Managing the stress of larger-scale practices
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“The secret of successful managing is to keep the five guys who hate you away from the four guys who haven’t made up their minds.”
– Casey Stengel
“When one must, one can.”
– Charlotte Whitton
Succession, the wildly popular HBO dramatic television series, is not about ophthalmology. It centers on the Roy family and its patriarch-industrialist Logan Roy, founder of a global media and entertainment company called Waystar Royco. The show satirizes the real-life News Corp. But that is not why I am bringing Succession up and urging you to watch it.
No. You should check out Succession because it poignantly reveals the frustrations of building and sustaining any large organization.
Even the largest ophthalmology conglomerates in America will never reach the scale of an international conglomerate like Waystar Royco. But the high stakes and complex logistics and relationships inherent in running even mid-sized medical practices eventually send many doctor leaders over the edge.
Unlike the fictional Logan Roy, who spends most of his time in boardrooms and private jets, interacting with a limited cluster of executives, large-enterprise ophthalmic physician leaders have hundreds of people each week picking at their sleeves: patients, support staff, along with an executive cohort like Logan’s crew.
Brian Cox, a classically trained Shakespearean actor, brilliantly portrays Logan through 39 episodes. In early episodes, he is generous with his time and kind to the hired help. In later episodes, we see a worn-down Logan, hanging by a thread and snarling like a wounded beast at everyone within earshot.
How does that square with eye care?
Some of the nicest docs I met at the start of their careers, when their practices were small, simple and boutiquey, turned into Logan-like beasts a decade later.
Why? You are probably already ticking off your own personal list:
- “Room 2 was a glaucoma patient who refuses to take her medication. Room 4 was a routine postop my optometrist should have seen. Room 3 was a cataract patient who wonders why I want to perform surgery differently from Dr. Google.”
- “Our accounting firm dropped the ball, and we missed out on yet another tax deduction.”
- “I’m the founder. How come I’m seeing all the Friday afternoon work-ins?”
- “I love my partner. But he’s the most undisciplined guy I know. When his clinic backs up, the overflow goes on my template.”
- “We’re working our tails off back in the clinic, but the billing staff are collecting only 85% of what they should be.”
- “Why am I raising my voice to my head tech? I’ll tell you why. She just approved vacations for three of my staff in one of the busiest weeks of the year.”
In a word, you are hugely dependent on people. Fallible, frustrating, slippery people. You cannot get much done without them. Their intelligence, training and commitment rarely match yours. Which makes most eye surgeons at least a little bit crazy. And this is leveraged the bigger the practice is.
In a small solo practice, you can personally observe what is going on and whether your people are following through on their responsibilities. Add another few doctors and their necessary support staff, and even the most vigilant managing partner loses touch with the details. This is why we classically see profitability and operational integrity stumble when practices get somewhere between five and eight providers.
Here is how we address these all-too-human problems in our consulting work:
- As the MD-owner, learn how to be a more effective people manager and motivator. In an ideal world, your aspirations for practice size match your innate people management skills and what you have learned along the way. If you want to build a major practice, you need to cultivate major people management skills: emotional intelligence, listening, communication, multitasking, charisma. Unfortunately, there is nothing inherent in acing molecular biology that is predictive of great human resource skills. As many of your peers who don’t start out as natural leaders find, a strong work ethic and good executive coaching can substitute for innate magnetism.
- Be realistic and patient about each person’s unique limits. You would not get angry at a rickety chair that breaks under your weight. But you get angry at staffers who are overtasked. Everyone has their talents and limits. (And by the way, you were the one who hired them in the first place.) Before delegating, ask yourself, “Does this person have the judgment, skill and free time to do what I’m asking of them?”
- Get smaller and less complex. It is no dishonor to tap out of the rat race that a hectic practice can become. Our experience shows that owner stress seems to be logarithmic, with practice ownership sometimes feeling four times more stressful when the practice merely doubles in size. It could be that a comparatively small retreat — eliminating a provider or office location or patient service — will take the edge off.
- Hire more providers and see fewer patients personally. If you aspire to build a larger clinic and enjoy business, it may be smart for you to reduce your clinical life and expand your commercial life. Do the math. The typical managing partner has to answer about 150 patient questions a day and another 50 staff questions. That is a lot of interrogation for one person to take in a day.
- Refer problematic patients out. It is likely that 10% of your patients generate 90% of your headaches. They may be on low-paying or annoying insurance plans. Or your youngest patients. Or patients with problems you don’t really enjoy treating. By eliminating a small segment of your practice, you may enjoy a disproportionately large improvement in your practice life.
- Replace substandard staff. The same 10/90 rule can be applied to your staff: 10% of staff generate 90% of your personnel problems. Every employer makes hiring errors. The key is to make your errors f-a-s-t-e-r.
- Get larger and hire higher-level oversight. Some practice founders get trapped by loyalty. They keep the perfectly great small-practice administrator years past when the organization has outgrown their skills. Continuously ask: “If I were recruiting a new administrator today, would my current administrator be in the running?” If the answer is no, it may be time to upgrade.
- Merge with or sell to a bigger practice or health system and let someone else take over. Rather than merely turning down the temperature of your personal hot seat, an alternative is to give it up altogether. This can be an attractive choice for senior owners in their last few years of practice. It comes with two benefits. First, selling or merging substantially reduces your business leadership duties and stress. Second, it takes money off the table, securing your retirement funding.
- For more information:
- John B. Pinto is president of J. Pinto & Associates, Inc., an ophthalmic practice management consulting firm established in 1979. He is the country’s most published author on ophthalmology management topics, including John Pinto’s Little Green Book of Ophthalmology: Strategies, Tips, and Pearls to Help You Grow and Manage a Practice of Distinction, UP: Taking Ophthalmic Administrators and Their Management Teams to the Next Level of Skill, Performance, and Career Satisfaction (with Corinne Wohl), Simple: The Inner Game of Ophthalmic Practice Success, and Ophthalmic Leadership: A Practical Guide for Physicians, Administrators, and Teams. Available now for purchase at slackbooks.com. Receive 20% off with promo code PINTO20. He can be reached at 619-223-2233; email: pintoinc@aol.com; website: www.pintoinc.com.
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