Ophthalmologists face unique practice management challenges

Ophthalmologists are tested with unique and difficult medical challenges every day, but practice owners and partners can take steps to address practice management challenges outside of the operating and examination rooms that can distract physicians from providing medical services.

Communication issues, disagreements on direction, disappointing employees, compensation equation challenges and inappropriate behavior in the workplace can threaten the success of any ophthalmic practice, no matter its size.

Clear communication and strong leadership are necessary for the success of an ophthalmology practice. The governance of a practice can ensure its success or its failure, OSN Chief Medical Editor Richard L. Lindstrom, MD, said.

Source: Steve Barbosa

“Discussions need to be frank in a practice, and with only two or three partners you can usually come to a consensus. In a larger practice, a managing partner is generally selected and elected to oversee the day-to-day management. If a doctor has an issue with another doctor or an employee, they discuss it with the managing partner,” Lindstrom said.

Setting rules

A set process to determine large decisions, such as whether to purchase an expensive piece of equipment or to sell a practice into private equity, needs to be in place for any practice, Lindstrom said.

“As far as controversial decisions go, every group has to set the rules. It always seems as though there is someone who has a hesitation or disagrees with a proposed direction or decision, so having a unanimous decision among partners may not be the best strategy. In our group, we use a supermajority for a decision. If seven of 10 of our partners vote yes, you can move forward on a decision,” he said.

Strong leadership can help steward a practice and steer the direction of its partners to success, but when a senior partner or a managing partner leaves the practice, a third-party consulting group is often necessary to set the practice on the right course.

Consulting groups can be helpful

Consulting groups are commonly brought in by physician owners when a practice is “no longer running smoothly,” OSN Practice Management Board Member Candace S. Simerson, FASOA, COE, CMPE, founder and president of iCandy Consulting LLC, said.

“For example, when a practice loses a CEO or a lead administrator, a qualified consultant can provide experienced leadership on a short-term basis until a permanent replacement can be found. Practices often stumble when they don’t have succession plans in place or qualified individuals who are sufficiently cross-trained to fill in as a replacement. If employees aren’t ready to step into a key position, trying to force the situation can produce catastrophic results. Individuals who see beyond day-to-day tasks and are proactive when dealing with problems take time to develop; they are not plug-and-play replacements,” Simerson said.

As ophthalmology practices become more complex, management structures must also advance. Unfortunately, one single “static structure” that works for all practices does not exist. As times change, the corresponding structure evolves, Simerson said.

Practices should continuously examine operations, taking into consideration current circumstances to reconfigure resources as necessary. Is the practice growing? What does the competitive landscape look like? Are there senior partners looking to transition into a lighter schedule, retire or sell the practice altogether? Every factor needs to be examined, and the organizational structure and management plan that supports practice goals need to be maintained and regularly updated, Simerson said.

“Plan to invest time and resources to determine who your best people are and rotate them into different roles. Figure out who has superior skills to actually drive the practice to success. You may find you don’t need a particular role in a practice, and in the extreme, you may find the entire organizational structure must be changed,” she said.

Compensation controversies

One of the more common problems ophthalmology practices face as they grow is a fair compensation equation for its partners. However, as practices expand, the equation can become complicated. Keeping compensation formulas simple is usually best for the practice, Simerson said.

However, compensation problems can arise when discrepancies appear between older and younger surgeons. There is no magical formula for compensation formulas, but it can be difficult to find one that is agreeable for all parties in a practice, OSN Cornea/External Disease Section Editor Elizabeth Yeu, MD, said.

There are three basic thoughts to compensation models when it comes to practices: a “socialistic” model in which partners split everything equally; an “eat what you kill” model in which all partners make their own percentage of what they personally bring into a practice; and hybrid models that combine factors from those two models, Yeu said.

It is one of the most common sources of conflict in many practices, she said.

“You see a lot of problems where older surgeons who were the most productive become less productive over time because they’re working less, seeing fewer patients or doing fewer surgeries. They’re bringing in less compared with younger surgeons who have built up a more productive practice. That disparity, that change, makes it difficult on compensation models,” she said.

A simple compensation formula is usually best, according to OSN Practice Management Section Editor John B. Pinto, president of J. Pinto & Associates Inc.

Compensation formulas should be “understandable by a bright sixth grader,” and in most settings, it is acceptable to split a minority of profits proportionally to ownership and the majority of profits proportionally to individual net collections, Pinto wrote in his Ocular Surgery News By the Numbers column. For example, in a practice of two equal partners, a fair compensation formula may be an even split of 30% of practice profits and then the remaining 70% balance may be split proportionally to individual collections, he wrote.

Diana H. Kersten, MD, partner at Harvard Eye Associates, said her practice hired an outside consulting group to simplify its compensation formula due to tension within the partnership.

Over several years, multiple modifications to the equation had become “overly complicated and difficult to understand” and contributed to a feeling that the practice felt less like a partnership and more like a group of individual doctors only looking out for their own interests, she said.

“It’s one of the interesting things about a practice — issues evolve over time. The compensation issue evolved over time. When we employed our consultant group, we realized we needed to embrace simplicity. After analyzing both systems, it became clear that the partners were taking home similar amounts using either system. We found simpler methods create fewer problems,” Kersten said.

Outside distractions

Conflict outside of a practice from the medical community can also pose challenging scenarios. One of the most difficult situations a partner can face is when a pattern of improper patient care emerges from a referring physician, Kendall E. Donaldson, MD, MS, medical director of Bascom Palmer Eye Institute at Plantation, Florida, said.

Donaldson practices in a tertiary care center and recalled a surgeon whose patients were presenting to Bascom Palmer. Several patients had one-piece multifocal lenses placed in the sulcus with vitreous to the wound, some posterior chamber lenses were placed in the anterior chamber, and several patients “even presented with complete corneal decompensation.” The patients had not been told of their complications, and they did not understand their delayed visual recovery, Donaldson said.

“This is a very difficult situation, as you want to support a colleague, but you also need to be an advocate for the patient. I usually begin by telling the patient that we need to start from that point in time and address the concerns and make a plan to move forward with recovery as opposed to looking back, in an attempt to diffuse any anger toward the primary surgeon. I then call the doctor to discuss the case and try to determine where things went wrong and try to engage the doctor in the plan moving forward,” she said.

Every surgeon will experience complications, but these examples were based on repeated negligence, Donaldson said.

“I think it is our duty to the patient to address it with the surgeon, generally through the local society or chairperson of a tertiary care facility. This situation was addressed through the local ophthalmologist organization, as many other subspecialists were engaged with multiple patients over several years,” she said.

When a complication occurs, Donaldson said the best strategy for a surgeon is to tell the patient either directly after surgery or at postoperative day 1. A surgeon needs to remain calm while discussing the details of the complication, outline a clear plan and inform the patient about how the problem will be corrected.

Kersten said the best strategy is to be honest with the patient and use common language when explaining what went wrong and how it will be corrected.

“If they start to get worried or frustrated, I’ll usually ask them to see a partner for a second opinion. Reassure them that it’s healing, and if necessary, you can get an academic consult. Any other way of dealing with complications is a big mistake. Be very honest about what happened,” she said.

Difficult discussions unavoidable

Communication inside and outside a practice is key to solving problems, yet often problems arise because discussions among partners or with staff are difficult to have, Mark Kontos, MD, senior partner at Empire Eye Physicians in Spokane Valley, Washington, said.

All employees, providers and partners need to have a clear understanding of what is expected of them when they are with a practice. It seems simple, but assuming that goals are understood by all can lead to a waste of time and resources, he said.

“We’ve recently had to deal with this in our practice, where we brought a doctor in, we were planning to bring them into the partnership track, and it didn’t work out. We assumed the physician’s goals were the same as ours, and we invested time and resources into building up their practice,” Kontos said.

Promoting a physician and building up a patient base takes time and resources. It is a significant process to bring a new physician into a partnership track, and it can be a detriment if the physician does not go through with the partnership and leaves.

In this case, Kontos said the practice invested more than 3 years of time and resources into building up the physician’s practice and were left with nothing more than a 6-month notice that the position would be vacated.

“The strategy is to understand in the beginning, when you bring someone aboard and they join the practice, that you have a good understanding of what’s expected of that person. What do you see coming from this union? What does this practice and the people in the practice expect from the physician or provider? You need to make sure that provider is on the same page,” he said.

Litigation common with termination

When a practice must separate itself from a provider or a staff employee due to behavioral or performance reasons, the pathway to do so has become much more complicated in the past several decades, Lindstrom said.

It is much more difficult now and “fraught with legal overtones” to relieve an employee or provider of their job duties. A structured process must be in place, and all steps must be followed if an employee or provider is to be let go, he said.

“An attorney can teach you the steps, but basically a supervisor needs to meet with the employee, discuss the issue, document a record of the incident and then create a way for the employee to rectify the issue. The employee or provider must be given the opportunity to respond and rectify the problem. If they don’t respond to your requests, you must again document they did not meet expectations, meet with the employee again and then have them put on probation,” Lindstrom said.

After going through this process, the employee or provider can eventually be let go from the practice. The process is different depending on the location of the practice, as state laws are written differently and some are “strongly written to protect an employee,” he said.

In states where laws are strongly in favor of employees, a practice can benefit from having a human resources director or practice attorney manage all employee issues due to the high potential for litigation.

“It may be in the practice’s best interest to have the practice attorney meet with an unsatisfactory employee first and to ensure all documentation of their behavior is perfectly completed before the employee is let go. ... Even then, when everything is done perfectly and it’s appropriate for an employee to be terminated, don’t be surprised if litigation is still issued and they win a settlement. It’s just the nature of our modern society,” he said.

A practice must have a documented compliance program for all employees and providers that can be addressed if issues arise, Lindstrom said.

Face-to-face is best

Behavioral issues can kill the morale of a practice. Knowing how employees and providers are perceived is important, so annual reviews are necessary to improve communication and keep abreast of any problems that may be derailing a practice’s productivity, Yeu said.

Outside of annual sit-down reviews, any complaints or code of conduct issues need to be dealt with immediately in person with the offending employee or provider.

“If there are concerns or complaints about an employee, then these need to be discussed, communicated and documented. These need to happen face-to-face as well. You’d think this would be common sense, but it can be an uncomfortable situation. Many people will turn to email or other forms of communication. It must be face-to-face and discussed clearly with an employee,” Yeu said.

Donaldson said the creation of a new position in her practice has helped deal with employees who may not be living up to the expectations of their job duties. The “technician education and trainer” meets and trains each new staff member to make sure they are current with their knowledge base and skill set.

If employees have a deficiency in their performance, Donaldson said the technician educator will create a customized rehabilitation program for the employee to follow.

“She runs sessions for continuing education for our staff and helps and encourages all of our staff to pursue their certifications. She has organized a lecture program and enlisted the help of other technicians, engaging them to participate in the education of their peers as well. This has really been a great way to encourage all of our staff to continue their engagement and education and treat their job as an opportunity to learn and to grow,” Donaldson said.

Office affairs common

Major litigation and whistleblower lawsuits can cripple a practice, so it is important to know everything that is occurring with your employees, providers and partners. This also extends to any potential romantic relationships between providers and employees, Lindstrom said.

Interoffice affairs and relationships can be a surprisingly widespread problem that should be acknowledged and managed, he said.

It is never appropriate for a partner to have an affair with an employee or a provider, and if discovered, it needs to be dealt with immediately, Kersten said.

“Once a manager-subordinate relationship is uncovered, you must do the right thing by changing reporting relationships or set parameters and have them work out of separate locations,” Kersten said. – by Robert Linnehan

• References:
• Devgan U. Dealing with and learning from surgical complications. www.healio.com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news/%7B576befff-2f3b-46c8-9f86-e52a4c6691f5%7D/dealing-with-and-learning-from-surgical-complications. Published March 25, 2018. Accessed Sept. 16, 2019.
• Pinto JB. Address partner compensation issues early and often. www.healio.com/ophthalmology/practice-management/news/print/ocular-surgery-news/%7Ba78a051e-089f-4384-aba2-268695d8b8fb%7D/address-partner-compensation-issues-early-and-often. Published April 10, 2017. Accessed Sept. 4, 2019.
• Simerson C, et al. Stories of sleepless nights. Presented at: Hawaiian Eye; Jan. 19-25, 2019; Waikoloa, Hawaii.

• For more information:
• Kendall E. Donaldson, MD, MS, can be reached at Bascom Palmer in Plantation, 8100 SW 10th St., Crossroads 3, Suite 3000, Plantation, FL 33324; email: kdonaldson@med.miami.edu.
• Diana H. Kersten, MD, can be reached at Harvard Eye Associates, 24401 Calle de la Louisa, Suites 300-312, Laguna Hills, CA 92653; email: drkersten@harvardeye.com.
• Mark Kontos, MD, can be reached at Empire Eye Physicians, 1414 N. Houk Road, Suite 103, Spokane Valley, WA 99216; email: mark.kontos@empireeye.com.
• Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 Dupont Ave. S., Suite 200, Bloomington, MN 55431-3200; email: rllindstrom@mneye.com.
• Candace S. Simerson, FASOA, COE, CMPE, can be reached at iCandy Consulting, Marana, AZ; email: candysimerson@gmail.com.
• Elizabeth Yeu, MD, can be reached at Virginia Eye Consultants, 241 Corporate Blvd., Suite 210, Norfolk, VA 23502; email: eyeu@vec2020.com.

Disclosures: Donaldson reports financial disclosures for Alcon, Allergan, Johnson & Johnson, Bio-Tissue, Bausch + Lomb, Sun, Kala Pharmaceuticals, Eyevance, Omeros and Carl Zeiss Meditec. Kersten reports she is a partner at Harvard Eye Associates. Kontos reports he is a senior partner at Empire Eye Physicians. Lindstrom reports he is the founder and attending surgeon of Minnesota Eye Consultants. Simerson reports she is the founder and president of iCandy Consulting. Yeu reports she is a partner at Virginia Eye Consultants.

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