5 Steps to Build a More Successful Surgical Practice: Insight From Ophthalmologist Dr. Gary Foster

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Gary Foster, MD, ophthalmologist at The Eye Center of Northern Colorado, is a volume cataract and refractive surgeon in Colorado. He is a principle investigator in numerous research projects to enhance eye treatment and also serves a consultant for several different eye research companies.


Dr. Foster identifies five steps physicians must take to build a successful surgical practice.


1. Know thyself. To build a strong practice, Dr. Foster says a surgeon must understand which parts of his or her practice bring the most joy. "If it's interacting with entire families or individuals from the cradle to the grave and having a longitudinal relationship with patients, then it would be counterproductive for a surgeon to specifically try to build a high volume surgical practice," he says. "Whereas if you find that you love surgery more than all the other parts of eye care, then it would make sense to emphasize that part of the practice."


He says it is not uncommon for individuals to take steps to grow the surgical part of their practice when in reality that is where they have the most anxiety. "I have found that I love helping patients with surgery," Dr. Foster says. "I am actually more relaxed in the OR than in the clinic so focusing on a surgical practice has been unifying for me.


"Some people think they're supposed to have high volume and they start running down a pathway that doesn't lead to joy in their life," he says. "There's no way you can sustain effort or excel if it doesn't reflect your true inner desires."


2. Respect and care for your patients. Dr. Foster says one of the most valuable lessons he was taught was that the way physicians treat their first 100 patients in their practice sets a basis for how their described and appreciated in their community and determines the course and trajectory of the practice.


"This bears special focus and attention," he says. "It had been a long since I saw my first 100 patients but recently I've became involved with a new practice where the ophthalmologist left town and I'm going through that same process again in a town outside of where I live. It's very obvious to me that the first 100 patients will absolutely determine if that's a success or not. Patients are all coming to meet the new guy … and they're all walking back out and talking to the other patients that came to this same office and making a determination on whether they will come see me or not. I can feel it very acutely."


These 100 patients are critical for establishing your reputation as thereafter people will come in with some pre-conceived notions about you based on how you treated your earlier patients, he says. "You can't have a mulligan on your first 100 patients, but you can make a goal on what will happen for your next 300 patients and change the direction of your practice," Dr. Foster says. "As your surgical volume grows, care must be taken to maintain and grow the quality of the experience each patients has as well as the quality of their outcomes. This requires that a surgeon never loses sight of why he or she went into medicine — to help patients. It comes down to care and respect for your patients and their individual needs."


3. Anticipate and manage the transitions. As your practice surgical volume begins to grow, you will eventually reach a stage where you're at the natural limit for how much surgery you can do in a week. Your time will be limited because of the need to allocate hours for preoperative visits, consults and postoperative visits. At some point a surgeon can no longer solve this bottleneck by working more hours.


When you reach one of those natural limitations, you must make a decision about whether you're going to grow your surgical volume or top out, Dr. Foster says.


"If you're going to continue to grow your surgical volume then you have to make certain sacrifices," he says. "Changes in staffing or flow could be required. It could mean that someone else is doing more of the primary care and sending the patients to you when it's time for cataract surgery or that someone else is helping you with the postoperative care so you have more slots to see surgical patients." Making changes consistent with your values at these watershed periods allows progress towards goals with fits and starts, while anticipating and preparing for them before they even occur allows for seamless progress.


4. Do great surgery. "Doing great surgery revolves largely around the principal of practice," Dr. Foster says. "The more surgery you do, the better you become. It follows the principles outlined in the book Outliers: To be great at anything you need to spend around 10,000 hours practicing that art. A surgeon that has done 3,000 cases will justifiably feel like they are a very good surgeon, while a surgeon that's done 10,000 cases will feel like they're a much better surgeon than when they had done 3,000. No surgeon that has done the cases would dispute this."


He says there are some improvements in surgery that come incrementally but he has observed significant improvements in surgical skill coming in quantum leaps, usually around every 1,500-2,000 cases. "I just competed one of those jumps earlier this year and feel that I am about a 15 percent better surgeon this year than a year ago," Dr. Foster says.


There are steps you can take to accelerate the process, just as with any skill that requires hand-eye coordination, judgment and wisdom combined all at once, he says. They include gaining additional training, doing site visits to watch great surgeons, studying book techniques and studying video clips of yourself or obtaining video of other surgeons. However, in the end, Dr. Foster says, there's no substitute for hours at the scope. "I have not sensed that the improvement that comes with volume ever stops, no matter how many cases you have done," he says.


Note: Dr. Foster warns that there is a danger in growing your surgical referral network ahead of your surgical abilities, especially with the more challenging cases. Referring doctors will not be keen to weather your building years if there are more skilled and collegial surgeons in the area. The quality of the relationship with the referring doctors and the overall care offered to patients would have to overcome this awkward phase for the network to endure.


5. Surround yourself with superstars that compliment your weaknesses. This step harkens back to step one of "know thyself," Dr. Foster says. "If you're going to have a high-volume surgical practice, there's a certain amount of division of responsibility that's inherent in doing that so that precise surgery occurs and with great customer care," he says. "That requires you surround yourself with superstars and allow them to shine in the process."


For example, if a surgeon has great surgical skills but does not have a healing personality, he or she would need to be surrounded by individuals who possess this trait so patients are able to have that component of their surgical experience. If a surgeon is less organized by nature, he or she would need to be surrounded by individuals who are profoundly organized, otherwise important details will be omitted, which will likely impact the outcome and quality of care.


"This sounds intuitive but if you think you have to be the sun, the moon and the stars on the team, then you will likely not be able to tolerate having any other superstars on your team," Dr. Foster says. "That [approach] places an absolute limitation on how far your practice can and will grow."


Learn more about The Eye Center of Northern Colorado and Dr. Gary Foster.

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