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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?
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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.
SINGLE HANDED PRACTICE
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.
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PARTNERSHIP
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 PRACTICE
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.
HOSPITAL PRACTISE
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.
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GOVERNMENT PRACTISE
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.
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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 !
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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.
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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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