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Little things work wonders


When the author moved from a large group to a small one, he found that he had much to learn--and something to teach.


Little things work wonders

When the author moved from a large group to a small one, he found that he had much to learn—and something to teach.

By Michael Kirsch, MD
Gastroenterologist/Highland Heights, OH

After completing a gastroenterology fellowship 10 years ago, I joined a 100-doctor multispecialty group. There, I could devote myself exclusively to patient care. Hustling for referrals, managed care contracts, staff issues, billing, and collections—all that would be someone else's problem.

But I had made a devil's bargain. A year prior to my coming aboard, the group had been acquired by a large hospital system. The two organizations were still in the honeymoon phase of this relationship when I was hired; the impact of the sale had yet to be felt. The group, which was more than 40 years old, had a reputation as a great place to work. Personnel turnover was negligible. The building was adjacent to a community hospital where the doctors admitted patients. For four decades, physicians and hospital staffers had worked side by side and been economically interdependent.

Naively, the group leaders didn't realize that new ownership would affect this longstanding relationship. In fact, it was abruptly severed, severely wounding our old friends both psychically and economically and inconveniencing patients. Patients who previously had a 10-minute drive to the hospital now had to travel at least 30 minutes to a downtown hospital belonging to our new owner.

There were other iniquities. For instance, I had a second office in another part of town, with privileges at a community hospital nearby. I was ordered to close that office, quit the hospital—which, like the other hospital we were forced to vacate, wasn't part of the new owner's system—and abandon my patients in that neighborhood. Naturally, we complained. "None of you is indispensable," our new CEO reminded us. For the first time in 40-odd years, doctors started to resign.

In 1998, I jumped, too, and joined a group of three gastroenterologists. Working in a small single-specialty group, of course, was quite different from working in a 100-doctor multispecialty practice. Before, my sole concern had been patient care. With the new group, despite my lack of business experience, I was expected to spend time discussing referral patterns, reimbursement issues, market competition, overhead, cost-cutting measures, and on and on.

More importantly, from my partners' perspective, I had to get referrals on my own. Was I up to the challenge of competing for patients? My new partners didn't know, and neither did I.

I was charged with expanding the group's GI practice into the community hospital near the office I'd been forced to close. Since I'd also been forced to resign from the staff of that hospital, I'd lost my privileges there. Now I sought to have them reinstated—a process that necessitated leaping over two hurdles: the ill will generated by my resignation, and the fact that the hospital only needed so many gastroenterologists.

Eventually, though, I regained my privileges. But yet another hurdle loomed: how to get referrals from staff doctors who barely knew me. Well, there are standard ways to generate referrals. I could accept stipends from pharmaceutical firms to discuss GI topics with primary care doctors, then try to convert them into referrers. I could attend hospital social functions, where everyone stands around awkwardly glancing at their watches, and hand out business cards. Or I could learn to play golf and try to ingratiate myself with primary care doctors on the fairway.

I opted for none of the above. Instead, I hung out in the hospital's physician lounge waiting for the odd doctor to drift in, introduced myself, and struck up a quiet conversation. I didn't mention referrals. Rather, I strove to give colleagues an unpushy sense of who I was as a person and physician. And then, if they needed to refer a patient to a gastroenterologist, I hoped they would think of me. Happily, some did.

My business-savvy partners saw that I had what it takes to build a practice. And they're learning that I have other things to contribute, such as keeping us focused on our true mission: caring for patients. We debated, for instance, whether to add even more options to our voice mail system in order to better handle the daily deluge of calls. I pressed instead for hiring a receptionist. Patients prefer dealing with a real person. She would also free our nurses from phone chores, enabling them to spend a few extra moments with arriving patients, rather than simply loading them into an exam room. I convinced my partners that a receptionist's salary, a modest investment, would reap dividends in patient and staff satisfaction. It has.

I've also shown them that some smart business moves don't cost a dime. I noticed, for example, that our hardworking staff often received gratuitously negative feedback from my partners. People do their best work when their efforts are recognized and appreciated. So I suggested that we doctors make an effort to compliment our staff more often. If we strive to build esprit de corps, I argued, morale will improve (it has), and both patients and doctors will receive better treatment (they do).

When you're totally focused on patient care, as I was in my former job, the power of the human touch is obvious. But when you have to worry about the bottom line as well, it's easy to forget how much the little things—"thank you," "nice job," "I appreciate your good work"—make a difference. I still have a lot to learn about the business side of running a practice. But I think my partners are starting to value me as someone who does more than simply generate referrals.


Michael Kirsch. Little things work wonders. Medical Economics 2002;8:93.

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