, set up their practice and wait for patients to arrive. The typical scenario: the patient arrives to the office, signs in, fills out paperwork, then waits for you to see him or her. Finally the patient is escorted to the exam room and undergoes the common procedures (clinical history, physical exam, etc.). You give a diagnosis and finally recommend a treatment. The patient pays and leaves the office.

The idea is that at the moment you meet the patient you need to ask yourself this question: What does this patient need? If your answer is simply to solve their problem that brought them to you in the first place, you are partially right. Partially correct because these days patients need more than just a few moments of your time and your treatment recommendations. Patients are in search of a whole service and your time and treatment are just part of this service.

Let me use an example: There are a lot of people that participate in sports. In Mexico, a popular sport is horseback riding. Horseback riding often causes injuries requiring the expertise of an orthopedic surgeon. In the community of people that practice horse back riding the members often consult the same orthopedic surgeon. Why? It is an easy answer: this doctor found the right niche and bécame expert about the common injuries and pathologies that occur with horseback riding. But there is more to it than knowing about the most common presentations. The best doctor for these patients is one of them. He is an avid equestrian himself, and because of his own riding experience he makes everything possible for his patients to get back on the horse as soon as possible. EVen more, you can often find him at the equestrian events where patients can talk to him outside the office and more as a friend. He does more for horseback riding patients than any other orthopedic surgeon in the area.

Now that you have answered yourself this, you must make yourself this other question:

What else

does patients need?

When you ask yourself this question about what are my patients’ unmet needs, the answer you are looking for goes beyond the expected. Even when you believe you have an answer you must question it again and again. Always ask yourself “What else does my patient need?”

Get Specific and Personal
Up to now in this discussion, we have made the question generic. Now it is important to make it personal. Ask what does MY patient need? I must admit that I really hate it when doctors say “my patient” because it is egocetric and they have not understood yet that doctors don’t have patients, patients have doctors (do you know how many of “your” patients are loyal to you?).

Now that we made clear this topic, asking yourself the question: what does my patient need? You pretend to find an answer that is specific to you and your practice. You have to remember that little things make big differences so maybe patients are not just searching for the doctor that have more titles or articles published, maybe they want smaller things like punctuality, to be heard, empathy, respect etc.

In identifying the value big companies in the world spend a lot of money doing research, market studies, focus groups and whatever else to understand what people want so they can attempt to give it to them. For physicians it is a little bit harder to do such big research studies. But there are ways to find this value with small polls or surveys that you can give to the patient at the end of the consultion, or via email. Be creative. It is also very important to listen to your team, your receptionist, nurse, administrator, assistant etc. They spend a lot of time with your patients and hear feedback patients may not share with you. You need to listen to what they have to say.

So think about it, talk to everyone, and always ask yourself questions to try to find out WHAT DOES YOUR PATIENT NEED?

Rodrigo Rubio, MD
Mexico

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.

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”.

Please add a piece of advice or useful tip that you use in starting or managing your own private practice. Use the comment section to this post. Once enough tips are suggested, they will be organized on the resources page.  If you have a dilemma or question, you can ask it here too. The plan for this website is to have a private doctor’s forum eventually, but I will wait until this community grows over time.

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?