CORR® International – Asia-Pacific: Moving from University to Private Practice
Year: 2019
Type: article
Abstract: The proportion of physicians involved in private practice in the Asia-Pacific region generally ranges from 60% to 70% [5, 6, 10, 13, 25]. For perspective, in the United States, only 31% of physicians (in a 2018 survey of nearly 9000) identified themselves as independent practice owners or partners [33]. Whether in the United States or abroad, private practicing physicians face obstacles that are not as much a part of academic practice, including administrative duties, building and maintaining surgical patient volume, lack of guaranteed income, and inconsistent work hours—all of which can lead to physical and mental exhaustion [11]. After recently moving on from a university practice to start my own private hospital, I endured my share of ups and downs. But in the midst of developing my hospital, I found myself concentrating on five key areas that might apply to those who are transitioning from university-based practices to private practices; these were: The science of efficient clinical practice, business, leadership, vision, and survival. By focusing on these areas with intention, I was able to prepare for and navigate around the pitfalls that can hamstring individuals transitioning into private practices. The Science of Efficient Clinical Practice In the Asia-Pacific region, nearly all universities are state owned, and private hospitals (staffed by private-practicing physicians) deliver most of the patient care. Academic and public facilities (staffed by employed physicians rather than private practitioners) are important, but they deliver only a minority of the care that patients receive. In South Korea, for example, 90% of the total medical institutions are private facilities [10]. The proportion of hip and knee replacements done in private hospitals is around 50% to 60% in Australia [5] and New Zealand [25]. In India, the private sector comprises of about 75% of the country’s total healthcare expenditures [6]. Naturally, transitioning from a university practice into a private practice is a time-consuming move. Still, surgeons need to take the time and devote the resources to setting up the proper systems and protocols for their major surgical procedures. Those who do not manage their time efficiently may cut corners or compromise patient safety for time-saving measures. How can private practicing physicians improve their efficiency without compromising patient safety? While practicing at my university, I would see about 200 patients a week. In my private clinic, this number ballooned to about 400 patients per week. Along with the decision-making process, I also have to be personally involved in history taking, detailed examination, administering intra-articular injections, and patient counselling due to limited human resources. Because of this, I’ve adapted some of my surgical techniques. I would never compromise safety for efficiency, but if everything else is equal, I need to be as resourceful with my time as possible. For example, while performing TKAs at my university hospital, I used to deflate the tourniquet after cementation and before insertion of the polyethylene liner to reduce blood loss, even though it was time consuming. Now, I start closure immediately after cementation and liner insertion with knee in extension, which is supported by several published studies [1, 34, 36, 37]. The time for cement setting is about 15 minutes per surgery. And considering I do six to seven TKAs per day; I save at least 90 minutes every day due to this change in my surgical technique. I’ve also stopped resurfacing the patella during routine TKA, except in selected patients like those with advanced patellofemoral osteoarthritis, patellar instability, and inflammatory arthritis. Whether and when to resurface the patella has been a topic of debate [21, 27], but with the improvement of surgical techniques and the wide availability of patella-friendly femoral components, the clinical outcomes in terms of pain and function with patella non-resurfacing have almost been identical [7, 16, 20]. So, again, where there is no difference in outcomes, private practice has forced me to prioritize economy of time and movement. So far, I’ve seen no apparent differences in pain or function compared to what I was getting before when I was resurfacing patellae more routinely. Similarly, our practice modified its post-surgical wound-management protocols. For example, we no longer use closed-suction drains after TKA [28, 31]. Instead, we have opted to use occlusive dressing material [8, 9, 30], compression dressings for 48 hours, and first dressing change on the fourth or fifth day just before hospital discharge [19]. As with my change to selective resurfacing of the patella, the surgical outcomes and satisfaction of patients with respect to wound management in my private practice after 2 years is similar to my previous experience at a university hospital. I believe that this is because all of the changes I’ve listed are well-supported by clinical evidence. By making reasonable and scientifically sound modifications in the surgical and postoperative management protocols, physicians can save time, as well as human and financial resources without compromising the quality of care. Business Managing the business and building high-quality infrastructure are administrative challenges for private practicing orthopaedic surgeons, and yet, from a global perspective, many orthopaedic surgeons lack formal training in these critical areas [15]. Private practices in developed countries must compete for business against better-equipped public hospitals that have robust infrastructures. In developing and underdeveloped countries, private hospitals—staffed by private-practicing physicians—face challenges from local bone-setters and traditional medicine practitioners who offer much-less-expensive remedies, potentially attracting orthopaedic patients away from hospitals [2, 26, 32, 35]. It is critical then to start with some reserve funding, which serves as a hedge against the first several months of operation, during which a new private practice will likely face low revenues. While private equity (venture capital) is one avenue for raising funds for private practices in the United States [22], this is not yet being done to any large degree in the Asia-Pacific region. Instead, practices generally raise their initial capital by relying on savings along with the personal or group loans from the practice’s physician(s). Even those practices with a reserve fund will likely be financially strapped at some point, and thus, orthopaedists running their own practices must prioritize their investments wisely, focusing on those items that provide not only quality care but also long-term growth. For example, I was initially skeptical about purchasing a high-quality MRI machine because of its initial cost. As it turns out, this was money well spent; better images have facilitated good care, which will pay dividends in terms of our practice’s reputation, and I expect greater durability than I would have seen from a lower-quality magnet. Leadership Business owners must not ignore their most important investment: Their employees. Despite the likely financial constraints associated with a new practice, private practice leaders must find ways to inspire their employees for the survival and growth of the practice. The only way to do this is to identify like-minded, capable, and enthusiastic employees who are extremely focused on reaching your practice’s stated goals. Once identified and hired, it is important to nurture your new employees so as to cultivate their strengths, and to empower them with the authority to realize their maximum potential. I believe that true leaders create more leaders. This idea led to the formation of something we call at my practice the “TK Academy”, which consists of fellows, operating room staff, nurses, and company personnel who are recognized for addressing critical tasks like the preparation of patient care protocols for medical clearance, perioperative care, or rehabilitation and nutritional support for elderly patients after surgery. TK Academy members also contribute to patient education and advertisement materials for our practice and even organize symposiums for general public about issues faced by our aging society [17]. Vision and Compassion The mission, values, and vision of an organization ultimately guide its code of ethics and the public perception that arises from it. Unlike public and large-establishment hospitals, where policymakers define these fundamental principles, in private practices, it is the physicians themselves who must take on this vital responsibility. Accordingly, I declared the vision of my private hospital as “TK life organization” with a mission to care for the growing elderly population. Our team strives to serve as a center of excellence that is guided by quality care, convenient locations, and reasonable hospital fees. Leaders who define their practices’ fundamental principles will likely impart a compassionate spirit into their teams and may even improve patient care. Survival Instilling a compassionate spirit into your staff is an important aspect of the private practice owner’s job because physician burnout is an increasing concern for orthopaedic surgeons across the globe and at all stages of their career [3, 4, 11, 12, 24, 29]. Private practice tests the resilience of orthopaedic surgeons, and it is difficult to triumph over the many pitfalls without physical, mental, and a spiritual well-being [18]. I believe that orthopaedic surgeons in private practice should consider physical workouts, meditation, or both as ways to combat burnout [14, 23]. Personally, meditation and mindfulness have helped me stay in the here and now, which gives me the power to take on the challenges of private practice one day, or even one moment, at a time.
Author: Tae Kyun Kim
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2963599331