Managing partner: The dirtiest job in eye care today

Leading a group practice can be a thankless, stressful, low-paying assignment, so here are ways to make it a more successful experience.

Issue: November 1, 2007

ByJohn B. Pinto

John B. Pinto

In the television series Dirty Jobs, part of the continuing wave of popular reality TV shows, oil rig roustabouts, hog farmers and sanitation system repairmen are profiled on the job in a largely successful effort to gross out the audience. The show’s ratings are through the roof, as might be expected given the state of our popular culture today.

But this show is missing a huge opportunity. To draw higher ratings, the producers should tape a segment called, “Managing Partner: The Dirtiest Job in Eye Care.” They would find a lot of pretty awful material:

Partners who support the lead doctor publicly but undercut him at every turn.
Lead doctors who spend hundreds of uncompensated hours annually with nary a thank you from the board.
Managing partners who start their tenures with high hopes that their contributions will make all the difference — only to learn that this “difference” is not so much practice-based as personal in exhaustion, frustration and a new appreciation for the challenge of working in groups.

Although I have scores of similar examples, here is one anecdote that says it all. Several years ago, I sat in on a board meeting for a profitable $26 million practice. On an evening with a full agenda, the partners spent 45 minutes arguing whether the new managing partner’s monthly honorarium — compensating him for about 10 hours a week of blood, sweat and tears — should be $1,500 or $2,000. As you can imagine, the new practice leader started out feeling like he had less than the board’s full confidence.

So it goes for an unfortunate majority of managing partners. It has always been lonely at the top.

Job responsibilities

As a neutral observer in such dealings, I have developed a few practical recommendations that may help whether you are the managing partner, a member of the board or an administrator caught in the crossfire.

The prime directive — aside from picking the right leader in the first place — is that the managing partner’s scope of authority and position description must be formally articulated in writing. Without this document, even the best-intended lead partners will either overreach or under reach their reasonable boundaries. Here is some sample language about your duties:

Up to 12 hours per week as an average time commitment.
Financial acumen sufficient to monitor progress toward agreed profit targets.
The ability to communicate directly.
The ability (and widely held credibility) to actively mentor fellow doctors and to not avoid uncomfortable confrontation.
Sufficient discipline to stick to board-agreed directives and not succumb to “mission drift” or self-serving projects.
Willingness to be the doctor’s disciplinarian, intervening when fellow providers are underperforming or misbehaving.
Willingness to ride to the defense of a partner or associate who is being unfairly picked on.
Help to prepare and periodically revise the practice’s strategic plan; lead the board approval process for each subsequent edition.
When other partners temporarily lose faith in the practice’s plan, show a willingness to carry the torch.
Ongoing work to coach individual doctors, helping them reach their profit and volume goals; brisk intervention when patient volumes or revenues lag.
Serve as a member of the practice’s management committee (a group composed of selected senior staff), which manages day-to-day operations.
Chairman of the practice’s board of directors.
Maintain ongoing senior-level contacts with the practice’s sources of referrals and with third-party payers in the region.
Is involved with all provider and senior staff recruitment.
Conduct risk management, utilization and quality assurance reviews or delegates these chores to fellow providers; in consultation with the board, has the ability to suspend or revise any clinical practices believed to be inappropriate.
Works to resolve provider-to-provider conflicts in such areas as scope-of-practice issues, patient assignment, compensation methodology, etc.
Responsible for applying a progressive discipline system to misbehaving partners and associate doctors, ranging from informal peer-to-peer counseling to termination.

How much to pay?

Compensation for a managing partner is influenced by many factors. If all of the partners within a practice take the role in equal rotation, then the position can be noncompensated. In most practices, however, the managing partner duties are not equally shared. Compensation in this case should definitely be paid.

What’s the proper amount? In the best of circumstances, the stipend ends up being little more than a token honorarium, roughly proportional to the size and success of the group. In a two to five doctor practice, a payment of $18,000 to $36,000 per year is typical. As you can see from this, a partner working 10 hours per week on the practice’s behalf is only going to earn about $50 per hour, far less than he or she would earn seeing patients. In larger practices, where more time is required, and the lead-partner’s stipend is divided among more owners, the managing partner may receive more than $50,000 per year.

In a small number of settings, managing partners receive a bonus based on practice collections or profits. However, this is uncommon and does not seem to influence performance. If anything, a struggle can erupt because the managing partner then tries to boost his bonus by overworking his colleagues.

Tenure in this leadership role should be 2 years or longer. An annual rotation — often chosen out of a misplaced desire to assure perfect fairness by giving everyone a shot at the job — results in doctors stepping down only as they are starting to learn the nuances of the position.

Succession in this role from one partner to the next should be handled with great sensitivity. Rather than a simple majority approval, it is preferable to nearly follow the rules for a papal election, in which nothing less than full consensus must be achieved.

In my experience, any practice with two or more owners should designate a formal leader, even if at this smaller scale all policies and decisions are typically derived through the complete consensus of the owners. Line staff in the trenches especially benefit when the organization chart makes it clear that they report to their immediate supervisor (head tech, billing supervisor, etc.), who in turn reports to the administrator, who then works most closely with the managing partner to execute the board’s mandate.

Keys to success

Here are some coaching points and success factors we have learned through the years from long-term lead partners who not only enjoy the durable support of their peers but have an absolute ball doing the job.

Stay informed. One of the best compensations of being the leader is the status of informational privilege that it confers. Knowing the way the wind is blowing both inside and outside of the organization is critical to your success and satisfaction in a leadership role.
Delegate avidly. You cannot do it all. In the busiest years, you cannot even touch half of the opportunities personally. You should be personally engaged only with those areas and projects that are the most interesting to you and crucial to the company. Remember that the best way in any group setting to stimulate involvement is to give people a job to do.
Set firm boundaries at the outset. For example, early in your tenure when you send an e-mail requesting feedback, set a deadline and follow up with stragglers. Do not let your partners get in the habit of blowing off meetings or failing to follow up with your reasonable requests.
Make everyone responsible for success or failure. Unless you are a practice dictator — in which case it is really all on you — your organization is going to rise or fall based on everyone’s contributions.
Find the right balance between dictatorship (which on the toughest days sounds pretty attractive), guile and collegiality. Sometimes it is appropriate to be in touch with your “inner-Machiavelli” and play one side against another for the benefit of the organization.
Hold your management accountable for their agreed projects in terms of content, quality and timeliness. Be clear about the specific outcomes you expect from them.
Communicate effectively. There are going to be times when you have to give speeches to the board, management team or total staff. If you are not a natural orator or tend to stray off your core message, speak from written notes.
Meet with staff members every few weeks over a casual lunch. These informal sessions will not only give you a glimpse of life in the trenches but your staff will see you as more approachable and will seek you out with their future concerns. This feedback is invaluable as a leader.
Be honest. Long-term success is only possible if you are authentic, approachable and ultimately vulnerable in your dealings with others. If you are at wits’ end with your board, your administrator or an outside party, say so, and let the chips fall where they may.

The right personality

Being the first among equals in your practice is not a position from which you command — it is a position from which you lead. There is a difference. A military commander’s directives are followed without question. A corporate executive can fire his entire cast of subordinates. But a leader — particularly in a medical setting with a slew of smart peers hanging around — starts with a clean slate every day and has to defend every new initiative. If you are not ready for the frustrations and gaps in control incumbent in this reality, do not step forward and volunteer for the position.

Few managing partners are ever abruptly fired. Actually, their tenure is usually quite long, which may be a better measure of the lack of willing substitute candidates than a vote of confidence in most of the settings that I visit.

However, this does not mean that most practice owners are overjoyed about your performance as a managing partner. Their greatest concerns commonly center on fair dealing. The fastest way to lose your board’s support is to appear to be spinning opportunities in your own direction at the expense of the rest of the partners. Instead, the most successful managing partners often have to vote actively against their own interests to be viewed as impartial.

Doing this job requires a perpetual “Goldilocks” sense of balance. Get too involved with the details and your board and administrator will accuse you of micromanaging. Become too aloof and you will be accused of abandoning the team. How should you determine the right tipping point? That is simple. Ask everyone you work with how you are doing with this balancing act and follow the advice that you are given.

Any way you look at it, being the managing partner of your group practice is a dirty, thankless, long-suffering, under-rewarded, overstressed and certainly under-compensated job. Every new lead surgeon’s get-started kit should include a thick skin, an abundant sense of humor and a hazmat suit. It is a tough, dirty job. Welcome to the head of the table, chief.

For more information:

John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. Mr. Pinto is the country’s most-published author on ophthalmology management topics. He is the author of John Pinto’s Little Green Book of Ophthalmology, Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement, Cashflow: The Practical Art of Earning More From Your Ophthalmology Practice, The Efficient Ophthalmologist: How to See More Patients, Provide Better Care and Prosper in an Era of Falling Fees and a new book, The Women of Ophthalmology. He can be reached at 619-223-2233; e-mail: pintoinc@aol.com; Web site: www.pintoinc.com.