Getting down to business: 4 gastroenterologists on learning the other side of medicine

The majority of a physician's training is spent learning the intricacies of medicine: how to perform procedures, diagnosis conditions and treat patients. Gastroenterologists leave fellowship training armed with the knowledge necessary to be an accomplished clinician, but what about the business side of healthcare?

Four GI physicians share their experience taking on the business aspects of practice and how young gastroenterologists can do so as well.

Question: Do you think medical training adequately prepares physicians for the business aspects of practice?

Dr. Larry GoodLarry Good, MD, FACG, founder, CEO Good Pharmaceutical Development, CEO, Compassionate Care Center of New York: Physicians are not adequately trained for the business aspects of medical practice. I am not aware of a single medical school curriculum in the United States that has business training in their curriculum. With the increased prevalence of salaried physicians likely to dominate the marketplace in the future, that is unlikely to change.

However, many physicians are aware that their lack of business skills is a handicap, and many professional societies now run practice management courses. Furthermore, many entrepreneurially physicians are returning to school for advanced business degrees to develop greater expertise in dealing with emerging challenges.

Rajeev Jain, MD, AGAF, AGA Institute Practice Management and Economics Committee Chair, Partner, TexasDr. Jain Digestive Disease Consultants (Dallas): The focus of medical schools and residency programs is to produce excellent clinicians and surgeons who have a deep understanding of medical science so they can appropriately care for patients. In my training in the late 1990s, there was no training revolving around business aspects of medical practice. Even now, our trainees are inadequately prepared for the business aspects of practice, which is vital regardless of what kind of practice setting the trainee enters.

Dr. KosinskiLawrence R. Kosinski, MD, MBA, AGAF, AGA Institute Practice Councilor, partner of Illinois Gastroenterology Group (Elgin): It does not. The time limits of medical school preclude spending important class time on the business of medicine. My brother is Dean of Students for a medical school and tells me that many of our core subjects, like anatomy and histology, are being pushed into college because of time constraints. Also, medical students go to residencies after medical school and sometimes onto fellowships from there. When would you teach them business? Their minds are on mastering the enormous volume of knowledge we call medical education. They just don't have the time until they are actually thinking about their choice for practice. Then, some go into academics, but most go on to private practice. Once this decision is made, that is the time to educate on business, as it will be different for all.  

Robert Lindenberg, MD, Endoscopy Center of Northwest Connecticut (Torrington): I can tell you that historically,Dr. Lindenberg given that my medical training took place 30-plus years ago, medical training did not prepare me for the business aspects of practice at all. Speaking with younger colleagues, I do not get a sense that has changed all that much.

Q: What do you think are the most important business issues for gastroenterologists to understand?

LG: The most important business issue for gastroenterologists is to properly value their services. Is the correct model a high volume, insurance participation plan with extensive use of physician extenders or is it a fee-for-service, low volume practice? Is an IPA a better option?

It is important to evaluate patient mix, demographics, overhead costs and pay careful attention to proper coding, billing and follow-up to make the best decisions.

RJ: Gastroenterologists need to better understand the issues that will directly affect their ability to care for patients and keep their practices financially successful. I think the move to value-based payments is a critical issue for GI physicians to better understand as their practices need to prepare for these new or alternative payment models as both the private sector and government are swiftly moving in this direction. Many insurance plans are creating tiered or narrowed networks which may adversely affect patient flow into GI practices by disrupting well-established referral lines. The AGA provides tools that can help gastroenterologists better understand value-based payments and new payment models at

LK: The single most important business principle that young physicians need to understand today is that medicine is not only a profession, it is also a business. You occupy a place in the total value chain of the provision of healthcare, and you must focus on building your niche. This means you need to develop a competitive advantage and exploit it. There is a significant barrier to entry in medicine and you have to make the most of it. It took many years of study to reach this point and the knowledge you have must be used to your advantage. Whether you are an academic, an employed physician or in private practice, these principles will drive your success. Finally just because you get an MD doesn't mean you have a 30-year ticket to success. Medicine changes constantly and you have to adapt accordingly.  

RL: I believe the most important business issue for gastroenterologists to understand encompasses knowledge of the current environment in which we practice as a specialty. This has a major impact on whether a gastroenterologist can survive as in individual or small group in this environment with the knowledge and savvy of running his own practice. In that regard it is essential to understand what the government regulations are and what insurance companies are doing to remain viable within the same environment.  

The shift to value-based practice of medicine will have a tremendous impact on how a GI practice will survive as a business, and will force gastroenterologists to make decisions on whether they can remain independent or, more likely, choose to become part of a specialty mega-group, or become part of a hospital based multispecialty organization.

With respect to ownership of free-standing endoscopy centers, understanding of single versus joint venture ownership (with a hospital with or without a corporate partner) will be important in order to ensure the future viability of any given center.

Q: How did you learn the business side of medicine?

LG: Like most physicians, I have learned the business aspects of practice by trial and error. Like most physicians, I have made many errors, but I hope that I have not made the same error more than once very often.

RJ: My knowledge on the business side of medicine has been gained by practical experience over the past 15 years. Also, I read articles related to the business side of medicine in the media and medical journals. Coding and practice management based courses offered by the AGA have been a great source of expanding my knowledge in this arena, which can be found at  

LK: I have always been a data wonk from the beginning and have been driven by using data to precipitate changes in physician behavior. One of the smartest things I did in my career was to go back to school in my 40s and get an MBA from a nationally recognized top-tier program, Northwestern University's Kellogg School of Business. It changed my life.  

RL: I learned the business side of medicine through a little of trial and error, but mostly by being surrounded by very knowledgeable consultants. We have had accountants who have been extraordinarily helpful in strategic planning, as well as assisting in analysis of financial trends within our own practice as well as with our endoscopy center.  We have a health attorney/consultant who is brilliant with respect to regulatory issues, as well as assisting in contract negotiations. Taking courses in practice management, as well as in depth courses on how to open an endoscopy center has helped to form a strong foundation from which to build upon over the years.

Q: How do you think knowledge of business has helped your practice over the years?

LG: Being sensitive to the business aspects of practice has actually improved my practice by making my staff and I realize that patient-centered care and patient satisfaction the primary goal.

RJ: I am fortunate to have colleagues in my practice who have a great interest and skill in the business side of medicine. We have used our collective knowledge to keep our practice sound and successful despite the pressures of declining reimbursements. I think having both common sense and business knowledge have helped us to make wise choices regarding the creation of an endoscopy center and other associated ventures.

LK: It has helped transform my small five-doctor practice into one of the largest single specialty practices in the country with 45 doctors, seven ASCs and a captive pathology company. In addition, it has helped my real estate and market-based investments tremendously. Most recently, it has allowed me to start a business, SonarMD, which will be my focus for the last five to10 years of my career.  

RL: The knowledge of business has helped us learn to make decisions that have allowed our practice to evolve in a way that we hope will meet the future of how medicine is practiced. We started as two small practices that merged into a group of five. More recently we spent two years in discussions about making a choice between becoming an employed part of our hospital multispecialty group versus merging into a large GI group. We have evolved into being part of an independent 41-physician GI practice that has the tools and knowledge to meet the current demands of this medical/political climate far better than we could do on our own.  

Q: What advice do you have for young physicians who are just beginning to practice and want to learn about the business of medicine?

LG: I would advise young physicians beginning their medical school careers to make life style decisions in choosing their specialties and be aware that physician incomes vary widely. Just recently, Medscape did an extensive review of physician income reporting the highest and lowest paid specialties. Family physicians and pediatricians are reported to have significantly lower incomes than orthopedists, cardiologists, gastroenterologists, dermatologists and plastic surgeons.

RJ: I would recommend that every young physician who is either finishing their residency or fellowship attend a practice management course, billing/coding seminar and have a more seasoned physician in their practice service as a mentor. These young physicians need to get involved in committees in their practice, hospital and societies. These experiences will provide another level of training and education which can be personally fulfilling and aid in a successful medical career.

LK: Read, read, read! Go to the business meetings that are held every year. I am always surprised and disappointed that some of the best business meetings in the country are not better attended by physicians. There is a lot of knowledge out there being shared. You have to suck it all up.  

RL: Physicians who are just beginning to practice and want (need) to learn about the business of medicine should attend practice management courses and seminars, especially those given by their specialty societies. They should speak with others already out in practice and learn who are the best consultants in the area to assist them in making the best business decisions, so that they can do what they originally intended to do, which is to take care of patients and be the best doctor they can be.

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