CHAPTER 1 Office practice of plastic surgery
Part 1: Introduction of the practice needs
Initial steps
Before establishing a practice, you have to decide where it is that you want to live. However, deciding on an urban, suburban, or rural area may be somewhat difficult. The first thing that one has to evaluate is the number of plastic surgeons who are practicing within the community. It would be very difficult to establish yourself in an area where there are multiple plastic surgeons who already have appropriate referral sources, and it is best to look for a community in which there is a definite need for a plastic surgeon, either with a group or in solo practice or even in academic medicine.
The location
Before you finish training, you should investigate the area in which you are interested. Look at demographics, population growths, median incomes, growth of the city and/or community, and evaluate the statistics of the metropolitan areas, particularly where there is the greatest density of plastic surgeons. Speak to plastic surgeons in the community to get their opinions, concepts and ideas, which sometimes may be negative since they may not welcome a new, young, well-trained plastic surgeon. Our sources for potential practice locales are the American Medical Association, which offers a market area profile (MAPS) that includes information about community demographics, or the local Chamber of Commerce in the area in which you are considering relocating. The hospitals in the area can be of great assistance in getting and interpreting whatever data you may need, for example, hospitals will tell you the number of plastic surgeons on staff, then you can evaluate which plastic surgeons are servicing that health community, what the referral sources are and whether there is a need for a younger plastic surgeon.
The practice
The next decision you have to make is the type of practice that you would like to join, a multi-specialty group with a large number of different types of specialties, i.e. a Mayo Clinic or Cleveland Clinic type of setup, a group practice of plastic surgeons practicing together. Alternatively, you may share space with another plastic surgeon, to help him or her decrease their overheads and at the same time have full advantage of their established plastic surgical staff. You may prefer an academic position, in a teaching institution or a sponsored or salaried position in a hospital that allows you a private practice, but where you are dependent upon referrals from and to that specific entity. Finally, there is the independent model or solo practice.
Let’s talk primarily about solo or group practices. Group practices, of course, provide economic security and a source of patients. All usually include built-in coverage for vacations and weekends, hopefully a congenial atmosphere of other plastic surgeons with whom you can discuss cases with access to appropriate equipment, and opportunities to pursue the area of specialization in which you are interested. Also, by practicing in an established geographic area with an established group you have instant name recognition.
However, group practice may be somewhat difficult because there may be frustration at the loss of autonomy, dissatisfaction with the inability to make independent decisions, conflicts with associates and difficulty with financial matters, which may not have been properly addressed during the initial interviews and contract. Other certain points need to be established prior to going into a group practice:
• Make sure that the philosophy of the group is the same as your philosophy, not only in the ethics of practice, but also in appropriate financial sharing of costs, billing, and remuneration.
• Meet all the doctors you are working with and make sure that there is an aura of compatibility; understand what differences and competition may exist within the practice.
• Speak to the youngest plastic surgeon or the last one who joined the group because they will be able to tell you what their frustrations and/or benefits are of being in a group practice.
• Check the reputation of the group practice within the community, that the practice is viable, growing and that it does need another plastic surgeon.
• Make sure that your spouse or significant other will be compatible with the spouses or significant others of the group. If the spouses are working in the same group practice, make sure that they will not be the controllers of your practice, otherwise this may cause a difficult professional and social situation.
• All written contracts should be reviewed by an attorney and/or consultant who is looking after your benefit, not theirs. Never start work without a written contract, have it reviewed, make sure that it fits your philosophy of practice and that it is beneficial to both parties; it must be a win–win situation.
Advisors
You must have advisors to help you manage a successful practice. First of all you need to have an accountant or a CPA who will handle all your financial needs, help you set up initial office accounting systems and handle tax matters, prepare monthly income and expense statements and counsel you on investments. You will need an attorney who will review all your contracts, a banker who will loan or give you the credit line to start out initially, an insurance broker for liability needs and a real-estate broker to find you a new home or help you locate an office if you are going into solo practice. Perhaps ultimately you might need a management consultant to evaluate and manage your practice, but not initially. Management consultants usually come in after an established practice needs tweaking or perhaps some rearranging.
Solo practice
If you are starting out in an independent practice, you will need to obtain the appropriate state occupational licenses and you really need to apply early for privileges at the specific hospitals where you wish to practice. Once you have decided on the community in which you wish to practice, you need to look for office space. You have to decide whether you want to purchase or lease. Initially I think it is easier to lease than to purchase, to avoid excessive overheads. Find a house in a community which you think would be adequate for your family; your spouse and your children will follow you wherever you go, but choose a community which will be adaptable and comfortable for them.
Once you decide on the area in which you wish to practice, you will have to begin to draw up an income and expenditure projection so that you can borrow the monies that you will need to start a practice and use as income for the initial months. Apply to the appropriate managed care programs and/or insurances which service the community, arrange for your liability, office insurance, office overhead, office liability, business interruption insurance, employee fidelity bonds, major medical insurance for you and your employees, disability, life and ultimately automobile insurance. Acquire an answering service, get a beeper, cell phone, print business cards and announcements, and arrange for accepting credit cards within your practice. From a social, professional standpoint, you need to meet referring physicians and interview prospective janitorial services and office personnel. Study your CPT codes and use appropriate billing of your services for the area.
Office space
There are certain rules for finding and designing your office space. You have to maintain privacy according to the HIPPA regulations. There has to be absolute privacy for the patients coming into your office. The waiting room has to be comfortable, and sizable to allow patients to sit comfortably. The secretarial staff should have an appropriate view of the waiting room to be able to welcome the patients, as well as keep an eye out as to what is going on in the waiting area. They should also be able to prevent any undue occurrences or pilfering of the material and/or furniture in the waiting area. Remember, the waiting room is the first contact that the patient has with your office. Your décor should make the statement that you want to make in your practice. Use the décor that is appropriate for your practice and which reflects you. Exam rooms should be practical, clinical, usable and comfortable for both the doctor and the patient. Please remember that first impressions are made in seven seconds, and you don’t get a second chance so the first impression of your office should be one that gives them a sense of trust.
Supplies and equipment are something that will be difficult to evaluate. I think that all of us need to purchase the appropriate supplies for office management. You do not need to buy every piece of equipment that you see at a meeting or exhibit, but have appropriate equipment to handle any type of emergency. I would recommend that every office have an emergency CPR kit, computerize your office early. It is much easier to run a practice with computers. There are enough computer programs which are directed specifically to plastic surgery to make your life and that of your staff very easy, and in some instances paperless.
Budget
How much money do you need to establish a practice? Once again, it depends on your personal style, how extravagant do you want to be and how much you want to spend in your practice; middle of the road is always the best approach. As previously stated, you need to borrow money in order to support yourself for several months, so you have to establish a credit line and relationship with a bank. Will you get a better deal because you are a doctor? The answer is “no”. In the past, doctors were favored banking customers and could get loans at low interest with real flexible terms. I do not think that is the case at the present time. You will get a credit line knowing full well that the bank hopes that you will be a long-term customer. When borrowing money, certain things are required: past tax returns, a pro forma, which is a statement that projects the sources of income for the immediate future and that you will have an income to repay this loan over a period of time. At the same time, it will project your fees for expected surgical procedures, and the amount of income you expect to have over the next several months. They will also ask you for your estimated expenses, a financial statement and so bear in mind the five Cs which a bank will require: collateral for the loan, your capacity to pay the loan, capital that you have available, your character and any conditions for the loan.
Summary
Once you have established a practice and have opened your office, initially it is better that you keep it small if you are in solo practice. At the same time, if you are in a group practice it might be better to maintain a low professional profile rather than trying to go out and “corner the market” because this may create antagonism among your older colleagues who think you are nothing but a young upstart without experience, and they may not back you in difficult situations. Keep your staff small, good, reliable and make sure that they follow your principles and philosophy of practice. As far as your equipment is concerned, buy what you need, keep your office open at appropriate hours and be available.
There are three things that make a doctor successful: ability, affordability, but above all availability. However, make sure that you charge patients for your services. Bill promptly; remember cheaper is not better. Do not practice to make money, just be a good physician and appropriate financial remunerations will follow. Do not commit fraud, do not lie to insurance companies, be honest about who you are and what you do and in your billing, and you will have a long successful practice. Do not do unnecessary surgery. Be honest to your patients and yourself, particularly when you are beginning; say that you are still learning but that you are a well-trained surgeon and that you can handle the complexities of any surgical procedure for which you were trained. Read and understand all managed care contracts. Do not negotiate with your patients and remember that maintaining a practice is dependent upon three things: reputation, reputation and reputation. Maintenance of the practice will depend on physician referrals, patient referrals, area of specialization, good results and constant monitoring. Do not create gimmicks to attract patients; do your job well enough to be an expert and the patients will come.
The staff
Employee empowerment
Your staff should generate enthusiasm, teamwork and pride in their work, but with responsibility to you and your structured organization. The patient will choose you for surgery if you can accommodate them surgically and financially, and if they like you and your staff. Your staff must meet the patient’s needs by customization and individualization of care and services. The staff should follow this simple creed:
The aim of your staff is to encourage prospective patients to convert from might to want to will, and to create a service that will expand your market share. Therefore, when trying to bring a new plastic surgical service to the community, the goal is market expansion and revenue increase.
Business development of plastic surgical services
You need to use business tactics to accomplish the expansion objectives by:
1. Developing a new product or service (plastic surgery).
2. Raising or lowering prices to make financing more available.
3. Creating a new promotion with advertising or internal marketing.
4. Establishing a definite public relations effort through your staff.
5. Developing new channels of distribution through your own patient population or other services (i.e. skincare line of products).
6. Establishing plans and timelines to evaluate and track the service.
Hence you have to develop a situation analysis in which you:
• Analyze market trends and the needs of the service being introduced.
• Determine the domestic, local, and international needs of the service.
• Study the implications of new trends. (Is this something that is going to last or is it something that is going to come and go?)
• Weigh the financial opportunities for this product or service. (Is it a product or service that only you are going to deliver or is the product or service so available that it is diluted?)
• Evaluate the competition. What are they doing and how are they marketing?
The service has to be visible, be convenient, and it must have a simple organizational layout with friendly and professional assistance. It must be priced fairly, be consistent and constant. Remember that in plastic surgery it is not a product that you are selling, it is a biological technical service, which is not returnable and not guaranteed with many variables. Besides product, the other three “Ps” of plastic surgery are:
• Positioning, which is dependent on your reputation.
• Price has never been a factor, because the consumer may equate expensive with better and cheaper with inexperience.
• Promotion is the only element that can be used to expose the public to plastic surgery. Maintaining a practice depends on three things: reputation, reputation and reputation.
So, be caring, concerned and available at all times for your patients. You want to be the plastic surgeon who will be in your prospective patient’s mind when and if they change the might to want to will. It takes about ten years to establish a good elective type practice, but it is good results and reputation that keep you established.
Tips for a successful practice
1. All patients should be appropriately billed; patients should know exactly what kind of service they are getting even if the service is free. When you do not charge, give the patient a bill with the appropriate discount so that they know how much you have discounted or not charged for the operative procedure.
2. Treat patients very well and be their confidant and trustful physician, but do not make patients friends; maintain a social distance from your patient population. This does not mean that your friends cannot be patients, but do not try to socialize within your patient population.
3. Patients will sue you for three things: because they do not like you, they do not like the bill and they do not like the surgery, or a combination of all three. So do not be surprised; it happens to all of us, just document accordingly.
4. Do not fool around with patients, you can lose your license and it certainly is not appropriate ethically or morally.
5. The office is like a confessional; nothing is ever discussed outside the office by you or your staff.
6. Your specialty is plastic and reconstructive surgery, not cosmetic surgery, which is just part of our specialty.
7. Don’t take yourself too seriously. Do not let life pass you by. Nobody is indispensable and plastic surgery is what you do for a living; it is not what you live for.
Style, substance and communication
What really attracts and maintains patients in your practice may not only be your surgical expertise, but your ability to communicate. So when you communicate, you have to project likeability, integrity, competence and sincerity. In other words, the patient has to like you to ultimately trust you for surgery.
Improve your communication skills by the following:
1. Listen to the patient, attentively.
2. Make eye contact with the patient and sit down, be at their eye level to speak to them.
3. Be positive in how you talk, but always speak the truth. Do not get defensive; once you get defensive with a patient, whether it is preoperative or postoperative, you are going to get into the guilt, hostility, arrogance cycle.
4. Give useful information, be honest, concise, positive, truthful, reliable, memorable but factual and keep it simple.
5. Your demeanor should be pleasant and sincere; smile appropriately and genuinely with patients.
6. Have a friendly, open face, no frown or distant stare.
7. Be interested in what the patient’s problem is. You should absolutely give them your full attention. Do not be in a rush to leave. Make them feel that in the few minutes that you are there, you have no other interests.
8. Your body language should be cordial with appropriate gestures. In consultations, sit, touch the patient with professional concern, always make the effort to make contact with the patient physically as well as emotionally and mentally.
9. Dress neatly and always talk calmly to the patient, in a warm distinct, deliberate tone with normal pitch and rate, using understandable language. Never be condescending or arrogant; remember communication is an intellectual act of love.
Part 2: Marketing and practice enhancement
How I market an aesthetic practice
Marketing may enhance your practice, but it is reputation that makes the difference. In managing my practice, one of the things that I put first is my personal family life. I try always to remember that plastic surgery is a profession, not a lifestyle, and that you have to put things in perspective with definite priorities. At the same time, you have to be yourself and not try to imitate or be any other plastic surgeon. The priorities are basically simple: if you are satisfied professionally, growing and financially stable, doing what you like to do, why change?
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