Office practice of plastic surgery

Published on 22/05/2015 by admin

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CHAPTER 1 Office practice of plastic surgery

Gustavo A. Colon

Part 1: Introduction of the practice needs

Initial steps

Before establishing a practice, you have to decide where it is that you want to live. However, deciding on an urban, suburban, or rural area may be somewhat difficult. The first thing that one has to evaluate is the number of plastic surgeons who are practicing within the community. It would be very difficult to establish yourself in an area where there are multiple plastic surgeons who already have appropriate referral sources, and it is best to look for a community in which there is a definite need for a plastic surgeon, either with a group or in solo practice or even in academic medicine.

The location

Before you finish training, you should investigate the area in which you are interested. Look at demographics, population growths, median incomes, growth of the city and/or community, and evaluate the statistics of the metropolitan areas, particularly where there is the greatest density of plastic surgeons. Speak to plastic surgeons in the community to get their opinions, concepts and ideas, which sometimes may be negative since they may not welcome a new, young, well-trained plastic surgeon. Our sources for potential practice locales are the American Medical Association, which offers a market area profile (MAPS) that includes information about community demographics, or the local Chamber of Commerce in the area in which you are considering relocating. The hospitals in the area can be of great assistance in getting and interpreting whatever data you may need, for example, hospitals will tell you the number of plastic surgeons on staff, then you can evaluate which plastic surgeons are servicing that health community, what the referral sources are and whether there is a need for a younger plastic surgeon.

The practice

The next decision you have to make is the type of practice that you would like to join, a multi-specialty group with a large number of different types of specialties, i.e. a Mayo Clinic or Cleveland Clinic type of setup, a group practice of plastic surgeons practicing together. Alternatively, you may share space with another plastic surgeon, to help him or her decrease their overheads and at the same time have full advantage of their established plastic surgical staff. You may prefer an academic position, in a teaching institution or a sponsored or salaried position in a hospital that allows you a private practice, but where you are dependent upon referrals from and to that specific entity. Finally, there is the independent model or solo practice.

Let’s talk primarily about solo or group practices. Group practices, of course, provide economic security and a source of patients. All usually include built-in coverage for vacations and weekends, hopefully a congenial atmosphere of other plastic surgeons with whom you can discuss cases with access to appropriate equipment, and opportunities to pursue the area of specialization in which you are interested. Also, by practicing in an established geographic area with an established group you have instant name recognition.

However, group practice may be somewhat difficult because there may be frustration at the loss of autonomy, dissatisfaction with the inability to make independent decisions, conflicts with associates and difficulty with financial matters, which may not have been properly addressed during the initial interviews and contract. Other certain points need to be established prior to going into a group practice:

• Make sure that the philosophy of the group is the same as your philosophy, not only in the ethics of practice, but also in appropriate financial sharing of costs, billing, and remuneration.

• Meet all the doctors you are working with and make sure that there is an aura of compatibility; understand what differences and competition may exist within the practice.

• Speak to the youngest plastic surgeon or the last one who joined the group because they will be able to tell you what their frustrations and/or benefits are of being in a group practice.

• Check the reputation of the group practice within the community, that the practice is viable, growing and that it does need another plastic surgeon.

• Make sure that your spouse or significant other will be compatible with the spouses or significant others of the group. If the spouses are working in the same group practice, make sure that they will not be the controllers of your practice, otherwise this may cause a difficult professional and social situation.

• All written contracts should be reviewed by an attorney and/or consultant who is looking after your benefit, not theirs. Never start work without a written contract, have it reviewed, make sure that it fits your philosophy of practice and that it is beneficial to both parties; it must be a win–win situation.

Advisors

You must have advisors to help you manage a successful practice. First of all you need to have an accountant or a CPA who will handle all your financial needs, help you set up initial office accounting systems and handle tax matters, prepare monthly income and expense statements and counsel you on investments. You will need an attorney who will review all your contracts, a banker who will loan or give you the credit line to start out initially, an insurance broker for liability needs and a real-estate broker to find you a new home or help you locate an office if you are going into solo practice. Perhaps ultimately you might need a management consultant to evaluate and manage your practice, but not initially. Management consultants usually come in after an established practice needs tweaking or perhaps some rearranging.

Solo practice

If you are starting out in an independent practice, you will need to obtain the appropriate state occupational licenses and you really need to apply early for privileges at the specific hospitals where you wish to practice. Once you have decided on the community in which you wish to practice, you need to look for office space. You have to decide whether you want to purchase or lease. Initially I think it is easier to lease than to purchase, to avoid excessive overheads. Find a house in a community which you think would be adequate for your family; your spouse and your children will follow you wherever you go, but choose a community which will be adaptable and comfortable for them.

Once you decide on the area in which you wish to practice, you will have to begin to draw up an income and expenditure projection so that you can borrow the monies that you will need to start a practice and use as income for the initial months. Apply to the appropriate managed care programs and/or insurances which service the community, arrange for your liability, office insurance, office overhead, office liability, business interruption insurance, employee fidelity bonds, major medical insurance for you and your employees, disability, life and ultimately automobile insurance. Acquire an answering service, get a beeper, cell phone, print business cards and announcements, and arrange for accepting credit cards within your practice. From a social, professional standpoint, you need to meet referring physicians and interview prospective janitorial services and office personnel. Study your CPT codes and use appropriate billing of your services for the area.

Office space

There are certain rules for finding and designing your office space. You have to maintain privacy according to the HIPPA regulations. There has to be absolute privacy for the patients coming into your office. The waiting room has to be comfortable, and sizable to allow patients to sit comfortably. The secretarial staff should have an appropriate view of the waiting room to be able to welcome the patients, as well as keep an eye out as to what is going on in the waiting area. They should also be able to prevent any undue occurrences or pilfering of the material and/or furniture in the waiting area. Remember, the waiting room is the first contact that the patient has with your office. Your décor should make the statement that you want to make in your practice. Use the décor that is appropriate for your practice and which reflects you. Exam rooms should be practical, clinical, usable and comfortable for both the doctor and the patient. Please remember that first impressions are made in seven seconds, and you don’t get a second chance so the first impression of your office should be one that gives them a sense of trust.

Supplies and equipment are something that will be difficult to evaluate. I think that all of us need to purchase the appropriate supplies for office management. You do not need to buy every piece of equipment that you see at a meeting or exhibit, but have appropriate equipment to handle any type of emergency. I would recommend that every office have an emergency CPR kit, computerize your office early. It is much easier to run a practice with computers. There are enough computer programs which are directed specifically to plastic surgery to make your life and that of your staff very easy, and in some instances paperless.

Budget

How much money do you need to establish a practice? Once again, it depends on your personal style, how extravagant do you want to be and how much you want to spend in your practice; middle of the road is always the best approach. As previously stated, you need to borrow money in order to support yourself for several months, so you have to establish a credit line and relationship with a bank. Will you get a better deal because you are a doctor? The answer is “no”. In the past, doctors were favored banking customers and could get loans at low interest with real flexible terms. I do not think that is the case at the present time. You will get a credit line knowing full well that the bank hopes that you will be a long-term customer. When borrowing money, certain things are required: past tax returns, a pro forma, which is a statement that projects the sources of income for the immediate future and that you will have an income to repay this loan over a period of time. At the same time, it will project your fees for expected surgical procedures, and the amount of income you expect to have over the next several months. They will also ask you for your estimated expenses, a financial statement and so bear in mind the five Cs which a bank will require: collateral for the loan, your capacity to pay the loan, capital that you have available, your character and any conditions for the loan.

Summary

Once you have established a practice and have opened your office, initially it is better that you keep it small if you are in solo practice. At the same time, if you are in a group practice it might be better to maintain a low professional profile rather than trying to go out and “corner the market” because this may create antagonism among your older colleagues who think you are nothing but a young upstart without experience, and they may not back you in difficult situations. Keep your staff small, good, reliable and make sure that they follow your principles and philosophy of practice. As far as your equipment is concerned, buy what you need, keep your office open at appropriate hours and be available.

There are three things that make a doctor successful: ability, affordability, but above all availability. However, make sure that you charge patients for your services. Bill promptly; remember cheaper is not better. Do not practice to make money, just be a good physician and appropriate financial remunerations will follow. Do not commit fraud, do not lie to insurance companies, be honest about who you are and what you do and in your billing, and you will have a long successful practice. Do not do unnecessary surgery. Be honest to your patients and yourself, particularly when you are beginning; say that you are still learning but that you are a well-trained surgeon and that you can handle the complexities of any surgical procedure for which you were trained. Read and understand all managed care contracts. Do not negotiate with your patients and remember that maintaining a practice is dependent upon three things: reputation, reputation and reputation. Maintenance of the practice will depend on physician referrals, patient referrals, area of specialization, good results and constant monitoring. Do not create gimmicks to attract patients; do your job well enough to be an expert and the patients will come.

The staff

Employee empowerment

Your staff should generate enthusiasm, teamwork and pride in their work, but with responsibility to you and your structured organization. The patient will choose you for surgery if you can accommodate them surgically and financially, and if they like you and your staff. Your staff must meet the patient’s needs by customization and individualization of care and services. The staff should follow this simple creed:

1. Do the little things right.

2. Go the extra mile.

3. Always exceed the customer’s expectations.

The aim of your staff is to encourage prospective patients to convert from might to want to will, and to create a service that will expand your market share. Therefore, when trying to bring a new plastic surgical service to the community, the goal is market expansion and revenue increase.

Business development of plastic surgical services

You need to use business tactics to accomplish the expansion objectives by:

1. Developing a new product or service (plastic surgery).

2. Raising or lowering prices to make financing more available.

3. Creating a new promotion with advertising or internal marketing.

4. Establishing a definite public relations effort through your staff.

5. Developing new channels of distribution through your own patient population or other services (i.e. skincare line of products).

6. Establishing plans and timelines to evaluate and track the service.

Hence you have to develop a situation analysis in which you:

• Analyze market trends and the needs of the service being introduced.

• Determine the domestic, local, and international needs of the service.

• Study the implications of new trends. (Is this something that is going to last or is it something that is going to come and go?)

• Weigh the financial opportunities for this product or service. (Is it a product or service that only you are going to deliver or is the product or service so available that it is diluted?)

• Evaluate the competition. What are they doing and how are they marketing?

• Determine the risks of your endeavor.

The service has to be visible, be convenient, and it must have a simple organizational layout with friendly and professional assistance. It must be priced fairly, be consistent and constant. Remember that in plastic surgery it is not a product that you are selling, it is a biological technical service, which is not returnable and not guaranteed with many variables. Besides product, the other three “Ps” of plastic surgery are:

• Positioning, which is dependent on your reputation.

• Price has never been a factor, because the consumer may equate expensive with better and cheaper with inexperience.

• Promotion is the only element that can be used to expose the public to plastic surgery. Maintaining a practice depends on three things: reputation, reputation and reputation.

So, be caring, concerned and available at all times for your patients. You want to be the plastic surgeon who will be in your prospective patient’s mind when and if they change the might to want to will. It takes about ten years to establish a good elective type practice, but it is good results and reputation that keep you established.

Tips for a successful practice

1. All patients should be appropriately billed; patients should know exactly what kind of service they are getting even if the service is free. When you do not charge, give the patient a bill with the appropriate discount so that they know how much you have discounted or not charged for the operative procedure.

2. Treat patients very well and be their confidant and trustful physician, but do not make patients friends; maintain a social distance from your patient population. This does not mean that your friends cannot be patients, but do not try to socialize within your patient population.

3. Patients will sue you for three things: because they do not like you, they do not like the bill and they do not like the surgery, or a combination of all three. So do not be surprised; it happens to all of us, just document accordingly.

4. Do not fool around with patients, you can lose your license and it certainly is not appropriate ethically or morally.

5. The office is like a confessional; nothing is ever discussed outside the office by you or your staff.

6. Your specialty is plastic and reconstructive surgery, not cosmetic surgery, which is just part of our specialty.

7. Don’t take yourself too seriously. Do not let life pass you by. Nobody is indispensable and plastic surgery is what you do for a living; it is not what you live for.

Style, substance and communication

What really attracts and maintains patients in your practice may not only be your surgical expertise, but your ability to communicate. So when you communicate, you have to project likeability, integrity, competence and sincerity. In other words, the patient has to like you to ultimately trust you for surgery.

Improve your communication skills by the following:

1. Listen to the patient, attentively.

2. Make eye contact with the patient and sit down, be at their eye level to speak to them.

3. Be positive in how you talk, but always speak the truth. Do not get defensive; once you get defensive with a patient, whether it is preoperative or postoperative, you are going to get into the guilt, hostility, arrogance cycle.

4. Give useful information, be honest, concise, positive, truthful, reliable, memorable but factual and keep it simple.

5. Your demeanor should be pleasant and sincere; smile appropriately and genuinely with patients.

6. Have a friendly, open face, no frown or distant stare.

7. Be interested in what the patient’s problem is. You should absolutely give them your full attention. Do not be in a rush to leave. Make them feel that in the few minutes that you are there, you have no other interests.

8. Your body language should be cordial with appropriate gestures. In consultations, sit, touch the patient with professional concern, always make the effort to make contact with the patient physically as well as emotionally and mentally.

9. Dress neatly and always talk calmly to the patient, in a warm distinct, deliberate tone with normal pitch and rate, using understandable language. Never be condescending or arrogant; remember communication is an intellectual act of love.

Part 2: Marketing and practice enhancement

How I market an aesthetic practice

Marketing may enhance your practice, but it is reputation that makes the difference. In managing my practice, one of the things that I put first is my personal family life. I try always to remember that plastic surgery is a profession, not a lifestyle, and that you have to put things in perspective with definite priorities. At the same time, you have to be yourself and not try to imitate or be any other plastic surgeon. The priorities are basically simple: if you are satisfied professionally, growing and financially stable, doing what you like to do, why change?

Several years ago, I began to evaluate my practice, how it had grown, and to look at the external factors and inherent factors that had pushed my practice to the point where I was. I found several things. I found out from questionnaires and focus groups among the patients and staff that I was a personable, caring physician, and a known factor in the plastic surgical community with a reputation, but that I was a bit quick with patients and seemed to have too many other things on my mind, and that I really needed to spend more time with the patients. Therefore, I began to formulate my practice into a much more patient-oriented centre, so that patients could obtain more information about aesthetic plastic surgery, not just from me, but from my staff. I hired a patient coordinator and began to evaluate the patient and track the results. We investigated why patients were scheduling, and the numbers of patients that were scheduled versus the number of new patients who were being seen. We began to instruct the patients during the initial consultation for a longer period of time, giving them a lot more information with videotapes, brochures, etc., and we began to evaluate the practice on a quarterly basis.

All these things have put the practice into more focus so that it is more business-like, efficient and better organized. My philosophy was never planned. It just evolved over the years as an extension of my personal principles:

My philosophy

1. To identify my personal professional goals and to continue at a productive level.

2. To emphasize the positive aspects of the practice.

3. To realize my limitations and be happy in what you are and what you have achieved and try to plan for the future.

4. To remember “ain’t nobody indispensable.”

The following section integrates my personal concepts and philosophies for creating a continuous and successful plastic surgical practice.

Why do patients come to you?

Primarily they come because you are new and available. You are new in private practice and patients may feel that they can get a better financial deal, not because of your expertise. However, your surgical services are judged on the same standards of care of any other plastic surgeon, not only in your community, but nationwide.

• Referrals. These usually come from physicians, patients, family, friends and staff, but they mostly come without much knowledge of plastic surgery or you. So make patients feel comfortable with you and trust you.

• Do not sell surgery. The patient comes to you for one procedure, but don’t suggest that they have another operative procedure simply because you need experience. Occasionally, two operative procedures may go together such as a chin implant and a rhinoplasty, or rather than having a breast augmentation, the patient may need to have a mastopexy; but do not sell an operative procedure that they are not seeking. Patients need to feel that you are honest, sincere, truthful and dependable.

• Be honest as to who you are. You are new in practice but well trained, available and competent.

• When seeing another doctor’s patient: Do not accept a patient from another physician without calling him first and finding out the other side of the story. It is important to understand that what one patient tells you about another doctor may not be the entire truth.

The initial consultation

Cosmetic patients are nervous, guilty and feel sometimes that they are taking up your time in asking for silly elective procedures when you could be doing more “important” surgery. Patients are usually out of their element when they talk to you. The first consultation with a plastic surgeon is always the most difficult one. Put them at their ease.

• Introduce yourself honestly, who you are and what you are. Address the patient with simplicity but respect.

• Tell them of your experience or inexperience with surgery. If you are dishonest, it will come back to haunt you. If it is the first time that you are doing an operation, tell the patient it is the first time that you are doing such an operative procedure, but then tell them that you are a trained surgeon and this is a surgical procedure that should not be difficult to do, or that somebody will be there who has more experience to help you.

• Never say don’t worry, because they are always worried and anxious. Just talk honestly and reassure the patient.

• Never say everything will be okay, because it may not be and it may not turn out to be perfect.

• Examine the patient thoroughly and vocalize all of your findings to them.

• Explain your surgical plan to them and tell them it is only a plan, not a blueprint and that things can change during the operation.

• Inform the patient thoroughly and honestly of common complications and problems that can occur, and even discuss complications that are not common.

• In this day and age, it is important to be absolutely thorough in your discussion with the patient.

• Do not get talked into or do surgeries that are not necessary.

• Do not say money is not an object, because to them it may be. If things go wrong, it is what they are going to sue you for, money.

• Do not sell or talk surgery in social situations. Discourage off-the-cuff consultations.

First impressions:

• They are made in seven seconds.

• Your whole practice and you will be evaluated by the patient in how and what you say, what your staff says, and how they and you are perceived by them.

• Good service leaves permanent good impressions and maintains a reputation.

Patient characteristics

• The driver. With these patients, it’s a quick consultation and a quick decision. They do not have time to be there for a long period of time. They want something done right away and a decision is made quickly. That patient will usually decide not to have the surgery as quickly as they make the decision to have the surgery. It is important that you spend some time with these patients and evaluate them. This type of patient is usually the high driving executive or the society matron who really does not have much time to spend with you. You are just another service person to them.

• The talker. This patient comes in and takes time and wants multiple consults during the initial consultation. They usually have ten single-spaced typewritten pages of questions to discuss with you. You have to evaluate these patients immediately as to what their needs are and spend some time with them, making sure that they are realistic in their expectations, within a reasonable consultative period.

• The planner. This one has his or her operation planned, and usually has decided how they want to have the surgery or what they don’t want to have in their surgery. They want to see if you and the surgery fit into their plan.

• The thinker. One who asks few questions, wants you to make decisions and doesn’t talk much during the consultation. They have been thinking about the surgery and now want to think about you and consider what you have to say. This is the patient who will say, “You are the doctor; you tell me what I need!”

• The shopper. Has seen other plastic surgeons and is comparing price, staff surgical availability, etc. Be yourself and don’t compete with other surgeons. Treat them with caution but without great expectations.

Handling the patient postop

Remember, it’s not over till it’s over. Patients are yours forever when you’re in practice. You never go off the service. If you lose a patient or they go some place else, you lost because that’s an unhappy patient.

Postoperative handling of a patient is as technically important as the surgery. If there is a complication or problem, reassure the patient that “you and she/he will get through it together.”

Things to do

1. You change the dressings, you remove the sutures, or be there when somebody in your staff is going to do it, or explain to the patient why you won’t be there. Make sure that the patient sees you and feels that you are as concerned about their postoperative treatment as you were about getting them to the operating room.

2. See the patient frequently whether they need it or not. They really need reassurance in the postoperative period, because many of them will get a postoperative depression.

3. Be supportive of any patient. Answer their questions honestly, quickly and thoroughly. Many of them are undergoing a surgical procedure for the first time, and while for you it may be a routine postoperative situation, for them it is not.

4. Be honest. If you see a problem, explain to the patient what it is. Tell them if there is a problem or complication, and explain your proposed plan of action. Remember, “just a little swelling” can get you just so far. Don’t blame a complication on a patient. Most problems that result between doctors and patients could have been resolved during the postoperative period. This is a golden period. They can love you or hate you in the immediate postoperative period.

The difficult and unhappy patient

Patients may be one of the following:

• The demanding patient. I want the surgery when I want it and how I want it. That’s what I’m paying you for, and if you don’t do it the way I want you to do it, I won’t pay you.

• The apologetic patient. This is a patient who comes in apologizing all the time for bothering you, apologizing for wasting your time when you have so many other important patients to see and sick patients to take care of. This is a patient who needs hand-holding. They need reassurance because they are very insecure about their situation and if you let them down, they may get paranoid.

• The flirtatious patient is a patient who says, “Oh, I’ve heard so much about you. You’re the most wonderful doctor in the world,” but usually is shopping around for a reduced fee.

• The hostile patient. “I’m not happy with my surgery.” “I’m not happy with you or your bill.” Your staff will tell you about the hostile patient, because they will have been extremely hostile to the staff a few visits before they get hostile with you.

• The angry patient is a patient who is not happy with surgery. “I am not going to pay you.” “If you try to bill me, I will sue you.” Usually somebody has told them that the surgery was inappropriate and poorly done.

• The negotiating patient is the patient who comes in and says, “I have a lot of friends waiting to have surgery. They want to see how I turn out. Couldn’t you please give me a discount?” Do not negotiate; make your fee appropriate for your services.

• The fraudulent patient is the one who says, “Couldn’t we just call it something else and see if my insurance will pay for it?”

Dealing with complications

Complications happen.

1. Try to identify the high-risk patient surgically and emotionally.

2. Deformity vs. concern in a patient. If the concern is so much greater than the deformity or if the deformity is so much greater than the concern, you have a loaded situation and these patients need to have a reality check. You need to sit down and talk to them about exactly how they feel about themselves and how they see themselves and their self-images. They may have BDS (body dysmorphic syndrome).

3. The multi-surgeon or multiple surgery patient. This is a very difficult patient. The patient has had multiple operative procedures and has visited multiple other surgeons. It is imperative that you speak to each of the surgeons who have operated on these patients, get their operative reports, and never accept a patient who won’t let you talk to the doctor (with appropriate consent) who operated on them beforehand. There are two sides to every story and that doctor may just very well tell you what you need to know, so that you don’t take this patient on as a problem case. You never want to be the last of a long list of problem surgeries.

4. If a patient has a real or imagined surgical problem, it is important for you to be there for them. You must be their anchor. You must be their rock and make them realize that the problem is minimal and does not require surgery. Otherwise, they are going to go someplace else. Be supportive, positive, but honest.

5. Talk to the family and patient and be careful how you phrase things. Also, when you speak to anybody other than the patient, make sure you have the patient’s permission. If you don’t, you may be violating the confidentiality of the doctor/patient relationship.

6. Deal with the patient’s problems, not with your anxieties or fears. All complications get resolved. What doesn’t get resolved is your attitude toward them.

Avoid the guilt/hostility/arrogance/counter hostility cycle!

If you get into this cycle with a patient, you have really lost the game with them, because the patient will make you feel guilty, then you’ll feel hostile to the way they are reacting to their problem, and you are going to get arrogant with this patient and stop answering their phone calls. Ultimately you are going to get counter hostility from the patient towards you, and this generally creates a litigious situation.

Effective internal marketing techniques for plastic surgery

Plastic surgery is one of the most visual and media expectant specialties in medicine today. Credibility in plastic surgery is tenuous and difficult to achieve, even without marketing, but with the amount of external marketing that we see today, it is even more difficult to maintain any degree of professionalism within the medical community.

Let us explore the acceptable internal marketing techniques that can be used effectively to promote plastic surgery, and even look at the methods that have been ineffective, counterproductive and cost prohibitive. The best marketing strategy for a plastic surgeon is to maintain patient loyalty and patient awareness in the specialty of plastic surgery.

General overview

Plastic surgery, unlike many other specialties, is enjoying an increasing growth and demand for services. Since the 1970s to the present, there has been a huge increase in plastic surgeries nationally; however, the increased competition from many other specialists who also do plastic surgery is increasing at an alarming rate. We compete for the upscale young, middle-aged men and women with discretionary income who are willing to pay for elective plastic surgical procedures.

The faces of competition

The competition, particularly in aesthetic surgery, is increasing. There is an increasing amount of marketing for plastic surgical patients from “marketeers”, hospitals and so-called “cosmetic surgery centers”. They all use media marketing and distribute patients among provider participants. However this high-profile marketing, which is supposed to attract patients with high to middle incomes for elective procedures, may not be as profitable because of the high cost of promotion and since the procedures are not paid for by third-party payers. So, there are large out of pocket costs to the patient, generating high fees, but necessary low reimbursements to outpatient facilities.

The many “marketing programs” that attempt to generate patients for select plastic surgeons or “cosmetic surgeons” through generic marketing efforts, have diluted the quality of plastic surgery and perhaps put in jeopardy the quality of surgeons who may be marketing with a corporate entity.

What is marketing?

Marketing and advertising are not interchangeable terms. Marketing is a process of learning who your customers are, what they need, and what they want from your organization, thus allowing you to access that information (research) to make policy, service and programmatic decisions (planning), to implement new policies, services and programs. Then feedback is requested (testing, tracking) to let your customers (patients) know that you have responded to their needs and concerns (communications). Customer satisfaction is the ultimate goal of any marketing program. Marketing is the soul of commerce. It is a fundamental principle of commercial activity and has become a recognized modality in the health care delivery system in the United States.

Definition of terms in marketing

Basically, marketing is an activity which places the producer (physician) of a product (medical service, surgical or otherwise) into a mutually beneficial relationship with the potential customer (patient) of that product. The concept of marketing traditionally addresses the four Ps:

1. The product or service, which is to be sold.

2. The positioning of the produce in the marketplace.

3. The price or cost of the product or service.

4. The promotion of the product.

We are going to concern ourselves with the last element, the appropriate, ethical, and financially efficient way of promoting our products, which are plastic surgical services.

External marketing and advertising

Because advertising combines creativity with marketing strategy, it does hopefully attempt to gain the best results for one’s dollar. Paid advertising, of course, allows one to control the timely placement of message and message content, and hopefully with careful planning and exposure, to create widespread awareness and ultimately increase patient flow into a physician’s office. With a good advertising campaign, a plastic surgeon can accomplish a successful public relations program that will create awareness, educate, be of generate interest, and hopefully enhance reputation.

Unfortunately, such a creative advertising and marketing program from an external approach does cost a lot of money. This does not work as well as medical marketing companies would lead us to believe. Plastic surgeons who have approached their marketing strategies by heavy media advertising have found that it almost becomes cost prohibitive and that the dollar return may not ultimately generate the expected bottom line. While public advertising may be a part of a general marketing program, it certainly cannot be the only means of attracting patients who we wish to have in our practice. The question is, is it easier for a plastic surgeon to attract prospective patients by advertising only, or is it more effective to attract and retain new patients from one’s own practice and physician referrals by using other marketing techniques?

Internal marketing

The cost of promotion to bring in new patients to the practice can be significantly diminished if internal marketing programs are in place and effectively used. Very simply put, what one does is deputize patients, friends, relatives, and hopefully physicians to refer to your practice. It is important, therefore, in internal marketing to have a large or growing base of patients who will be interested in elective plastic surgical procedures, and at the same time approach groups outside your immediate practice circle through some effective cost-efficient external marketing techniques other than mass media advertising.

Therefore, you must evaluate your practice:

• Find out if your practice is enjoying a fair market share of existing patients.

• Identify the most promising potential consumers of elective plastic surgical services for your practice and hopefully create new market sectors where patients can be tapped (aesthetic surgery, pediatric plastic surgery outpatient facility, skin care, etc.).

• Are there new operative procedures that you can learn and put into practice so that your practice has an ever-expanding armamentarium of procedures for your patient population (microsurgery, craniofacial surgery, hand surgery)?

The basic steps of developing a plan and strategy are:

• Scrutinize your practice.

• Find out what are its strengths and its weaknesses.

• Define the service that you are providing.

• Find who else you could employ to provide them.

• Keep track of your competition and find out what they do right, what they do wrong, who they are, and why you are better or worse.

Examine what promotional efforts you have had in the past. If you have not had any, then begin to develop some within your practice. You have to create a program that will enhance your image as an ethical, professional plastic surgeon and maintain a professional atmosphere that patients will be attracted to. The bottom line is that you have to be able to produce and the product is good results in plastic surgery. You can package your image any way that you want, but if you cannot produce a final result of good ethical quality plastic surgery, you will not survive, no matter how much marketing you create. Remember, reputation is the key.

Things that you can do immediately to improve your practice

Well-trained staff

The best internal marketing tool is a well-trained staff. The staff person who answers your phone makes the first impression with prospective patients. As obvious as this seems, I have noticed that many doctors are probably not aware of how their phone is being answered. Patients should feel, from the very first phone call that their needs are your most important concern. They should also perceive that your appointment schedule and other aspects of your office management are handled in a highly efficient manner. These impressions can be easily conveyed if the person answering the phone uses appropriate language and a bright pleasant tone of voice. I advise against using an answering service or machine during normal business hours, including lunchtime; however, if you do, make sure that the service is coached in the proper way to handle your calls and that they identify your office and do not just say, “Doctor’s office.” Have a human being answer the phone, not a machine.

Initial office visit

The next step in creating a positive impression is the initial office visit. Office décor should be consistent with your practice and comfortably appealing. Avoid ostentatiousness as this may very well have a negative psychological effect on patients who may automatically assume they cannot afford you.

Flow of patients

The flow of patients in the office should be smooth; try to keep appointments with prospective patients comfortably separate from postop patients. We have all had those occasional patients who want to argue over fees or make other complaints; as minor as they may be, they are surely disconcerting to new patients. Remember, the patients want their doctor’s office to be well organized for psychological reasons as well as practical ones. After all, if a doctor’s office is chaotic, might not his operating room be similarly haphazard? You do not want such thoughts ever to enter a patient’s mind.

Probably the best thing that I have done in my practice is to hire a patient coordinator. Typically, the patient coordinator will meet with the patient, either before or after his/her appointment. She will show the patient any videos, photos or computer images relative to the procedure of interest, discuss the patient’s history, expectations and answer questions, and put the patient at ease. It also helps the doctor compile a more complete profile of the patient than would be possible through a typically time-constrained consultation. Remember, it is vital that all staff members who deal with the patients are consistent in their approach; be sure you adequately prepare them through a comprehensive staff training program. You always want your staff to express your philosophy, plans and procedures, not their own personal ideas.

Small touches

Small touches are important. No patient ever visits our office without receiving a thank you note mailed out the next day. We also make a point of sending thank you’s to referring patients and physicians. Keep in touch with past patients, even if it is only a once-a-year mailing of a newsletter, practice brochure or patient questionnaire. People enjoy receiving information on new techniques in aesthetic surgery or being updated on changes within your practice. If you send out any kind of literature, invest the time and money to make the piece attractive. A poorly designed newsletter or brochure will not achieve positive results for your practice.

Track patients through a computer system to make periodic mailings a relatively easy task. On a monthly basis, track potential surgical patients against new patients seen in consultation. At least once or twice a year compile and check this ratio. If the ratio is less than 50% of new patients actually scheduling for surgery, try to find out what is happening to the rest of your prospects. Consult your records for clues. This review is likely to suggest changes that you might make in your practice management and your personal style and/or your staff’s approach to patients. Use personal public relations rather than advertising to boost your image in the community. This will keep your promotional costs down. Offer seminars on aesthetic surgery or plan an open house in your office. Especially if you have an office surgical center, prepare your staff adequately for these kinds of professional or social interactions in or outside of your office.

Personal contact

In any patient contact, be personal. Show the patient through eye contact and brief touch that he or she has your respect. Jot down in your notes personal items, which the patient mentions such as a new job, an upcoming vacation, the wedding of a son or a daughter, etc. The next time you see your patient, ask her how the new job is or how the vacation to Bermuda went. The patient will be amazed at your memory and such inquiries will help convey genuine interest and maintain your concern in the patient. It is that kind of friendly professionalism which earns trust and shows that you are a caring physician.

Happy and informed

Remember, your most receptive audience are your patients. Keep them happy and informed. Remember, a happy patient, on average, will tell three or four other prospective patients about you, but an unhappy patient will spread the bad news to 20 or more patients. Remember, a professional, ethical reputation is the key.

Steps in creating an internal marketing program

Introduction

In structuring practice enhancement, you must:

1. Evaluate the needs of your practice.

2. Plan a budget.

3. Look critically at your practice.

4. Look outside your practice.

5. Plan and outline a program that fits you personally.

Let’s look at these areas individually:

1. Evaluate your practice

A. Are you satisfied?

B. Are you financially viable?

C. Do you have a good patient mix?

D. Are you growing?

E. Where do you want to go with your practice?

If the answer is “yes” to A–D then you need to go no further, but if the answer is “no” to any of them, then you need to proceed with a customized marketing program that fits your personal image.

2. Plan a budget

A. 10–15% of revenue to start.

B. 5–7% of revenue to expand.

C. 7–10% of revenue for new ventures.

D. 3–5% of revenue to continue as you are after you have established a program.

These percentages are estimates; budget what you can afford.

3. Look at your practice

A. Who are your patients?

B. Who are your referrals?

C. How good is your staff?

D. What is your image?

This is a real test of your ability to assess your present practice honestly, so that you can address the areas in your office that need tweaking.

4. Look outside your practice

A. Who is your competition?

B. How is your location?

C. Do you need to promote yourself?

D. How does your practice measure up to others in your community?

The bottom line of structuring is a practice enhancement program; after you have established such a program it is important that you evaluate and track your practice’s finances on a quarterly basis. You should only commit the monies that you can spare into any program. It takes at least 6–12 months to see any results of any marketing program. The results are never direct, but will show up in the number of patients that you see, the turnover of new patients to surgeries and obviously your profit and loss statement. Remember, you can do it yourself with minimal outside help. You know your practice better and plastic surgery better than anybody else. Just take the time to look at your practice. Remember that advertising is like a drug habit; once you start, you cannot stop it because that may be your source of new patients. And finally, do not let your overheads bury you!

Strategic plan

Introduction

A strategic plan is nothing more than future plans based on progressive ideas solidly backed by concrete facts and concepts. Remember, while one cannot predict the future, all new concepts and ideas come from somebody’s dream of what he/she would like to do or be. We have to see where we are today, where we want to go and where we would like to be realistically in the future. Hopefully, with organized planning, we will take all the right steps and do all the right things to achieve the proposed concepts.

But to achieve a strategic plan, one has to sit down and formulate an overall concept, and certain questions need to be answered before formulating a plan.

Questions

1. What do you want to do? (MISSION).

2. What are you today? (CURRENT STATE).

3. What do you want to be? (VISION/FUTURE STATE).

4. What do you have to do? (AREAS OF FOCUS).

5. How do you get there? (STRATEGIES).

6. How will you know when you are doing these things well? (TRACKING).

Then create a stepwise overview project to organize the steps in putting any program into effect.

Overview

Step I: Project organization. (Decide where you want to go with your practice.)

Step II: Information collection.

Step III: Situational assessment. (What do you need to change to achieve these goals?)

Step IV: Strategy development. (Develop a place with some professional assistance if needed.)

Step V: Implementation. (Implement a reasonable approach which fits you.)

Different plans for implementation

Phase I

1. Evaluate your practice.

2. Evaluate your patient population.

3. Evaluate your surgical mix.

4. Create identifying images (logo).

5. Streamline your office patient care.

6. Discuss your new patient approach with staff.

7. Develop brochures or use them more efficiently.

8. Develop a newsletter. (May not give direct results and is very expensive and occasionally overdone.)

9. Develop patient acknowledgment letters, cards and thank you notes.

10. Develop patient follow-up letters.

11. Develop representative programs for plastic surgery to prospective patient groups in or outside your office complex.

12. Directory advertising. (Is just another yellow paper ad – unless you are first, e.g. AAAA Plastic Surgery.)

13. Patient coordinator program in office.

14. Use hospital marketing director to market plastic surgery.

15. Direct media advertising.

16. Tracking system for patients.

17. Evaluate the costs of any program versus the bottom line.

18. Abandon any program if results do not justify the expense.

Phase II

1. Paper trail of informational booklets, i.e. pre and postoperative instructions on all procedures.

2. Personalized all-purpose book on plastic or aesthetic surgery.

3. Elegant, stylish brochure about your practice.

4. Personalized videotapes of procedures.

5. Personalized informed consent and brochures.

6. Website (important).

7. Office surgery.

8. A postoperative extended care facility.

Phase III

1. Open house for patients, public and physicians.

2. Contracts with managed care programs (HMOs, PPOs, etc.).

3. Financing for non-covered surgical services.

4. To referral sources offer more than a letter of thank you or a Christmas present:

a. to patients; offer discounts
b. to doctors; offer discount to their patients and/or free consultations.

5. Gifts to patients, i.e. flowers, scrub shirts, scarf, pocket calendar, cosmetics, etc.

6. Amenities: facials, body massages, a day of luxury.

7. Skincare/spa or service with cosmetics with logo (creams, lotions, anti-wrinkle creams, etc. – expensive investment).

Conclusion

Marketing is like a tree. It must be planted, allowed to take root, to grow and to leaf out before you can expect it to bear fruit. Before you begin any marketing program, take a hard and thorough look at where you are in relation to where you want to be. Look at your life-long goals and assess your areas of strength and areas in which you need to improve, not only in your practice, but in your own personal life and find out if professional marketing is something that you can feel comfortable with, that you can live with and that will fit into your overall financial strategies. To be successful, you have to communicate effectively that you can satisfy the patient’s needs as well as your personal needs. You have to choose the types of communication that are in line with your own comfort level, and follow those activities that you feel are appropriate for you as a surgeon and as an individual.

Further reading

Albrecht K, Zemks R. Service American – doing business in the new economy. Homewood, IL: Dow Jones-Irwin; 1989.

Antin HB, Antin A. Secrets from the lost art of marketing. New Orleans: The Antin Marketing Group; 1992.

Baum N. Marketing your clinical practice. Gaithersburg, MD, 1992

Beckaham JD. Marketing your practice – a practical guide for physicians. Arlington Heights, IL: Health Market, Inc; 1993.

Brown S, Nelson AM, Branhesh S, Wood S. Patient satisfaction pays. GaithersburgMD: Aspen Publications; 1995.

Brown SW, Morley AP. Marketing strategies for physicians. A guide to practice growth. Oradell, NJ: Medical Economics Books; 1996.

Colon GA, Church JM. Office surgery – old concept modernized. J Louisiana State Med Soc. 1982;134(5):7–9.

Colon GA. Office surgery. Current Therapy in Plastic and Reconstructive Surgery. J Louisiana State Med Soc. 1988:416–419.

Hillestad SG, Berkowitz E. Health care marketing plans: from strategy to action. Homewood, IL: Dow Jones-Irwin.

Jewell M, Jewell M. Practice management. Newport Beach, CA: ASAPS; 1998.

LeBoeuf M. How to get and keep the customer for life. New York: Putnam; 1997.

McCormack M. What they Don’t Teach Your at the Harvard Business School. New York, NY: Bantam Books; 1997.

Naisbitt J. Megatrends – ten new directions transforming our lives. New York, NY: Warner Books; 1997.

Nelson AM, Wood S, Brown S, Branhesh S. Improving patient satisfaction. Gaithersburg, MD: Aspen Publications.

Office management and practice management. Chicago, IL: ASPRS, 1987.

Poppe F. 50 Rules to keep a client happy. New York: Harper and Row; 1988.

Portnoy S, Stromberg E, et al. Acquiring and enhancing physician’s practices. New York: American Hospital Publishing; 1993.

Practice development for residents. Chicago, IL: ASPRS, 1992.

Quick J. A short book on the subject of speaking. New York, NY: McGraw Hill.

Ramirez LD, Lowder JD, Lowder BL. Practice growth through effective patient relations (proven techniques for plastic surgeons to increase cosmetic surgery). Salt Lake City, UT: Medical Marketing Service, Inc; 1999.

Sachs L. Do-it-yourself marketing for the professional practice. Englewood Cliffs, NJ: Prentice-Hall.

Starr P. The social transformation of American medicine. New York, NY: Basic Books; 1985.

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