Starting a practice

Starting or building a practice requires that physicians let practical concerns flow from more philosophical decisions, such as why one entered dermatology in the first place, said experts at the Cosmetic Surgery Forum (Las Vegas, 2014).

Sabrina Guillen Fabi, M.D.Getting started

Sabrina Guillen Fabi, M.D., said that the key in starting her practice was knowing "why" she was doing so. In this regard, she emphasized, making money should never be the end goal, as it is not typically sustainable for lasting joy and professional fulfillment. Rather, "money will always be the result if things are done for the right reason." She is a double board-certified dermatologist and dermatologic cosmetic surgeon based in San Diego, Calif.

In any business, said Dr. Fabi, people don't buy what you do – they buy why you do it. For her, "Having a clear why has allowed me to make better decisions along my path. I believe in helping patients look and feel their best at any age. When you start your practice, I encourage you to have a very clear mission statement, because it will guide you in making decisions such as whether you want to teach, do research, work part-time, enter private practice," or combine various possibilities.

READ: Looking at your practice through the eyes of patients

Michael Greenberg, M.D., said that one of his best decisions was refusing to close his practice and assume the busier practice of a retiring colleague, although doing so looked like a no-brainer. Asked why, he said, "Because after 35 years, I'm in love with my patients, and they're in love with me. That's what it's about. It sounds corny, but it's my job as a doctor to make my patients part of my life and family. And all the other stuff will follow." Dr. Greenberg is an Elk Grove Village, Illinois-based dermatologist in private practice.

NEXT: Designing and customizing a larger space

Gerald M. Goldberg, M.D., began his medical career as a pediatrician. He is now clinical professor of dermatology at the University of Arizona. After training in dermatology, "I was an associate originally in a two-person practice for 18 years. My senior partner retired, and I now have two physician assistants, four aesthetic providers, a dermatology associate and a Mohs surgeon who works with us. So we've expanded into a 10,000-square-foot space. We currently utilize 7,500 square feet and will soon expand into the additional 2,500."

READ: Narrowing networks create harrowing choices

Designing and customizing a larger space was one of the best decisions he's made, said Dr. Goldberg, "rather than being confined to a small space where the space dictated how one practices. It involves some risk to move forward, but I knew I needed to be larger rather than smaller if I wanted the economy of scale to be able to afford the latest in laser technologies and keep up in this field."

To establish himself and his practice, said Dr. Goldberg, "I found it useful to create a niche – it's so hard to do everything well." Specializing in lasers has allowed his practice to create a premium brand. Other decisions that have boosted his career include emphasizing private practice over academia, but still maintaining his relationship with the university and teaching, as well as purchasing his own real estate. This has allowed him to have the freedoms of being his own boss and fashioning an ideal blend of patient care, procedural dermatology, and teaching students and residents for more than 30 years, he stated.

NEXT: Avoding missteps

Avoiding missteps

Conversely, Dr. Goldberg said his worst decisions have included initially hiring an associate who didn't share his vision. A few years later, he added, he regretted not hiring a potentially terrific associate when the opportunity arose.

Dr. Goldberg also admitted he has held onto problem employees longer than he should have, and in other instances has micromanaged. Nowadays, "I'm letting people rise to the level of their capabilities. It's important to empower the people around you to make them feel as valued as they are. They're allowing us to practice the way we want to practice."

To that end, Dr. Greenberg advised avoiding headaches – any event that elicits a strong emotional response. Examples range from angry patients to needless paperwork. In one such instance, he refused to fill out an eight-page form simply to validate a patient's visit for his employer.

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Whatever the problem, said Dr. Greenberg, "It's always about people – and, more importantly, communication. Either you didn't say it right, or they didn't hear it right."

To resolve such situations, he quoted professional speaker and retired dermatologist Steven K. Shama, M.D., M.P.H. – "Be care-full." Patients who create problems are scared, said Dr. Greenberg. Rather than escalating the situation, he offered the following suggestions for dealing with virtually any practice problem:

• Treat patients and staff like family. Here, Dr. Greenberg considers what he would do – and, more importantly, not do – if the problem involved his own child.

• Always tell the truth. If you do, "You don't have to worry about what you said."

• If somebody does something better than you, "Refer the problem to them." From chiropractors to homeopaths, "I have relationships with all kinds of people that in my generation we wouldn't even talk to. And they send me patients. It's wonderful."

• Admit when you don't know something – and journey with the patient toward the answer. If you do this, "Patients will respect you more. They don't expect you to know everything."

• When you're wrong, "get very comfortable saying, 'Please forgive me.'" Merely saying you're sorry demands nothing from the listener, he explained. "If you say to the patient, 'Please forgive me for making you wait,' you bring them into the process."

• Get used to saying thank you. Whenever you resolve a problem, Dr. Greenberg suggested thanking those involved for being so reasonable. Patients thank their doctors all the time. Dr. Greenberg turns the tables by saying, "Thank you for coming to see me." To attendees at the forum, he said, "It's a privilege to be a doctor. It's not about you and how much money you can make. This gift is about how much service you can give, and how good you can make other people's lives. That's how you get to be really happy."

Regarding daily operations, added Dr. Fabi, "Don't perform procedures where you're not comfortable managing their complications." During her training, she said she selected an American Academy of Cosmetic Surgery cosmetic surgery fellowship because like most residents, "I didn't get good cosmetic dermatology training in residency. Though Accreditation Council for Graduate Medical Education guidelines state that we should be competent in some of these procedures, I didn't feel that I was competent enough. And I wanted to feel comfortable managing the complications that can arise from these procedures," said Dr. Fabi.

NEXT: Building your business

Building your business

Dr. Fabi also suggested calling patients who have undergone cosmetic procedures the following day. "That helped me build my practice, because it helped me establish a rapport with my patients, and they knew I cared. Also, not many people do it, so it set me apart from others," which is especially important in the highly competitive Southern California market.

Making these calls also prevents adverse events from proceeding unchecked for several days. "More importantly, it helps you learn about some of the common – and not so common – adverse events. Now, four years down the line, I can be better prepared in managing them."

On the billing side, Dr. Goldberg said, "It's extremely important in our day and age to document what we do very well – not to dumb it down with iPad and iPhone photographs. You can't really do quality work without doing quality photography." Excellent photography is crucial in cosmetic work, as well as simply documenting biopsy sites, he said. Accordingly, Dr. Goldberg recommended standardizing patient positioning, lighting, and camera angles, which his practice does "on-the-fly" in patient rooms and in a separate space using the standardized Visia imaging system (Canfield).

READ: Winning patients over while asking for money

Dr. Goldberg uses two flashes on a ring mount: "I take one flash off to get contour light, to accentuate texture and scars. I also have photo 'direct capture'’-the capability to capture and display images during the patient visit so I can put up side-by-side comparisons and show the person what they looked like three months ago. I can't tell you how many times this has kept me out of trouble" with patients who have denied that treatment produced results.

Thanks to the Mirror imaging and archiving system (Canfield), said Dr. Goldberg, "I have more than 100,000 digital images in my database that I can call up by the patient, procedure, diagnosis, or other parameters."

Dr. Goldberg added that honing and sustaining his brand requires constant patient feedback. Here, he uses the Demandforce automated survey system. "It's been terrific for our practice. The instant a patient leaves the practice, Demandforce sends an e-mail saying, 'Please let us know how we're doing.'" Although 95 percent of patients rate his practice as excellent, "Every now and again we get constructive criticism that makes us better."

NEXT: References

Disclosures: Drs. Fabi, Greenberg and Goldberg report no relevant financial interests.

For more information: www.cosmeticsurgeryforum.com