Physician management seminars. Part I: Building a better office team ANTHONY WHITTINGHAM
In ever-increasing numbers, physicians throughout the country are finding themselves squeezed between the zooming costs of operating a medical practice on the one hand and the painfully slow increases in benefits paid by provincial medicare plans on the other hand. They are searching anxiously for any avenue leading to higher productivity, greater efficiency and incomes that at least keep pace with the cost of living. Many physicians faced with this depressing situation find encouragement and help in the 3-day courses of MD Management Ltd. These courses have six half-day seminars. The first seminar deals with management concepts at a very basic level. Yet as the seminar unfolds, it's clear there is a whole host of useful nuggets and handy pointers offered up, primarily of the gee-whydidn't-I-think-of-that? variety, and, since the focus is on management rather than medicine, there's plenty there for a physician to learn. That was the impression conveyed among the 25-plus doctors and medical office managers who attended this half-day workshop in Toronto. Organized by Michael Landry, MD Management, and Gregory Korneluk, American Medical Association, the session was probably representative of the response it will receive throughout the country in coming weeks. Successful systems "Sure, a lot of it was pretty obvious - the kind of organizational information you more or less work out for yourself once you've set up
your practice," was the typical reaction expressed by one doctor. "But there were enough useful little pointers scattered here and there to make me feel the session was worth my while." There were one or two doctors present, however, upon whom the underlying concept of the seminar seemed to make a major impact.
The thrust? That doctors have to be successful (or at the very minimum competent) businessmen to practise medicine successfully. That means taking a good, hard look at how the doctor's practice is organized and how his time is spent, and, where necessary, applying a healthy dose of analytic management tech-
362 CMA JOURNAL/AUGUST 26, 1978/VOL. 119
niques to improve the organization of the practice. This is to make sure the doctor is always using his own time to perform the task he wants to do, is skilled to do and is paid to do: practise medicine. Other tasks that distract the doctor or use up potential hands-on time with patients should be delegated to staff members who are themselves more skilled and efficient at carrying out the various non-medical or paramedical tasks integral to the running of a medical practice. If such a person is not already on staff, the doctor should hire one. "Our aim," said conference cochairman Gregory Korneluk, "is to help doctors make a more productive and efficient medical practice. We're not talking just about dollars, but more about competence and capability. "In any operation, including a doctor's practice, every person should be working at his highest and best use and at his most efficient level." It didn't require much illustration to bring this point home. Assuming an hour's work by a clerk is worth $4, a secretary $5, a clinical assistant $6, a nurse $10 and a physician's hands-on time with a patient $50 it's fairly easy to see where the physician should be spending his time and where the other lines of job delineation should be drawn. "Face it," said Korneluk, "if you're a doctor spending a lot of time doing clerical work, you're not really enjoying practising medicine... Cochairman Michael Landry summed up this important point by stressing that a properly trained med-
ical office team (emphasizing team) under a doctor's supervision is almost certain to be more productive. Furthermore, it should provide a better quality of care in a shorter time than a disorganized medical practice in which . the physician is haphazardly helped by his or her staff. The right attitude should result in a better quality of care - as well as higher net earnings. 'Copter doctor As an example of the dramatic impact that efficiency and proper organization can have on the balance sheet, Korneluk cited the case of a doctor currently practising in rural Pennsylvania, who operates several regional offices with a large auxilliary staff, and travels between uffices by helicopter. By operating at this megalevel and by operating as a team, the "copter doc" and his colleagues are able to see a staggering 1000 patients per week and bring in a weekly gross of $200 000. Another set of statistics presented at the seminar served to illustrate a similar point on a more down-toearth level. According to one study, a typical Canadian physician operating as a solo practitioner using only one examining room and employing no auxiliary staff will process approximately 45 patient visits per week, bringing in gross annual earnings of about $46 000. The same MD using an efficient team approach with three full-time office aides and five examining rooms, is able to more than double his annual gross, bringing in more than $96 000. The key ingredient of the whole approach, according to Korneluk, lies in setting up an office regimen designed to ensure that the physician "saves.. time. A minute here and a minute there: they all add up. If a doctor improves his efficiency enough to see just one extra patient every hour, Korneluk said, he would increase his daily earnings by $40. Assuming 200 office days per year, that doctor would see his annual earnings jump by an impressive $8000. Korneluk was so excited by the whole concept that he actually got right down to breaking the day into seconds. He urged doctors in the seminar group to resort to every possible
means of shaving crucial seconds off their normal procedures. By using code numbers to designate a medical diagnosis on government health plan cards, for example, instead of writing out the diagnosis in words, he said a doctor could save up to 2 seconds per patient, which, multiplied by 30 patients per day, could mean savings of up to $200 per year just on the basis of that time-saver alone. This seemed to some of the doctors in the group a somewhat zealous application of theory-based timemotion principles to what many would like to believe is still an intensely human profession. But Landry insisted that while the actual seconds in this example should not, perhaps, be taken too literally, it still illustrates the general point that doctors should always aim to set up their practices with maximum efficiency built in from the very beginning. What is important is the overall approach, if not the specific details. Goodwill and goli It's the combination of little things that, added together, make the difference between an office operating at peak efficiency and one that just muddles along. Among the little things they recommended as helpful time-savers were the use of push-button phones, having a secretary dial a doctor's calls in advance, having a secretary or nurse do a doctor's preliminary reading and pr.cis-work and use of preprinted prescription pads. Time saved doesn't necessarily have to be rechannelled into other means of generating additional income, either. It could just as usefully be employed in spending a few extra minutes with each patient, thus helping to improve the doctor's bedside manner or patient goodwill. It could be used to give the doctor additional time for writing, research or non-remunerative outside professional activities. Or, for that matter, it could go into an extra nine holes of golf once a week or an extra half hour at home every day with the family, or anything else that contributes to maintaining sanity in a pressurized professional life. Once a doctor has realized the enormous efficiencies to be gained from setting up a competent office
team rather than trying to run the entire practice alone or understaffed - and Landry and Korneluk spent nearly half the seminar getting this important point across - the next steps fall neatly into place. From that point on, it becomes a simple matter of knowing how to hire, motivate, organize and fire your staff. Most doctors attending the seminar agreed that this was pretty basic stuff - elementary management techniques that apply to anyone operating a business in the real world, to a butcher or tailor or real estate agent just as much as to a doctor. Hiring and firing But it was also clear that most of the doctors appreciated being reminded that a good office organization doesn't just drop from heaven but requires a thoughtful, thorough approach by the doctor as well as continued and ongoing vigilance to make sure it keeps on working properly. Landry and Korneluk had a whole host of useful little tidbits and suggestions to offer in this area. A few examples: When hiring: * Consider two part-time employees rather than one full-time worker. * Always check previous job references - preferably by phone. * Interview the short-listed candidates personally - and remember, you learn more by listening than by talking. * Prepare a thorough job description for each position and make sure the candidate knows exactly what he or she is expected to do. To keep the office running smoothly: * Set up a regular performance review procedure, meeting with employees privately and individually to discuss progress and job satisfaction. * Arrange regular office meetings to monitor daily activity as well as boosting office morale by stressing the "team" approach. * Create a good incentive mentality to keep employees on staff and working efficiently - by monetary bonuses or professional praise. "Always keep in mind," said Landry, "that staff are not merely a
CMA JOURNAL/AUGUST 26, 1978/VOL. 119 363
trifling operating expense. They are a depreciating asset and should be treated as a valuable resource.., "At the same time however," added Korneluk, "you must remember that you're operating a medical practice - not an annuity plan. You must demand good work from your employees, and if you don't get it, you'll have to take steps to get rid of them, no matter how much sentiment may be involved." This point - seemingly so obvious - evoked a particularly strong response from a surprising number of doctors and office managers at the seminar. They recounted personal experiences in which an entire doc-
tor's practice had become badly bogged down for prolonged periods because the doctor just didn't "have the heart" to sack a staff member whose work habits or personality were clearly damaging the practice. Overall, the seminar provided a useful opportunity for participants to hone down their thoughts about the nuts, bolts and technicalities involved in running what is, by anybody's standards, a "small business The informal structure of the seminar - a manageable number of people seated intimately in horseshoe shape, combined with the lively tworing circus provided by Landry and Korneluk - encouraged questions
and open discussion throughout the 4-hour session. While one or two doctors felt the session could have been compressed into a shorter period, the consensus seemed to be that the existing format was good in so far as it allowed plenty of time for questions and helpful personal anecdotes. "We know a lot of the course may be repetitive or overly simplistic for most experienced doctors," Landry commented. "But if we get across just one or two new ideas to each person - which he or she can then go back and use to good effect in the practice - then we feel the time has been worthwhile."
Part II: Reassessing and streamlining your practice Imagine yourself faced with the de- rangements within a joint practice. This session continued in a vein cision whether to set up a partnership with two other doctors - and, similar to the morning session (which what's more, to become involved in looked at how to build a better medthe financing and construction of a ical office team) but concentrated building to house your new joint more on the physical and organizational structure of the office and the practice. The other two doctors are each medical practice rather than on the very different from yoi. and from problems of task delegation and staff one another - not only tempera- management. In this way, "reassessing and mentally, but in personal and professional goals. In fact, the only streamlining your practice" fell into thing you appear to have in common two distinct halves. The first - and is that you are all physicians prac- by far the more interesting - dealt with matters relating to the organizatising medicine in the same town. Would forming a partnership tion of a medical practice involving under these circumstances be a good two or more doctors, including partidea? Could it be made to work, or nership agreements, income and exwould it be doomed to failure? What pense sharing and distribution forlegal, financial and organizational mulae, and division of responsibilproblems would such a partnership ities within the practice. The second half concentrated on raise, and how could they be resolved? What practices would you, the somewhat more pedestrian as one of the doctors, insist on in- though also obviously important corporating within the partnership so aspects of operating a practice, inyour values, goals and customary cluding the pros and cons of owning modus operandi would not be com- or renting a medical office, the ins promised or sacrificed to an insup- and outs of leasing or buying office equipment and the best methods of portable degree? This knotty little problem formed securing against burglary. the basis for the CMA's second halfday business seminar. This session Partnership models provided a 4-hour look into the variConsider the three doctors thinkous considerations all doctors should take into account if they're interested ing about forming a partnership and in streamlining their medical practice building a medical arts building. This to get the best use of the building little model - similar to the case they're in and the best mutual ar- study approach popular at business 364 CMA JOURNAL/AUGUST 26, 1978/VOL. 119
schools - was devised by MD Management to illustrate the many considerations that go into a partnership or cost-sharing agreement. Each of the three imaginary doctors in the case is at a different point in his career, each has a slightly different philosophy about the practice of medicine and each has different financial and personal goals. Dr. Saunders, at 52, is a stalwart of the town, a doctor with a solid reputation and a well-established family practice, who entertains vague political aspirations. He has access to the necessary capital and is the moving force in the proposal to build a small medical arts building and set up the medical partnership. Dr. Brown, a 38-year-old go-getter, operates a high-volume family practice with two office assistants, enabling him to process enough patients to maintain a relatively large income. His philosophy is "get them in and get them out", and he doesn't relish losing any of his independence. Dr. Lowell, a recent medical graduate working as a locum in Dr. Saunder's practice, sees himself as a patient educator in preventive medicine, and as such is more concerned with the community than individual patients. He has no real roots established in the town. Each of these imaginary doctors is a stereotyped blending of qualities with which any doctor, anywhere,
could identify to one degree or another. So when workshop leader Landry asked the seminar participants to divide into three camps, each representing one of the three doctors, it gave a specially personal touch to the real point of the exercise - which was to analyse the problems the doctors would have to confront as they hammered out the pluses and minuses of entering into a partnership together. Each group was given about half an hour in order to accomplish two primary objectives: to crystallize the position its doctor would adopt, theoretically, in a discussion with the other two, and to identify the five primary issues on which agreement would have to be reached if the proposed partnership agreement went ahead. What was particularly interesting about this participatory approach was that most of the doctors taking part in the seminar had, in fact, undergone such a process themselves, and thus had their own ideas about the kind of problems that would arise and how they could best be dealt with. Ownership and expenses Though the basic issues identified by each of the three groups were largely the same, the individual approach to these problems in some cases differed sharply. The basic issues: * Ownership and equity participation in the building and the practice amongst the three doctors, including provisions for buying in and selling out in the future. * Expense-sharing. * Remuneration - shared or separate? * Division of responsibility, hours, coverage during sickness and other contingencies. * Management of the office and resolution of potential disputes or disagreements over the short- and long-term running of the practice. Each of these issues, as Landry explained, gives rise to several possible arrangements and no one scheme necessarily provides the single right answer. A look at medical practices across the country, for example, would show a wide range of permutations and combinations of different agreements.
As one example, Landry cited four possible real-life approaches to the question of how three doctors, each generating different gross fees, can deal with the question of dividing expenses and distributing income within a partnership. First, each doctor retains his own share of total earnings and all expenses are divided equally - which of course places the greatest strain, proportionately, on the doctor with the lowest billings. Second, each doctor also retains his own total billings, but expenses are divided into two halves - fixed and variable. Each doctor pays his one-third share of the fixed expenses, while the other half is prorated in proportion to each doctor's gross billings. This places a slightly heavier burden on the doctor with the highest billings. Third, all expenses are divided in proportion to gross billings and subtracted directly from each doctor's gross fees. This means the doctors with higher billings are shouldering a disproportionate share of the expense burden to the benefit of the low-billing doctors. Fourth, all income and expenses are thrown together into the ring, blended together and paid back out to each doctor in equal amounts regardless of original differences in gross billings. That's what you might call a true partnership. The point Landry made is that, even in the case of an arrangement as basic as income and expense sharing, there's no single right answer. Each group of doctors in partnership may, for their own reasons, find one approach most suited to their particular needs, but none can be shown conclusively to be better than the others. Get it in writing
formal request by one of the partners. In addition, make sure there's a formal procedure for settling disputes, such as majority vote or arbitration. "Remember," he said, "partnerships are entered into when everyone involved is in high spirits and there doesn't appear to be a problem in sight. Just wait and see what happens to a 'gentleman's agreement' once difficulties start to arise and the goodwill vanishes." This isn't mere cynicism or pessimism either. Partnerships among physicians fall apart with amazing frequency. Cochairman Korneluk estimated the current "divorce-rate" within medical partnerships throughout North America is about 60% - a statistic that shows it is just plain common sense to tie down the agreement carefully at the beginning to minimize any problems that arise later. Whatever the nature of the doctor's practice - either in one form of partnership or another, or in solo practice - he still needs an office or a building in which to carry out his work. And so the second half of this seminar touched on some of the practical considerations relating to the straight economics of where to locate, what to buy and how to keep the building or the office burglar-proof. Grandiose schemes
For doctors considering buying (or building) their own medical arts building, there are two simple points to consider: * Will the building he buys give the doctor more satisfactory space than he can rent? * Will it represent a profitable investment (taking into account longterm real estate values, potential rent income and long-term return on investment)? In the case of doctors determined to build their own medical centre from scratch, Landry emphasized that the building should be located in a commercially zoned area (so it could be sold or diversified at a later date), if anything, it should be built toothat, big rather than too small
He did, however, recommend two important points for those planning to set up a partnership. First, make sure all aspects of the agreement - whatever its particular wrinkles may be - are spelled out, in writing, to the most minute degree. And second, make sure that the agreement sets out a clear and formal procedure for reviewing the terms of - and above all, that it should be the partnership, either on fixed dates, continued on page 382 such as every 2 or 3 years, or upon CMA JOURNAL/AUGUST 26, 1978/VOL. 119 365
credited by the Liaison Committee on Medical Education (LCME), regardless of whether the school is located in the United States. All Canadian medical schools are accredited by the LCME. Note that the Federation Licensing Examination (FLEX) and the ECFMG examination are not currently considered by the secretary of HEW to be equivalent to Parts I and II of the National Board of Medical Examiners examination. The visa qualifying examination of the national board (3930 Chestnut St., Philadelphia, PA 19104) is the only examination deemed equivalent. Foreign physicians must make a commitment to return to the country of their nationality or their last residence upon completion of the education or training for which they are going to the United States, and the government of that country must provide written assurance that there is a need in that country for persons with the skills the physician will acquire in the United States. In Canada this documentation will be provided by the health services directorate, Department of National Health and Welfare. The duration of the foreign physician's participation in the program for which he or she is going to the United States will be limited, in the first instance, to 2 years, but may be extended for 1 more year at the written request of the government of
the individual's nationality or last residence, if the school providing or arranging the program agrees in writing to such an extension. It will not be possible to add a 4th or 5th year of training immediately. Physicians will have to return to Canada for at least 2 years. Physicians contemplating taking postgraduate training in the United States under exchange-visitor programs are advised to contact the director general, health services directorate, Department of National Health and Welfare, Ottawa, Ont., KiA 1B4, as soon as they begin to make applications. The process will take less time if, when contacting the department, applicants provide their full names, permanent and mailing addresses, countries of which they are citizens, schools from which they graduated in medicine, ECFMG number if known, specialty in which postgraduate training is planned, date of commencement of program, intended duration of training in USA, name and address of program director in USA and address of US consulate at which visa application will he made. Applicants must also sign and date the following declaration: I hereby state that I intend to return to Canada on completion of my training in the US and that I intend to enter the practice of medicine in the specialty for which I have received training. U
Librax (chlordiazepoxide HCI clidinium bromide 'Roche') Rx Summary Indications Adjunctive management of irritable bowel syndrome, peptic ulcer and other gastrointestinal disorders associated with hypersecretion, hypermotility and spasm and accompanied by anxiety or tension states. Contralndlcatlons Hypersensitivity to chlordiazepoxide and/ or clidinium bromide. Glaucoma, prostatic hypertrophy and benign bladder neck obstruction. PrecautIons In elderly or debilitated patients limit the initial dose to the smallest effective to preclude the development of oversedation or ataxia. Use with caution in severely depressed patients and in those who may increase the dosage on their own accord. Advise patients against concomitant ingestion with alcohol or other ONS depressants and caution against engaging in activities requiring complete mental alertness or physical coordination. Use only in women who are or who may become pregnant when benefits have been weighed against possible hazards to mother and fetus. Use with caution in patients with impaired renal or hepatic function; periodic blood counts and liver and renal function tests may be advisable during prolonged therapy. Adverse Effects As for chlordiazepoxide.
SEMINARS continued from page 365
built with efficiency foremost in mind. "If you want to build a unique building, it'll be fine for the architect and he'll win a prize," added Korneluk, "but you may end up paying for it for the rest of your life" perhaps a fair reflection on a number of doctors whose own grandiose schemes may have got the better of them. As for office equipment - and whether a doctor's office should buy or lease - Landry and Korneluk agreed that the matter really boils down to a judgement call. They came out strongly in favour of using (and thus buying, as they're not expen-
sive), cassette dictating machines for a wide range of office tasks. But as for copying machines, they said, it really depends on how much use the machine gets; whereas a solo practitioner is probably better to lease, a larger practice including three or more practitioners might find it more economical in the long run to buy. On burglary, the chairmen had two main points: * Change the locks any time a key disappears, or when a former employee with previous access to a key leaves the office, particularly if he or she has been fired. * Investigate some of the newer "keyless" security technologies, such as magnetic card entry systems or push-button combination locks.E
382 CMA JOURNAL/AUGUST 26, 1978/VOL. 119
In addition, clidinium bromide may cause dryness of the mouth, blurred vision, urinary hesitancy; constipation particularly when combined with other spasmolytics and/or low residue diet. Dosage Adults-ito 2 capsules 3 or 4 times daily, before meals and at bedtime. Supply Each capsule contains chlordiazepoxide HOl -5 mg, and clidinium bromide 2.5 mg; green opaque body and cap with ROGHE and LI (black ink) alternating betweenBRAX body and cap. Bottles of 100 and 500. Complete prescribing information available on request. ROCHE Vaudreuil, Hoffmann-La RocheJ7V Limited Quebec 6B3
In ever-increasing numbers, physicians throughout the country are finding themselves squeezed between the zooming costs of operating a medical practice on the one hand and the painfully slow increases in benefits paid by provincial medicare plans on the other hand. They are searching anxiously for any avenue leading to higher productivity, greater efficiency and incomes that at least keep pace with the cost of living. Many physicians faced with this depressing situation find encouragement and help in the 3-day courses of MD Management Ltd. These courses have six half-day seminars. The first seminar deals with management concepts at a very basic level. Yet as the seminar unfolds, it's clear there is a whole host of useful nuggets and handy pointers offered up, primarily of the gee-whydidn't-I-think-of-that? variety, and, since the focus is on management rather than medicine, there's plenty there for a physician to learn. That was the impression conveyed among the 25-plus doctors and medical office managers who attended this half-day workshop in Toronto. Organized by Michael Landry, MD Management, and Gregory Korneluk, American Medical Association, the session was probably representative of the response it will receive throughout the country in coming weeks. Successful systems "Sure, a lot of it was pretty obvious - the kind of organizational information you more or less work out for yourself once you've set up
your practice," was the typical reaction expressed by one doctor. "But there were enough useful little pointers scattered here and there to make me feel the session was worth my while." There were one or two doctors present, however, upon whom the underlying concept of the seminar seemed to make a major impact.
The thrust? That doctors have to be successful (or at the very minimum competent) businessmen to practise medicine successfully. That means taking a good, hard look at how the doctor's practice is organized and how his time is spent, and, where necessary, applying a healthy dose of analytic management tech-
362 CMA JOURNAL/AUGUST 26, 1978/VOL. 119
niques to improve the organization of the practice. This is to make sure the doctor is always using his own time to perform the task he wants to do, is skilled to do and is paid to do: practise medicine. Other tasks that distract the doctor or use up potential hands-on time with patients should be delegated to staff members who are themselves more skilled and efficient at carrying out the various non-medical or paramedical tasks integral to the running of a medical practice. If such a person is not already on staff, the doctor should hire one. "Our aim," said conference cochairman Gregory Korneluk, "is to help doctors make a more productive and efficient medical practice. We're not talking just about dollars, but more about competence and capability. "In any operation, including a doctor's practice, every person should be working at his highest and best use and at his most efficient level." It didn't require much illustration to bring this point home. Assuming an hour's work by a clerk is worth $4, a secretary $5, a clinical assistant $6, a nurse $10 and a physician's hands-on time with a patient $50 it's fairly easy to see where the physician should be spending his time and where the other lines of job delineation should be drawn. "Face it," said Korneluk, "if you're a doctor spending a lot of time doing clerical work, you're not really enjoying practising medicine... Cochairman Michael Landry summed up this important point by stressing that a properly trained med-
ical office team (emphasizing team) under a doctor's supervision is almost certain to be more productive. Furthermore, it should provide a better quality of care in a shorter time than a disorganized medical practice in which . the physician is haphazardly helped by his or her staff. The right attitude should result in a better quality of care - as well as higher net earnings. 'Copter doctor As an example of the dramatic impact that efficiency and proper organization can have on the balance sheet, Korneluk cited the case of a doctor currently practising in rural Pennsylvania, who operates several regional offices with a large auxilliary staff, and travels between uffices by helicopter. By operating at this megalevel and by operating as a team, the "copter doc" and his colleagues are able to see a staggering 1000 patients per week and bring in a weekly gross of $200 000. Another set of statistics presented at the seminar served to illustrate a similar point on a more down-toearth level. According to one study, a typical Canadian physician operating as a solo practitioner using only one examining room and employing no auxiliary staff will process approximately 45 patient visits per week, bringing in gross annual earnings of about $46 000. The same MD using an efficient team approach with three full-time office aides and five examining rooms, is able to more than double his annual gross, bringing in more than $96 000. The key ingredient of the whole approach, according to Korneluk, lies in setting up an office regimen designed to ensure that the physician "saves.. time. A minute here and a minute there: they all add up. If a doctor improves his efficiency enough to see just one extra patient every hour, Korneluk said, he would increase his daily earnings by $40. Assuming 200 office days per year, that doctor would see his annual earnings jump by an impressive $8000. Korneluk was so excited by the whole concept that he actually got right down to breaking the day into seconds. He urged doctors in the seminar group to resort to every possible
means of shaving crucial seconds off their normal procedures. By using code numbers to designate a medical diagnosis on government health plan cards, for example, instead of writing out the diagnosis in words, he said a doctor could save up to 2 seconds per patient, which, multiplied by 30 patients per day, could mean savings of up to $200 per year just on the basis of that time-saver alone. This seemed to some of the doctors in the group a somewhat zealous application of theory-based timemotion principles to what many would like to believe is still an intensely human profession. But Landry insisted that while the actual seconds in this example should not, perhaps, be taken too literally, it still illustrates the general point that doctors should always aim to set up their practices with maximum efficiency built in from the very beginning. What is important is the overall approach, if not the specific details. Goodwill and goli It's the combination of little things that, added together, make the difference between an office operating at peak efficiency and one that just muddles along. Among the little things they recommended as helpful time-savers were the use of push-button phones, having a secretary dial a doctor's calls in advance, having a secretary or nurse do a doctor's preliminary reading and pr.cis-work and use of preprinted prescription pads. Time saved doesn't necessarily have to be rechannelled into other means of generating additional income, either. It could just as usefully be employed in spending a few extra minutes with each patient, thus helping to improve the doctor's bedside manner or patient goodwill. It could be used to give the doctor additional time for writing, research or non-remunerative outside professional activities. Or, for that matter, it could go into an extra nine holes of golf once a week or an extra half hour at home every day with the family, or anything else that contributes to maintaining sanity in a pressurized professional life. Once a doctor has realized the enormous efficiencies to be gained from setting up a competent office
team rather than trying to run the entire practice alone or understaffed - and Landry and Korneluk spent nearly half the seminar getting this important point across - the next steps fall neatly into place. From that point on, it becomes a simple matter of knowing how to hire, motivate, organize and fire your staff. Most doctors attending the seminar agreed that this was pretty basic stuff - elementary management techniques that apply to anyone operating a business in the real world, to a butcher or tailor or real estate agent just as much as to a doctor. Hiring and firing But it was also clear that most of the doctors appreciated being reminded that a good office organization doesn't just drop from heaven but requires a thoughtful, thorough approach by the doctor as well as continued and ongoing vigilance to make sure it keeps on working properly. Landry and Korneluk had a whole host of useful little tidbits and suggestions to offer in this area. A few examples: When hiring: * Consider two part-time employees rather than one full-time worker. * Always check previous job references - preferably by phone. * Interview the short-listed candidates personally - and remember, you learn more by listening than by talking. * Prepare a thorough job description for each position and make sure the candidate knows exactly what he or she is expected to do. To keep the office running smoothly: * Set up a regular performance review procedure, meeting with employees privately and individually to discuss progress and job satisfaction. * Arrange regular office meetings to monitor daily activity as well as boosting office morale by stressing the "team" approach. * Create a good incentive mentality to keep employees on staff and working efficiently - by monetary bonuses or professional praise. "Always keep in mind," said Landry, "that staff are not merely a
CMA JOURNAL/AUGUST 26, 1978/VOL. 119 363
trifling operating expense. They are a depreciating asset and should be treated as a valuable resource.., "At the same time however," added Korneluk, "you must remember that you're operating a medical practice - not an annuity plan. You must demand good work from your employees, and if you don't get it, you'll have to take steps to get rid of them, no matter how much sentiment may be involved." This point - seemingly so obvious - evoked a particularly strong response from a surprising number of doctors and office managers at the seminar. They recounted personal experiences in which an entire doc-
tor's practice had become badly bogged down for prolonged periods because the doctor just didn't "have the heart" to sack a staff member whose work habits or personality were clearly damaging the practice. Overall, the seminar provided a useful opportunity for participants to hone down their thoughts about the nuts, bolts and technicalities involved in running what is, by anybody's standards, a "small business The informal structure of the seminar - a manageable number of people seated intimately in horseshoe shape, combined with the lively tworing circus provided by Landry and Korneluk - encouraged questions
and open discussion throughout the 4-hour session. While one or two doctors felt the session could have been compressed into a shorter period, the consensus seemed to be that the existing format was good in so far as it allowed plenty of time for questions and helpful personal anecdotes. "We know a lot of the course may be repetitive or overly simplistic for most experienced doctors," Landry commented. "But if we get across just one or two new ideas to each person - which he or she can then go back and use to good effect in the practice - then we feel the time has been worthwhile."
Part II: Reassessing and streamlining your practice Imagine yourself faced with the de- rangements within a joint practice. This session continued in a vein cision whether to set up a partnership with two other doctors - and, similar to the morning session (which what's more, to become involved in looked at how to build a better medthe financing and construction of a ical office team) but concentrated building to house your new joint more on the physical and organizational structure of the office and the practice. The other two doctors are each medical practice rather than on the very different from yoi. and from problems of task delegation and staff one another - not only tempera- management. In this way, "reassessing and mentally, but in personal and professional goals. In fact, the only streamlining your practice" fell into thing you appear to have in common two distinct halves. The first - and is that you are all physicians prac- by far the more interesting - dealt with matters relating to the organizatising medicine in the same town. Would forming a partnership tion of a medical practice involving under these circumstances be a good two or more doctors, including partidea? Could it be made to work, or nership agreements, income and exwould it be doomed to failure? What pense sharing and distribution forlegal, financial and organizational mulae, and division of responsibilproblems would such a partnership ities within the practice. The second half concentrated on raise, and how could they be resolved? What practices would you, the somewhat more pedestrian as one of the doctors, insist on in- though also obviously important corporating within the partnership so aspects of operating a practice, inyour values, goals and customary cluding the pros and cons of owning modus operandi would not be com- or renting a medical office, the ins promised or sacrificed to an insup- and outs of leasing or buying office equipment and the best methods of portable degree? This knotty little problem formed securing against burglary. the basis for the CMA's second halfday business seminar. This session Partnership models provided a 4-hour look into the variConsider the three doctors thinkous considerations all doctors should take into account if they're interested ing about forming a partnership and in streamlining their medical practice building a medical arts building. This to get the best use of the building little model - similar to the case they're in and the best mutual ar- study approach popular at business 364 CMA JOURNAL/AUGUST 26, 1978/VOL. 119
schools - was devised by MD Management to illustrate the many considerations that go into a partnership or cost-sharing agreement. Each of the three imaginary doctors in the case is at a different point in his career, each has a slightly different philosophy about the practice of medicine and each has different financial and personal goals. Dr. Saunders, at 52, is a stalwart of the town, a doctor with a solid reputation and a well-established family practice, who entertains vague political aspirations. He has access to the necessary capital and is the moving force in the proposal to build a small medical arts building and set up the medical partnership. Dr. Brown, a 38-year-old go-getter, operates a high-volume family practice with two office assistants, enabling him to process enough patients to maintain a relatively large income. His philosophy is "get them in and get them out", and he doesn't relish losing any of his independence. Dr. Lowell, a recent medical graduate working as a locum in Dr. Saunder's practice, sees himself as a patient educator in preventive medicine, and as such is more concerned with the community than individual patients. He has no real roots established in the town. Each of these imaginary doctors is a stereotyped blending of qualities with which any doctor, anywhere,
could identify to one degree or another. So when workshop leader Landry asked the seminar participants to divide into three camps, each representing one of the three doctors, it gave a specially personal touch to the real point of the exercise - which was to analyse the problems the doctors would have to confront as they hammered out the pluses and minuses of entering into a partnership together. Each group was given about half an hour in order to accomplish two primary objectives: to crystallize the position its doctor would adopt, theoretically, in a discussion with the other two, and to identify the five primary issues on which agreement would have to be reached if the proposed partnership agreement went ahead. What was particularly interesting about this participatory approach was that most of the doctors taking part in the seminar had, in fact, undergone such a process themselves, and thus had their own ideas about the kind of problems that would arise and how they could best be dealt with. Ownership and expenses Though the basic issues identified by each of the three groups were largely the same, the individual approach to these problems in some cases differed sharply. The basic issues: * Ownership and equity participation in the building and the practice amongst the three doctors, including provisions for buying in and selling out in the future. * Expense-sharing. * Remuneration - shared or separate? * Division of responsibility, hours, coverage during sickness and other contingencies. * Management of the office and resolution of potential disputes or disagreements over the short- and long-term running of the practice. Each of these issues, as Landry explained, gives rise to several possible arrangements and no one scheme necessarily provides the single right answer. A look at medical practices across the country, for example, would show a wide range of permutations and combinations of different agreements.
As one example, Landry cited four possible real-life approaches to the question of how three doctors, each generating different gross fees, can deal with the question of dividing expenses and distributing income within a partnership. First, each doctor retains his own share of total earnings and all expenses are divided equally - which of course places the greatest strain, proportionately, on the doctor with the lowest billings. Second, each doctor also retains his own total billings, but expenses are divided into two halves - fixed and variable. Each doctor pays his one-third share of the fixed expenses, while the other half is prorated in proportion to each doctor's gross billings. This places a slightly heavier burden on the doctor with the highest billings. Third, all expenses are divided in proportion to gross billings and subtracted directly from each doctor's gross fees. This means the doctors with higher billings are shouldering a disproportionate share of the expense burden to the benefit of the low-billing doctors. Fourth, all income and expenses are thrown together into the ring, blended together and paid back out to each doctor in equal amounts regardless of original differences in gross billings. That's what you might call a true partnership. The point Landry made is that, even in the case of an arrangement as basic as income and expense sharing, there's no single right answer. Each group of doctors in partnership may, for their own reasons, find one approach most suited to their particular needs, but none can be shown conclusively to be better than the others. Get it in writing
formal request by one of the partners. In addition, make sure there's a formal procedure for settling disputes, such as majority vote or arbitration. "Remember," he said, "partnerships are entered into when everyone involved is in high spirits and there doesn't appear to be a problem in sight. Just wait and see what happens to a 'gentleman's agreement' once difficulties start to arise and the goodwill vanishes." This isn't mere cynicism or pessimism either. Partnerships among physicians fall apart with amazing frequency. Cochairman Korneluk estimated the current "divorce-rate" within medical partnerships throughout North America is about 60% - a statistic that shows it is just plain common sense to tie down the agreement carefully at the beginning to minimize any problems that arise later. Whatever the nature of the doctor's practice - either in one form of partnership or another, or in solo practice - he still needs an office or a building in which to carry out his work. And so the second half of this seminar touched on some of the practical considerations relating to the straight economics of where to locate, what to buy and how to keep the building or the office burglar-proof. Grandiose schemes
For doctors considering buying (or building) their own medical arts building, there are two simple points to consider: * Will the building he buys give the doctor more satisfactory space than he can rent? * Will it represent a profitable investment (taking into account longterm real estate values, potential rent income and long-term return on investment)? In the case of doctors determined to build their own medical centre from scratch, Landry emphasized that the building should be located in a commercially zoned area (so it could be sold or diversified at a later date), if anything, it should be built toothat, big rather than too small
He did, however, recommend two important points for those planning to set up a partnership. First, make sure all aspects of the agreement - whatever its particular wrinkles may be - are spelled out, in writing, to the most minute degree. And second, make sure that the agreement sets out a clear and formal procedure for reviewing the terms of - and above all, that it should be the partnership, either on fixed dates, continued on page 382 such as every 2 or 3 years, or upon CMA JOURNAL/AUGUST 26, 1978/VOL. 119 365
credited by the Liaison Committee on Medical Education (LCME), regardless of whether the school is located in the United States. All Canadian medical schools are accredited by the LCME. Note that the Federation Licensing Examination (FLEX) and the ECFMG examination are not currently considered by the secretary of HEW to be equivalent to Parts I and II of the National Board of Medical Examiners examination. The visa qualifying examination of the national board (3930 Chestnut St., Philadelphia, PA 19104) is the only examination deemed equivalent. Foreign physicians must make a commitment to return to the country of their nationality or their last residence upon completion of the education or training for which they are going to the United States, and the government of that country must provide written assurance that there is a need in that country for persons with the skills the physician will acquire in the United States. In Canada this documentation will be provided by the health services directorate, Department of National Health and Welfare. The duration of the foreign physician's participation in the program for which he or she is going to the United States will be limited, in the first instance, to 2 years, but may be extended for 1 more year at the written request of the government of
the individual's nationality or last residence, if the school providing or arranging the program agrees in writing to such an extension. It will not be possible to add a 4th or 5th year of training immediately. Physicians will have to return to Canada for at least 2 years. Physicians contemplating taking postgraduate training in the United States under exchange-visitor programs are advised to contact the director general, health services directorate, Department of National Health and Welfare, Ottawa, Ont., KiA 1B4, as soon as they begin to make applications. The process will take less time if, when contacting the department, applicants provide their full names, permanent and mailing addresses, countries of which they are citizens, schools from which they graduated in medicine, ECFMG number if known, specialty in which postgraduate training is planned, date of commencement of program, intended duration of training in USA, name and address of program director in USA and address of US consulate at which visa application will he made. Applicants must also sign and date the following declaration: I hereby state that I intend to return to Canada on completion of my training in the US and that I intend to enter the practice of medicine in the specialty for which I have received training. U
Librax (chlordiazepoxide HCI clidinium bromide 'Roche') Rx Summary Indications Adjunctive management of irritable bowel syndrome, peptic ulcer and other gastrointestinal disorders associated with hypersecretion, hypermotility and spasm and accompanied by anxiety or tension states. Contralndlcatlons Hypersensitivity to chlordiazepoxide and/ or clidinium bromide. Glaucoma, prostatic hypertrophy and benign bladder neck obstruction. PrecautIons In elderly or debilitated patients limit the initial dose to the smallest effective to preclude the development of oversedation or ataxia. Use with caution in severely depressed patients and in those who may increase the dosage on their own accord. Advise patients against concomitant ingestion with alcohol or other ONS depressants and caution against engaging in activities requiring complete mental alertness or physical coordination. Use only in women who are or who may become pregnant when benefits have been weighed against possible hazards to mother and fetus. Use with caution in patients with impaired renal or hepatic function; periodic blood counts and liver and renal function tests may be advisable during prolonged therapy. Adverse Effects As for chlordiazepoxide.
SEMINARS continued from page 365
built with efficiency foremost in mind. "If you want to build a unique building, it'll be fine for the architect and he'll win a prize," added Korneluk, "but you may end up paying for it for the rest of your life" perhaps a fair reflection on a number of doctors whose own grandiose schemes may have got the better of them. As for office equipment - and whether a doctor's office should buy or lease - Landry and Korneluk agreed that the matter really boils down to a judgement call. They came out strongly in favour of using (and thus buying, as they're not expen-
sive), cassette dictating machines for a wide range of office tasks. But as for copying machines, they said, it really depends on how much use the machine gets; whereas a solo practitioner is probably better to lease, a larger practice including three or more practitioners might find it more economical in the long run to buy. On burglary, the chairmen had two main points: * Change the locks any time a key disappears, or when a former employee with previous access to a key leaves the office, particularly if he or she has been fired. * Investigate some of the newer "keyless" security technologies, such as magnetic card entry systems or push-button combination locks.E
382 CMA JOURNAL/AUGUST 26, 1978/VOL. 119
In addition, clidinium bromide may cause dryness of the mouth, blurred vision, urinary hesitancy; constipation particularly when combined with other spasmolytics and/or low residue diet. Dosage Adults-ito 2 capsules 3 or 4 times daily, before meals and at bedtime. Supply Each capsule contains chlordiazepoxide HOl -5 mg, and clidinium bromide 2.5 mg; green opaque body and cap with ROGHE and LI (black ink) alternating betweenBRAX body and cap. Bottles of 100 and 500. Complete prescribing information available on request. ROCHE Vaudreuil, Hoffmann-La RocheJ7V Limited Quebec 6B3
