Enhancing Practice Performance

Avoid doctor-to-doctor conflicts

How to reverse the problems borne of a changing practice environment.

By Corinne Wohl, MHSA, COE and John B. Pinto

The job of running an ophthalmic practice becomes more challenging with each passing year. Leading and running a practice will never again be as easy as it is today.

The performance bar is inexorably rising for all of us: surgeons, practice executives, technical specialists (like us) and industry vendors who do their best to help doctors and patients alike.

In this new bi-monthly column, we’ll address a kaleidoscope of practical ideas to help take your game to the next level, whether you are the practice’s managing partner or business leader, or rising through its ranks as a mid-level manager.

An axiom of psychology is that all change (both positive, like a new house, and negative, like getting fired) begets stress. In the past 20 years, ophthalmology has had its fill of both.

The changes in our industry have included:

• Tapering residency enrollments

• Arbitrary disenrollment from insurance plans

• A David vs. Goliath struggle with community and neighborhood hospitals, teaching centers and larger competing clinics

• One wave after another of “gotcha” reimbursement oversight rules.

An axiom of practice management is that all stress leads to practice conflicts — even the subtle stressors. An underrecognized stressor that we’ve seen during our consulting work is the growth in the size of the average practice.

This is significant because a practice with just two providers has one-sixth the odds of a four-doctor practice to be conflict-ridden (two-doctor practices have just one dyadic pairing while a four-doctor practice has six possible pairings).

Knowing what can lead to stress can help you avoid it.

REVISE THAT COMP MODEL, PART I

Here are two examples of the change→stress→conflict cycle abstracted from our consulting work.

Dr. Senior and Dr. Junior have practiced together for eight years. They shared practice income 50-50, which worked fine so long as they each worked about the same hours each week, both at the same intensity. But, two years ago, Dr. Senior, now 63, thought it was time to slow down a bit. Without consulting Dr. Junior, he shifted to a four-day week. Because of his reduced work hours but unchanged pay, Dr. Senior made $400 per hour, while Dr. Junior made $300 per hour. After two years of withholding his honest feelings, Dr. Junior finally blew his top, and the partners got back on track by revising their comp model (it should be re-examined every year).

Unfortunately, it doesn’t always work out that well.

REVISE THAT COMP MODEL, PART II

In another example, Dr. Retina, a new partner, was perfectly happy making $250,000 per year as a young associate. But years later she is generating $2 million in annual net collections in a five-surgeon multi-subspecialty practice with a 65% overhead rate. She received 35% of her net collections, just like all of her peers, a pediatric ophthalmologist, two generalists and a glaucoma subspecialist. She had never been too happy subsidizing her partners in this way, and requested an outside review to no avail.

At an Academy meeting, she met with a colleague, a fellow retinologist, who was out on his own, taking home 55% of his personal collections. After the meeting, Dr. Retina returned home and said she would leave if she didn’t get at least 45% of her collections. Without doing the math, or checking for contemporary approaches to compensation, her partners didn’t make the compensation model fairer, and Dr. Retina left.

The four doctors left behind each have taken a $75,000 pay cut because their overhead is no longer subsidized by a high producer. Today, her ex-partners are back at the drawing board looking for a new retinal surgeon, who will command a $350,000 base salary and probably the same partner comp plan that should have been granted to Dr. Retina in the first place.

AVOID IT OR REVERSE IT

Here are eight things you can do to avoid doctor-to-doctor conflict and reverse it when it arises.

1. Objectify that which is subjective.

Conflict is hard to measure, which makes discussing it harder for objective, numbers-focused doctors to describe and discuss.

Similar to asking patients to score their pain on a 0 to 10 scale, you can ask doctors in conflict to score their perceived conflict with each other on a 0 to 10 scale. If two doctors agree that they are at a “7” today (a pretty high level of conflict), ask, “What would have to occur to make that score a 4, 5 or 6?”

2. Know your numbers.

Many conflicts arise when doctors argue with each other over things they don’t understand. The typical partner doesn’t take the time to study the practice’s financial statistics and benchmarks. (Become familiar with the vital signs of the practice in the same way that you deeply understand each patient’s visual acuity or IOP.)

Hold an annual teach-in for all partners and partner-track physicians to help them understand the underlying figures that can cause — and help to resolve — conflicts.

3. Know contemporary approaches to practice governance.

Even some of the largest and best-thought-of practices in the country apply legacy approaches to practice governance, leadership and operations that no longer work at their present scale or in the current environment. Common difficulties include:

• Too many board members

• A lack of orderly, focused board meetings with agenda and minutes

• Absence of a formal managing partner

4. Avoid “we’ve always done it that way” thinking.

Take a zero-based approach to practice management standards. Start with a clean slate: If we re-invented the practice today, what would be our compensation model? Policy regarding weeks off per year? Honorarium for our managing partner?

5. Meet more than you think is necessary.

Meetings at every level (board, managers, staff) are the bane of practice management. Like exercise, they are easy to put off or cut short. Boards should meet monthly, after hours (not jammed into lunchtime) and include a social component that often includes having a meal together. The managers, administrator and managing partner should meet at least every two weeks.

6. Cleave to your fiduciary responsibility.

Make decisions with the benefit of the whole practice in mind, not just what works best personally. If the practice flourishes, so will you.

7. If necessary, resolve a conflict point externally.

Marriage counselors, rabbis and parish priests help squabbling couples get back on track when they fail to do so alone. The same outside help is valuable in partner-to-partner squabbles. Use your attorney, accountant and various advisers to break ties or introduce new ways of thinking.

8. Avoid making your administrator the “Monkey in the Middle.”

A practice administrator can reasonably break some low-risk boardroom ties, like the color of new staff scrubs. But, larger items (and especially ties over compensation modeling, large capital outlays and the like) need to be punted to outsiders. Administrators who choose sides in big-ticket boardroom decisions win some doctor friends — but can make just as many career-ending enemies.

CONCLUSION

Ronald Reagan once said, “Peace is not absence of conflict, it is the ability to handle conflict by peaceful means.” Using the aforementioned tips, you can avoid and reverse change- and stress-driven conflicts. OM

	Corinne Z. Wohl, MHSA, COE, is president of C. Wohl & Associates, Inc., a practice management consulting firm. Corinne earned her Masters of Health Services Administration degree at The George Washington University and has 30 years of hospital and physician practice management experience. She can be reached at czwohl@gmail.com or 609-410-2932.
	John Pinto is president of J. Pinto & Associates, Inc., an ophthalmic practice management consulting firm established in 1979. He is the leading author in America on the business of ophthalmology. His latest book, “Simple: The Inner Game of Ophthalmic Practice Success,” is now available at www.asoa.org. He can be contacted at pintoinc@aol.com or 619-223-2233.