The Efficient Ophthalmologist

An MD Extender Can Play a Key Role

By Steven M. Silverstein, MD, FACS

No single decision I have made to date has had a greater impact on my personal clinical experience, created greater efficiencies in the practice and increased our bottom line more than adding an optometrist to our practice as an MD extender over a decade ago.

His name is Kelsey, and he has become much more than an “extension” of my practice; Kelsey has become a dear friend. He first teamed up with me following his one-year fellowship in our practice, during which time he became immersed in the preand postoperative care of cataract and premium IOL patients, corneal transplant and anterior segment surgery, glaucoma surgery of every complexity, and all aspects of kerato-refractive procedures, including LASIK, PRK, Intacs, corneal inlays, RK and artificial corneas for recalcitrant corneal disease and patient rehabilitation.

Kelsey's Skill Set

Spending countless hours together reviewing and sharing patients, Kelsey has developed an exceptional and most trustworthy approach to surgical options as well as handling postoperative outcomes and the potential need for enhancement or other medical/surgical procedures, which are sometimes necessary as part of the rehabilitative process.

He is also a keen diagnostician, comfortable with most clinical scenarios of acute or chronic ophthalmic disease, but he also understands his limits and does not hesitate to involve me or another subspecialist if it is in the patient's best interest.

Kelsey is modest, the product of a loving South Dakota family, and his is one of the strongest work ethics I have ever encountered. I am most fortunate to have him.

How Extenders Can Contribute

Similar key relationships in other specialties are certainly nothing new. Nurse practitioners are vital to primary care and primary care subspecialties, and physician assistants (PAs) are licensed to perform intraoperative wound creation and closure, inpatient hospital rounds, and write inpatient and outpatient orders and prescriptions for many surgical specialties.

In my practice, many of the clinic procedures and patient care protocols are either influenced by or the direct result of Kelsey's observations and input. He is a wise businessman, and approaches our practice through the eyes of a business owner. Kelsey owns half of our optical LLC, and one third of our Hearing Centers LLC. He is treated, and therefore respected by the staff, as a partner, with his own dedicated scribe/clinic leader, exactly as the MD partners enjoy.

As a result of his fellowship experience with and personal enjoyment of clinical research, Kelsey is a subinvestigator on each of our pharma and surgical device studies, and works very closely with the staff of our dedicated research department. As part of his salary and compensation package, Kelsey is incented via a percentage formula for his work with research patients so that this significant amount of effort and time may be recognized.

Compensating Kelsey

Because Kelsey is my MD extender, I am solely responsible for his contract, including salary, incentives, benefits and meetings. No expenses associated with him are treated as shared corporate overhead except for his role with research, which is regarded as a practice-wide department, and as such, all income and expenses generated by research is subject to our practice formula, which addresses the handling of expenses and distribution of income.

As a result, all monies collected based upon Kelsey's productivity are credited to my productivity, and in return, he is compensated by me with both a base salary and pre-established productivity percentage of collections over a set dollar amount. In this manner, Kelsey is fairly salaried, and he knows that he can influence his bottom line just as any employed ophthalmologist associate may do. Kelsey, in fact, helped write and approve his contract. It requires mutual trust, corporate transparency and respect, with each party being the advocate for the other's success.

I deliberately went into such detail about Kelsey's attributes because they most accurately reflect the ideal characteristics of what you should be looking for as you contemplate adding a similar position to your practice. In addition to business management (Kelsey is included in our monthly advisor-administrator-physician meetings) and research discussed previously, the role of the MD extender in our practice includes the following opportunities:

► Seeing all postoperative patient visits, which opens several thousand paying patient exam slots in my template throughout the year.
► One-day refractive surgery postop visits from surgery performed on Friday are seen by Kelsey on Saturday.
► Kelsey takes first call for the practice on weekends (not Monday-Thursday), with me as back up.
► Kelsey is our primary head of OD relations, regularly interacting with our OD network.
► Kelsey generates separate clinic revenue and is an excellent source of referral for diagnostic testing, ancillary practice services, and necessary surgical care.

Do You Need an Extender?

In summary, an MD extender is an invaluable aspect of my practice. It has allowed me to be 30% more productive in my own clinic while incorporating the revenue generated by this person (and the expenses) under my clinic umbrella. Think of it as clinic cloning, running two clinics simultaneously, or running one clinic while you are also in surgery, thus maximizing clinic services and employee time.

I would suggest that you are ready for an MD extender when 30% or more of your template is filled with bundled postop surgical patients and/or patients are waiting longer than 4-6 weeks for an appointment to see you.

Initially, there is a decline in your clinic schedule, which allows patients access to your clinic without waiting weeks or longer for an appointment. One must think about this relationship as a partnership, with terrific communication and sharing of ideas. In the end, a fiscally enhanced opportunity awaits both of you and positively benefits the dilution of overhead. In an ideal sense, the most important result is a genuine friendship which endures both inside and outside the practice. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@ silversteineyecenters.com.