At the risk of excess anthropomorphism, subspecialists --and particularly retinologists --are the high-strung, raptorial falcons of the profession who need to be coaxed gently to perform at their best, while general ophthalmologists are the happy dogs of eye care, comparatively easy to hire, train and manage. Here's a recap of how I apply these and other lessons to subspecialist management as a practice advisor.

Assessing your actual costs

First of all, make sure you have enough referral business to internally support a subspecialist. If you have just two or three average generalists in your current group, the only way you're likely to support a new retinal surgeon or glaucoma specialist is with external referrals, which competing generalists may be reluctant to supply, or by having your new doctor pursue a mixed subspecialty/general practice.

To make this work, you'll need to have sufficient control over not just practice capacity, but volume as well. If your practice is spending $150,000 this year to hire a corneal surgeon to bring LASIK into your practice, you may also need to spend several times that amount on promotion.

Make sure your practice has high enough profit margins to support a subspecialist, or be willing to bend your compensation model. Many multispecialty practices run into a Catch-22 in that retinologists and others unfavorably compare their retina-only overhead (50% or less) with the typically higher overhead of a larger mixed group practice (60% or more.) This works in reverse with lower-producing pediatric or neuro-
ophthalmology subspecialists, who may need to be subsidized by the group or have a different compensation model applied.

Beyond the base cost of hiring a new doctor, be prepared to make significant investments in equipment, facilities and staffing. Spell out for any potential candidates what the budget for technology and personnel will be. Draw your candidates out as to their expectations. Are they expecting an open checkbook every year, or do they understand the concept of applying a cost-benefit analysis to every capital expenditure?

When you're ready to hire

The following strategies will help ensure that you choose the best person for your practice:

�        Be wary of the very best specialists. It should be obvious that you wouldn't want to hire the worst candidate. But it's not as obvious that in most settings you should also avoid the top people in the subspecialty as well. The smartest, most ambitious and most rarified of subspecialty providers can be extremely difficult to manage. Subspecialists with long academic pedigrees can find the transition to the productivity demands of private practice extremely taxing.
Most of my clients find that hiring from the middle majority rather than the "top 10 percenters" works best.

�        Two may be better than one. If your practice has a critical need for any particular subspecialist (let's say you have a large practice in a rural setting and need an in-town retinologist), you should ideally have two such subspecialists on board to cover on-call shifts and hedge against future departures, given the higher turnover rate and greater recruiting difficulties associated with some subspecialties.

�        Don't settle for the first candidate who surfaces. Get the largest possible pool of candidates. Send letters to colleagues in the region, contact training programs, and use the Internet, placement ads and search firms. Sift through the CVs, and don't discard any out of hand. And don't overlook mid-career surgeons, who are often much easier to manage than new graduates.

�        Credential deeply. This can be difficult with newly-minted fellowship-trained subspecialists, whose only job history is in an academic setting. Seeking a professor's recom- mendation is a little like asking an assembly line worker if you should buy his car. You can often get better information from technicians and managers at the training center than from the program chair.

�        Look for clues that suggest teamwork and a good work ethic. Did the candidate play team sports? Is he a joiner or a loner? Has his social history been stable? Did he float through school on the strength of external goading, or was he self-directed? Most important (in my opinion): At what age did the candidate have his first paying job? The kid who was delivering newspapers or babysitting at age 13 is the candidate who will arrive on time and take criticism with a smile.

�        Trust your staff members' opinions. Before you hire, make sure your potential new doctor has met with most members of your staff. Their first impressions will be as piercing as those of your patients. (You hire a doctor over the strong objections of even a single thoughtful staff member at your peril.)

�        Have sufficient face-to-face time with any candidates before offering them a position. Share several meals together. Meet their spouses. Take a long walk to discuss your goals and theirs. Challenge them with hard questions, not just the softballs: What would you do first if a patient sued you? What's more important to you, your career or your family? What would you do if a health crisis meant you could no longer operate?

Managing future partners

The difference between managing a partner-track associate and a permanent employee physician is actually larger than the difference between managing a subspecialist and a generalist. Since most subspecialist hires are for future partners, make sure that you spell out in writing, as part of the employment contract, the expectations of a partner-to-be. Be specific about volume performance goals, help with continuing staff education, community outreach, local volunteer work and the like.

Once you make the hire, match your new doctor to a partner-level physician, who will act as his "sponsor," assuring that all is going well through regular meetings and the preparation of a formal, written career development plan. This plan should include target deadlines for patient visit volumes and cases by type and revenue. Each of these areas should be tracked monthly and used as a measure of the associate's progression toward full economic productivity and eventual partnership.

If your new doctor is in line for partnership, begin the financial and practice management tutorials early. Err on the side of over-disclosing the financial status of the practice and help your new doctor understand his or her economic context.

If conflicts arise that are beyond the skill level of the partners or administrator to resolve, hire outside professional management assistance. Through round-robin conversations with partners, staff and the associate doctor, it may be possible to rescue a relationship that was heading toward divorce. The cost of professional help to salvage a failing relationship could be much lower than the cost of starting over with a new search, especially when the loss of even a single, critical subspecialist's cash flow can lead a wobbly practice to economic disaster.

Understanding the subspecialist sensibility

Finally, make sure your practice has sufficient leadership. Better still, have two leaders --a strong medical director/managing partner and a strong administrator. Most subspecialists have reached their rarified heights by being more diligent, persevering and competitive than their peers. Like all highly evolved predators they will intuit, test and attempt to overthrow any perceived weaknesses in management.

John Pinto is president of J. Pinto & Associates, Inc., an ophthalmic practice management consulting firm established in 1979. John is the country's most published author on ophthalmology management topics. Recent books include John's Pinto's Little Green Book of Ophthalmology and Turnaround: 21 Weeks to Practice Survival and Permanent Improvement. You can call him at (800) 886-1235, e-mail him at pintoinc@aol.com or find him on the Web at www.pintoinc.com