Building a Clinical Practice

This book provides an overview of the unique aspects related to a university based clinical practice. The development of relationships with senior colleagues and referring providers, building multidisciplinary programs within an academic institution, financing of academic medicine, and issues specific to the speciality are discussed.

Building a Clinical Practice aims to highlight the importance of developing a successful clinical practice in an academic setting and to help guide readers through the challenges associated with that process.

This book is relevant to senior surgical trainees and young surgical faculty who are facing the challenges associated with developing a clinical practice.

• Language: English
• Publisher: Springer
• Release date: Jan 1, 2020
• ISBN: 9783030292713

Book preview

Part IThe Nuts and Bolts of a University-Based Practice

© Springer Nature Switzerland AG 2020

T. S. Wang, A. W. Beck (eds.)Building a Clinical PracticeSuccess in Academic Surgeryhttps://doi.org/10.1007/978-3-030-29271-3_1

1. Building a Successful Academic Practice Using the Three A’s: Availability, Affability and Ability

T. Clark Gamblin¹  

(1)

Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

T. Clark Gamblin

Email: [e-mail]

Initiating a successful clinical practice has many elements, and most young surgeons are unaware of the existing structure for patient intake/communication in the clinical practices they join after training. Most academic centers have existing mechanisms for patient intake and outside physician referrals, which may be a central call center and/or practice-based methods of patient intake, such as staff within a division office. In the absence of existing mechanisms, resources such as these are sometimes established in the negotiating phase of recruitment and include aspects such as commitment of personnel, resources, and mentorship. In academic medicine, teamwork and a group practice mentality is essential, and successful groups are able to meld various talents to provide a unique culture with a central vision and mission. The core values of the practice, division, or department must align with newly recruited members to promote professional satisfaction and success for both the individual and the group.

Focusing internally on individual attributes that faculty should utilize to build a successful practice is the focus of this section. Specifically, the three A’s of Availability, Affability and Ability are common pillars for a thriving clinical practice. They must each be present, balanced in effort, and modeled for others to build a clinical mentality and culture necessary for success.

1.1 Availability

Availability is focused on ease of access to the physician. It is what the patient likely sees as the most important physician attribute, as capacity and competency may take a back seat to who is easily accessible when the patient is in need. Although ultimate accessibility would be providing referring providers or even patients with a mobile phone number, this is not always necessary, especially in a collaborative multiple surgeon group. In an effort to balance the demands of one’s professional and personal life, availability may mean ensuring an efficient call center or ensuring that a practice protocol exists for patient communication, with a group mentality for management of patient and referring provider phone calls during, especially during off hours.

Properly organized call centers provide patients with assurance their physician will be informed of any issues they are having, and also provide first-line communication to the patient about access and timely appointments or expedited transfers. Establishing proper protocols for how to handle patient calls is essential to ensure well-organized and timely service.

Referring providers are the cornerstone of a successful practice. Call centers are often the point of entry and interactions had by the referring physician with staff provide lasting impressions about the surgeon or group, irrespective of whether the surgeon Is directly involved in communication. Using an impersonal phone tree or staffing the phone with individuals untrained in customer service rather than investing in the front line of communication can, without question, be detrimental to a practice over time.

Many successful physicians provide direct access for referring providers with an email address and/or a cell phone number. This access is helpful to make referrals as easy as possible and make second opinions immediately available. With such an approach, some referring providers may even call in the presence of the patient to demonstrate their deep commitment to the patient and their relationship with a particular physician. Oftentimes referring providers may want to ensure that the patient understands that if they can’t take care of the problem themselves, they have direct access to the person who can. Including a cell phone number and an email address in all communication to the referring providers firmly demonstrates the concept of availability. In addition, forwarding a pager and having a clear system of coverage when out of town or unavailable again illustrates a thoughtful plan for access.

Timely communication avoids the criticism of an academic black hole that some referring providers feel exists when they refer a patient to a tertiary referral center when they receive limited or no follow-up communication. If referring providers utilize a personal phone call to make the referral, a rule of thumb should be that a return call is expected. Letters of communication should be sent within a week of an office visit and operative notes with pathology reports should accompany the letter from the first postoperative visit. The power of communication is often neglected and represents one of the simple methods to improve patient care and remain in the mind of the referring providers.

In addition, communication on the operative day is essential. Referring providers may, in some cases, be very close to the patient and family, with years of previous care. A call, text message, or email to let the referring care team know the operation has occurred and how the patient is doing is valuable, as it links the primary and referring team to the events. One of the most important calls is when an unanticipated complication occurs. Calls to describe morbidity or mortality are difficult, but are extremely appreciated by the referring team.

The presence of web-based information and links is another example of availability. Editing and providing frequently asked questions, blogs, and support group contacts makes information for patients and referring providers readily available.

Being a point of access for patients into a system is a practice goal and a position of influence. Not uncommonly, you may receive a call and the patient requires the expertise of a someone other than you. In those instances, it is best to take the patient’s information and inform the referring provider that they will be called back that day by the provider specifically needed for the next step of care. Rather than merely giving the referring provider the name of the doctor, facilitating the referral demonstrates a high level of commitment to the process and an attempt to make the referring connection as easy as possible. This also demonstrates a global commitment to patient care and good service at your institution, which will pay dividends with future referrals.

1.2 Affability

While availability is vital to building a practice, affability must be present, or patients and referring doctors will not want to pursue care after their initial interaction. In simple terms, it means being pleasant, friendly, or sociable. Many believe that affability is the single most overlooked area of training in medical school. Thousands of hours are spent establishing expertise, but the ability to connect is the softer side of a successful practice and no less important. Establishing rapport with the medical community is essential to cultivate and build a successful network. This can involve active membership in local societies where a sense of community is established and personal relationships develop. It also involves professionalism and manners when speaking with referring providers.

I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.

Maya Angelou

In some instances, referring providers are calling for a second opinion, a complication, or an area outside their scope of practice. Humility and kindness must be present to receive such a call if future referrals are expected. In most cases, the referring provider is calling hoping to send the patient. Therefore, you should make sure to offer to see these often-complex patients early in the conversation. While complex referrals sometime provide learning opportunities, the referring provider may not be in the frame of mind to have an in-depth discussion or field multiple unnecessary questions, especially if they are initiating a transfer for a complication that they feel they have caused. More appropriate times will certainly exist in the future to share expertise and opinions after the patient’s problem has been managed. Obtaining data and insight from the referring provider should be done carefully and every attempt should be made to avoid a tone of interrogation. If the case represents a serious complication, calls to the referring provider during the course at the receiving institution should occur often and will permanently link future referrals.

Understanding the particular practice of a referring provider is a key to success as it demonstrates a high level of awareness and tailors the management approach. For example, if a referring provider performs venous access cases or endoscopy, cases that require these procedures prior to definitive surgery should be referred back to them, rather than performed being referred within your institution. Even utilizing services and/or physicians that may be preferred by the referring provider is helpful, as it demonstrates support of their practice pattern and facilitates their practice growth.

Affability is probably most important with the patient and family. Well beyond the procedure itself, such an approach calms nerves and assists patients with listening and comprehending. The rapport with the patient and family should be honest and offer hope. Communication with patient families (if not present in clinic at the initial visit) the same day are important in the outpatient setting and should occur daily on the inpatient side. Physically sitting down during the visit in the outpatient setting demonstrates that patients are not rushed and simply listening shows respect and compassion. If the day is running late, as often occurs in busy outpatient practices, a sincere apology should start the conversation. Confirming the referring physician’s name with the patient during the initial visit reinforces a team approach and ensures that communication is properly directed.

1.3 Ability

Ability is the last of the three A’s, and may not matter if availability and affability are not present. Proper training and certification is an assumed prerequisite; however, ability goes far beyond. Outlining the training and expertise has an important place on a website or perhaps printed literature that patients and referring doctors receive. Recent academic publications and newsletters from the division or department may also serve to validate ability.

Understanding one’s own abilities and working collaboratively in a team means helping one another when necessary. It also means taking a call for assistance or discussion of a challenging case very seriously. Planning of an operation with the appropriate team is vital to success and discussion in a conference should occur as often as possible. Most cases are vetted preoperatively; however, in some cases of emergent surgery discussion may occur postoperatively. These discussions help guide care, address avoidable issues and prevent future repetition of mistakes.

Ability also means growing during one’s professional life and this is most often accomplished with senior mentorship. It requires humility to ask for insights and assistance but provides expertise for the patient and cultivates learning. Increasing ability comes from experience, which comes from performing many operations over years of clinical practice. Young faculty should recognize that their most important years of training may be their first years out in practice and should take every opportunity to learn from senior faculty, especially with difficult cases. Don’t hesitate to ask a senior colleague for advice with a case, as this is most often viewed as a healthy behavior rather than a weakness. Ultimately, senior members of the group have worked for years to develop their reputation and are going to care about your outcomes as much as their own to preserve the reputation of their overall practice. As a young faculty, you are ultimately a reflection of your group and your institution.

In addition to mentorship, continuing medical education allows for physicians to stay current and evolve their approach. In academic medicine, research and familiarity with the current literature allows for adaptation of advances and leadership for those not as familiar with the field.

Sharing ability with referring providers and patients is important as it instills confidence in the team but should be done with genuine humility. All procedures carry some risk and those who portray themselves as without complications have wagered in a high-stakes endeavor that they will eventually lose. Capturing photos in the operating room are a valuable way to document the case, share information with the referring provider, and engage the patient and family with the procedure. Photos and sketches will communicate the level of care provided in a factual manner and demonstrate skill.

1.4 Conclusion

The three A’s discussed above are applicable to any form of business, and are tantamount to the success of early clinical practice building. These characteristics are well within the control of young surgeons, and given the ever escalating online reporting of physicians, personality and service are increasingly important. Patients and their families as well as referring healthcare providers use the web as their source of information, and bedside manner is often central to any reviews. The A’s of success are dependent on one another and although some may be more interested in one than others, none can be neglected if the goal is to build a successful academic career.

© Springer Nature Switzerland AG 2020

T. S. Wang, A. W. Beck (eds.)Building a Clinical PracticeSuccess in Academic Surgeryhttps://doi.org/10.1007/978-3-030-29271-3_2

2. Outline for Developing Relationships Chapter (Wang/Beck)

Matthew A. Nehs¹   and Adil Haider²  

(1)

Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA

(2)

Medical College, The Aga Khan University, Karachi, Pakistan

Matthew A. Nehs (Corresponding author)

Email: [e-mail]

Adil Haider

Email: [e-mail]

One of the greatest values of mentors is the ability to see ahead what others cannot see and to help them navigate a course to their destination.

—John C. Maxwell [1]

Keywords

MentorshipTrustRelationshipsRole modelCase conference

2.1 Involving More Senior Colleagues and Faculty

Professional relationships are the life-blood of surgical practice. They are what connect you to your patients through trust and honesty; they allow you to tap into the experience and wisdom of senior faculty; they lay the foundations for students, residents, and fellows on their path towards competence and mastery; and they connect you to referring physicians who commission you to solve a surgical problem. As a new surgical faculty member, establishing these important relationships is among your most important tasks. Here we share a few tips on how to involve and learn from senior faculty in your institution.

2.2 Establish a Mentor and Keep Old Mentors: Collect Advocates

Mentorship is a fundamental aspect of academic surgery [2–6]. At every level, mentors can help steer your career path and help you see the long arc that is a career in Surgery. It is therefore essential to establish mentorship relationships early in a new surgical practice. Remember that mentorship is a two-way street, and both the mentor and mentee should benefit from the relationship. Most senior mentors who are willing to serve in this role derive great satisfaction in cultivating your skill and practice. They view your success as their success (reflected glory). In this way, your senior mentors are advocates for you and stakeholders in your success.

If you have multiple job offers and can be selective in the institution you join, consider who could be your senior mentor when deciding where to join. It’s wonderful to find a practice that pays well, but who will be around to help guide you through your initial struggles as an attending? Who will you discuss challenging cases with? Who will sponsor you when you have an idea for a clinical innovation project or leadership position? These questions should be considered carefully when negotiating a contract or choosing among various faculty positions. Seek out places that want to cultivate and support young surgeons and avoid institutions where you will be seen as a competitor or where you are on your own with clinical issues.

You should use every opportunity to keep in touch with previous mentors from your training program. Program directors and fellowship directors want you to succeed because your successes are a reflection of them and the quality of the training they provided to you. Get into the habit of calling them periodically to discuss a complex case. It’s reassuring and responsible to get several experienced opinions for the most difficult cases. Lean on your previous mentors from training to discuss complications and how to handle them (clinically and emotionally). Every surgeon will face complications, and this is an important place for the senior surgeon to guide, advise, and share wisdom. You will likely see your mentors at professional meetings, and this can be an excellent opportunity to have in-person discussions about challenging cases, update them on your current progress, and to remind them of the ways they influenced you. Keep your best mentors in your professional circle as long as possible, and keep collecting advocates—you never know when you might need them.

2.3 Operate on the Same Day as Your Mentor: Surgery Is Easier When Experienced Backup Is Right Next Door

If you have an elective practice, consider operating on the same day as your senior faculty mentor whenever possible. This facilitates natural discussion between cases and more opportunities for collaboration. Your senior mentor is much more likely to be available for intraoperative consultation and guidance compared with a nonoperative clinic day or research days. For surgeons in Trauma and Acute Care Surgery, where the clinical flow is unpredictable, having a senior colleague as backup serves the same function.

For surgeons performing elective procedures, don’t overbook your operative day if you have a particularly challenging case, and strategize to start the hard case early in the day. Difficult cases become even more challenging when most of the staff has gone home and during shift changes in the OR. If you don’t have OR block time when you start out, involving a senior surgeon as a collaborator might also improve your chances to have the case done during daylight hours with a team of anesthesiologists, nurses, and OR technicians who are experienced in your field.

2.4 Take on the Hardest Cases: Jump into the Deep End of the Pool

We recommend starting your practice with the belief that you can take on the most challenging cases as long as you have appropriate senior back-up. The goal here is to capitalize on your momentum from residency or fellowship where you were taking care of the sickest patients and doing the most complex operations. If you are in the good habit of asking colleagues for help and their opinions, and planning your cases wisely, these cases will go smoothly and as planned, especially with the help of your senior colleagues. If you are uncomfortable asking for help in the first year or two, you might find yourself making errors of judgement that could be avoided from seeking the counsel of someone who has faced similar situations before. Embrace the challenges of the difficult case—but ask for help along the way.

2.5 Participate in a Weekly Case Conference: It’s a Built-in Opportunity for Clinical Advice

Given that it can be difficult to connect to mentors with busy clinical schedules, it is helpful to have a weekly case conference to discuss your most challenging and interesting operations. This structure allows access to senior partners’ opinions and learn from their prior successes and failures. In one of our practices (MN), we have a clinical case conference to discuss the week’s endocrine surgery patients. We meet from 7 to 7:30 a.m. and we have five faculty whose cases are presented by a resident or fellow. This is an excellent opportunity to gain the wisdom of the group and to ask for others’ input on your clinical decision-making and operative strategy. This conference dovetails as an excellent learning opportunity for the students, residents, and fellows as well. If there are not established case conferences at your institution, consider approaching your senior faculty and gauging interest for starting one. They may be willing to put you in charge of running the conference, which can be a good way to develop a leadership opportunity as well.

2.6 Interacting with Trainees as a New Faculty Member

As a new attending surgeon, you are in an excellent position to understand the struggles of residents and fellows given the proximity of training. Having just completed your training, you can relate to the residents perhaps better than more established attending surgeons and can use that as an opportunity to build trust and rapport with the trainees. Acting as a new attending and guiding trainees through complex operations can be challenging when you are still learning yourself. It is critical that you balance patient safety and outcome with trainee learning and professional development, while also avoiding the pitfalls of being perceived as a poor teacher in early in your career. Below we’ve outlined a few ways to get the most out of this relationship.

Maximize trainee learning in every operative case. Your surgical practice is often slow in the beginning as a new attending, and you should use this to your advantage! This affords you the opportunity for robust preoperative discussion, intraoperative teaching, and post-operative feedback with residents and fellows. This is a strategic teaching advantage that less-busy new faculty have over the high-volume established surgeon.

Learning to grant appropriate graduated autonomy for each PGY level is challenging, but should be a focus of your early development as an academic surgeon [7]. Too little autonomy (show and tell) can lead to residents avoiding your cases (I did not do anything in his/her room). This can create a cycle of senior residents avoiding your cases and you operating with the most junior trainees who can’t yet be granted autonomy. Of course, too much autonomy could lead to a higher complication rate or lack of trust by OR staff (passive help/no help).

For example, consider a routine laparoscopic cholecystectomy. A PGY2 might be thinking of how to expose the cystic duct or find the plane of dissection between the gallbladder and liver. On the other hand, you might be considering complex and rare variants such as replaced right hepatic artery, fused cystic duct-common duct, or aberrant right lateral segmental bile duct. These higher level issues might not be on the forefront of their mind during the case, but are certainly important considerations during what may otherwise appear to be a routine case. In a large training program with residents at all levels and experience, how does the young surgeon tailor the operation to match the skill of the resident and teach them these higher level concepts?

One approach that we often use is to have a preoperative discussion [8] with the trainee and ask, what parts of the case do you want to focus on? This sets a learning objective for a specific part of the operation (e.g. taking down the upper pole of the thyroid gland or mobilization of the splenic flexure of the colon) when the resident might not yet be ready for the critical part of the case (dissection of the recurrent laryngeal nerve or a TME dissection). This sets an achievable action that can be built upon for subsequent cases. Keep in mind what you can fix and what you cannot fix as the attending surgeon. You can easily fix a bleeding superior thyroid artery. You cannot fix a transected recurrent nerve. We recommend establishing a very high level of trust with your trainees before granting maximal autonomy as a new attending surgeon.

Importantly, real trust is not implicit and is always earned, and above all, you must do the what is right for the patient. Model the actions and behavior that you want emulated by the trainees even if it compromises their learning objectives for any particular case. There will always be another case from which to learn.

2.7 On the Wards/Clinic

Make a point to walk-round with the residents in the afternoon to see your patients. This is a great opportunity for teaching, especially for junior residents and medical students. If you are going to make afternoon rounds, page the intern to come with you. You can discuss the details of the pathophysiology and operative details that they likely missed out on initially. It’s a way to deepen their learning and also to make sure that they are attending to the specific details for your patients.

The clinic is one of the best places to get to know trainees and teach them. In many programs, residents’ experience is necessarily focused around operations, in-patient care, and emergency issues. This is a great chance to have one-on-one discussions about all aspects of care that are not commonly seen on the wards. For example, almost all trainees are familiar with postoperative fever, tachycardia, and oliguria. But only rarely do they get to participate in preoperative work up of a breast mass or melanoma or discuss the details of adjuvant chemotherapy. These clinic visits help to build resident-faculty relationships and trust. The practical reality is that most of the time, the trainee who performs the operation with you will not be present at the postoperative clinic visit. As a junior surgeon, consider sending a copy of your post op note to the trainee by email or a quick note saying, I saw our patient from last week, and she’s doing great. The pathology showed a 2 cm adenocarcinoma. By doing this, they will be reconnected to the learning points from your case. Is all this necessary? No—of course not. That’s exactly the reason to do it, and that’s why it will make an impression on the trainees.

Offer to mentor trainees. Mentorships occurs at all levels of training in the long arc of a surgical career. Consider offering formal mentorship relationships to trainees. Share with them your struggles, errors, and missteps during residency and fellowship. This honesty can help normalize their experience as a trainee and build trust. Junior faculty are also much more likely to be perceived as a non-threatening colleague to have open and frank conversations. Junior faculty also represent a light at the end of the tunnel to those who are in the midst of residency training. This is especially evident if you stay on at the institution where you completed your training, since residents will remember you in a prior role (Chief Resident, Fellow, etc.). We recommend establishing a formal mentoring relationship including defined goals with regular meetings (e.g. quarterly) to discuss the trainee’s progress or concerns.

2.8 Interest Group and Formal Lectures

If one does not already exist, consider establishing an interest group or mentorship group (e.g. vascular surgery interest group) for residents who are interested in your specialty. This can be a good way for residents and fellows to get to know you and to review papers or clinical cases as part of a teaching program. At most teaching programs, there are opportunities for formal didactic sessions as part of the structured curriculum. Offering to teach a session on your area of expertise helps the residents and students get to know you out of the OR. These mentorship relationships are also important as part of academic faculty promotion criteria at most medical schools.

References

1.

Maxwell JC. The leadership handbook: 26 critical lessons every leader needs. Nashville: Thomas Nelson Inc.; 2015. p. 212.

2.

Entezami P, Franzblau LE, Chung KC. Mentorship in surgical training: a systematic review. Hand. 2012;7(1):30–6.Crossref

3.

Healy NA, Cantillon P, Malone C, Kerin MJ. Role models and mentors in surgery. Am J Surg. 2012;204(2):256–61.Crossref

4.

Drolet BC, Sangisetty S, Mulvaney PM, Ryder BA, Cioffi WG. A mentorship-based preclinical elective increases exposure, confidence, and interest in surgery. Am J Surg. 2014;207(2):179–86.Crossref

5.

Patel VM, Warren O, Ahmed K, Humphris P, Abbasi S, Ashrafian H, Darzi A, Athanasiou T. How can we build mentorship in surgeons of the future? ANZ J Surg. 2011;81(6):418–24.Crossref

6.

Kibbe MR, Pellegrini CA, Townsend CM, Helenowski IB, Patti MG. Characterization of mentorship programs in departments of surgery in the United States. JAMA Surg. 2016;151(10):900–6.Crossref

7.

Teman NR, Gauger PG, Mullan PB, Tarpley JL, Minter RM. Entrustment of general surgery residents in the operating room: factors contributing to provision of resident autonomy. J Am Coll Surg. 2014;219(4):778–87.Crossref

8.

Pernar LI, Breen E, Ashley SW, Peyre SE. Preoperative learning goals set by surgical residents and faculty. J Surg Res.