Lindstrom’s ‘six A’s’ to help young ophthalmologists build successful private practices
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In this commentary, I will share a few thoughts targeted to the young ophthalmologist about to start practice. I will focus on core advice I have found useful for anterior segment fellows at Minnesota Eye Consultants.
The highest priority goal when leaving training is to build a meaningful personal private practice. We spend a large amount of time during our training learning the skills associated with ophthalmic surgery. However, building an ophthalmology practice starts in the office. Ophthalmology is a surgical subspecialty, but most of us spend 4 days a week in the office and only 1 day a week in the operating room. So, 80% of our clinical work is office based.
There are six A’s to building and sustaining a robust private practice, and the order of importance may surprise some. The first A is availability. The more available you are, the more patients you will see.
Second is affability. If you and your team are nice, kind and caring to patients, they will not only return themselves but also send you their family members and friends. If referred by another heath care professional, they will sing your praises, resulting in more referrals. The alternative, negative word of mouth, is almost impossible to overcome. Ask every happy patient to send you their family and friends. If a patient or their family is unhappy, find out why and rectify the issue.
Third is ability, and many are surprised to find that skill and knowledge are not No. 1. The classical saying that “Patients do not care how much you know until they know how much you care” is true. Even when exhausted and frustrated, be nice, kind and caring. Available and affable trump superior skills and knowledge nearly every time.
In the past decade, I added two more A’s for the highest level of success and recently a sixth.
At No. 4 is access to and ideally equity ownership in a high-quality, patient-friendly ASC or office-based OR.
No. 5 is advertising/awareness. This includes doing what is needed to let your community know you are in practice, including personal visits to potential referring doctors, the use of social media and participation in local societies and meetings. For some, tasteful internal and external marketing is appropriate. If no one, patients and potential referring doctors, knows you are available, the other A’s will not help.
At No. 6, consider some level of advocacy for your profession. Join your state ophthalmology society, support the American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery political action committees, and get to know and support your state and federal elected representatives. Over time, some involvement in advocating for your profession is critical.
Next, a few more thoughts on the critical importance of the office-based practice to a typical comprehensive ophthalmologist. The average comprehensive ophthalmologist completes about 5,000 office-based patient visits a year. Each 10 office visits generate one surgical case, so seeing 5,000 patients a year generates about 500 surgical cases. According to Medscape, the take-home pay for an established ophthalmologist in 2022 was $417,000. Today, overhead is about 70%, so to take home $417,000, the ophthalmologist needed to generate $1,390,000 in revenue.
To put ophthalmology in perspective with our colleagues, the average surveyed orthopedic surgeon had a take-home pay of $557,000, and the average primary care physician, including family practice, internal medicine and pediatrics, $254,000. How much of the typical ophthalmologist’s revenue comes from the 4 days in the office, and how much from the 1 day in the OR? Today, an office visit including refraction, ancillary testing and office-based procedures generates about $180 per visit, so 5,000 visits × $180 per visit is $900,000 per year. While OR revenue per case varies depending on case mix and premium IOL use, a reasonable average is $800 per case to the surgeon. So, 500 surgery cases a year × $800 per case is $400,000 per year. Again, we achieve a similar $1,300,000 in total revenue generated. Thus, 70% of a typical comprehensive ophthalmologist’s revenue is generated in the office and only 30% in the OR. Every ophthalmologist’s numbers will be different, and I recommend that each individual calculate their own numbers every year as an important benchmark to follow.
This analysis leads to another important fact. The best way to enhance one’s income is to see more patients every day, week, month and year. And, as an added benefit, the more patients you see in the office, the more surgery you will generate. Surgical density will vary from one city to another, from one practice to another and from one subspecialty to another, and it increases with practice maturity, but it is a truism in ophthalmology that the more patients you see, the more surgery you will perform, and the more income you will generate.
With adequate technical support and a scribe, it is easy for an ophthalmologist to see four patients an hour. That is 32 patients a day and 128 patients a week if one works a 4-day week in the office. At one surgical case per 10 patients seen in the office, you will have 12 to 13 cases to do on your OR day. If you increase to six patients per hour, that is 48 patients per day and 192 patients per week in the office, and you will have 19 to 20 cases to do on your OR day. If your surgical density increases such that every eight patients in the office generates a surgical case, you will be doing 24 surgical cases a day on your OR day, requiring two rooms and three cases an hour in an efficient ASC.
It is important for each ophthalmologist to know how much revenue their average office visit generates and their average revenue per surgical case. In a practice in which the doctor sees six patients an hour with an average billing of $200 per office-based visit, $1,200 per hour worked is generated. In order to beat that level of income productivity in the OR, one must perform two or more cases per hour. Carefully analyzed, some ophthalmologists will find they are more productive in the office than in the OR. Each ophthalmologist can and should calculate their own office vs. OR revenue productivity, but the critical point is that an efficient and patient-friendly office is essential to building a robust private practice and generating a good income.
In conclusion, the path to success for the young ophthalmologist starts in the office. Be available, be affable and ask your patients to send their family and friends. With the quality of training available today, ability and knowledge are a given for most. Try to operate in an efficient and patient-friendly ASC and, if available, seek and acquire equity ownership. Make your community aware of your presence and any special training or skills with tasteful advertising. Finally, engage in advocacy for your profession.
The six A’s of building a successful and prosperous practice are available to all. The demand for ophthalmologists’ services is growing as the population ages, and as I do the numbers, there are about 50 fewer of us each year. Every young ophthalmologist can build a large and sustainable private practice by remaining mindful of the six A’s.
One of my favorite quotes is that of Louis Pasteur: “Fortune favors the prepared mind.” The young ophthalmologist who understands the basics of ophthalmology’s unique medical economics will be better positioned to prosper in these challenging times.
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