2008

I was completing my cosmetic fellowship. I had completed a basic plastic surgery residency at the Cleveland Clinic but I felt I needed more private practice experience. I chose an advanced Aesthetic Fellowship in Beverly Hills, one that had offered an associate position attached to the end of the fellowship. What could go wrong? I had the final step of my training ahead of me and a job offer in a prestigious practice. While I had no prior idea of what a mortgage backed security was, nor did I know what Lehman Brothers had to do with plastic surgery, the financial meltdown that was taking place in the US would soon drag the cosmetic surgery industry into a maelstrom. The practice where I was doing my fellowship had an untimely streak of bad luck to coincide with the 2008 crisis: An expensive office renovation, the loss of a high income generating partner, the lead surgeon's expensive divorce, and a trickle of financially fearful patients coming through the door by December of that year. Expenditures overran the business and shortly thereafter the practice had to file for bankruptcy. With it went my dreams for an easy start to my career. My job offer evaporated.

Job options were limited for a young surgeon just starting out, especially at that time. I remember being laughed out of two banks in January 2009 when I went to apply for a practice startup loan. Only a year earlier they were sending me postcards for low interest rate loans for physicians, now those same banks were facing bankruptcy! I had no savings, no assets, and no way to start a practice. I took a job in another state, with a group doing insurance-based hand surgery, reconstructive surgery, and plastic surgery. That experience, while providing good economic stability for my initial move into practice, was unfulfilling. I'd see 40-50 patients a day, with each encounter an effort to balance “face time” with patients against efficiency. We used an Electronic Medical Record (EMR) and there was rarely enough time to enter all the pertinent information during the encounter. I didn't want to “shortchange” my patients by spending their one-on-one time with me entering notes into the computer, so I would take brief notes and finish them at the end of the day. Exhausted each evening, but not done with my work, I'd spend an additional two hours finishing those EMR notes and making sure diagnosis codes were correct. I felt like I was becoming a data entry clerk. My hard work eventually paid off. My commitment to patient care and sacrifices to my personal life led to me becoming even busier but without a commensurate increase in income. When three years had rolled around, I did an audit of our EMR, and found I had more than 11,000 patient encounters! Eventually, the OR became a sort of factory, which was not the way I wanted to do surgery. I started to dislike the direction my career was going. It became more about CPT, ICD-9, Letters of Medical Necessity, and Prior Authorizations, than patient care.

After about three and a half years I had enough. I decided that I did not want to stop loving my profession but I needed a different direction. I mustered the courage to take the plunge and start my own practice, one that I intended to be a closer, more customer-friendly practice—a boutique, not an assembly line. That experience turned out to be one of the most challenging but at the same time most educational parts of my life. I am glad to say that, well over a year after starting my practice, business is thriving.

Based on my experience, I share here some strategies for success. This is just the first in a series of articles in Modern Aesthetics® in which I will provide tips for successfully starting an aesthetic medicine practice.

1. IDENTIFY YOURSELF

What's in a name? Everything! I knew from the start that I wanted a customer-focused practice. The practice name needed to reflect that. Very often, consultants talk about the impact of our receptionist on the patient encounter—whether by phone or in person. Certainly, the patient's first personal interaction with the practice is important. But the practice name makes an impact even before the prospective patient picks up the phone, clicks the mouse, or walks through the door.

I settled on “VIP Plastic Surgery,” because I want every patient that walks into our office to feel that they're the most important person. We're not the VIPs; the patients are. That sets the tone for the culture of our practice.

I go to Nordstrom to shop because I know customer service there is impeccable. And we try to mimic that in our practice. If we sell a skin cream the patient is not happy with, we'll take it back even if they've used half. I'd rather them to get something they like and continue to use and continue to see us, rather than start looking elsewhere

I look at companies like Apple. When you walk into an Apple store with a problem regarding a product, they will sit down with you and help you to the best of their abilities. That's what good businesses are built on: customer service, a friendly atmosphere, good relationships, and most of all caring.

2. MAKE THE COMMITMENT

Anyone starting a practice must be prepared to endure the first year. For me, the first year was the toughest. I think I probably stood and stared out the door more than one day wondering where the patients were. There were many times that first year that I woke up in the middle of the night wondering why I had done this. I went from having a stable salary to not receiving a regular paycheck. That was a tough realization.

When you start your own practice, you know that you are giving up a regular income stream. The reality of this change is challenging to grasp until you are actually in the situation. Your livelihood depends on your success. When transitioning to your own practice, you must commit to this path. You must be financially prudent, willing to endure financial selfsacrifice and hold off personal expenditures. Regular paydays don't happen, and you need to be prepared for that. All too often it may feel like there won't be any ahead. But eventually breaks come. You can't look back; you have to push through.

3. FIND INSPIRATION

It's easy to feel alone when starting your practice. I thought that the fears I had and the disappointments were only unique to me, but nearly all practices endure the same hardships in the first year. One resource I used was the book, Suddenly Solo: The Physician's Guide to Surviving & Thriving in Your Own Medical Practice by Richard Schoor, MD, which is available online as a download for free. It helped me and provided some important tips. Although the book is a little dated now—some information is from 10 or 15 years ago— it gave me a basis to start. And it gave me the reassurance that I would eventually achieve success. It took the author a year to fully establish his practice; At the end of the year he said he would never change anything. Having weathered my first year, I now agree.

4. HIRE THE RIGHT PEOPLE

I recruited my best employee, which was my fiancé at the time, to work with me. That made the difference. To start a practice, the physician can't do everything. Somebody who is vested personally in the practice—a sibling, a son or daughter, a significant other, somebody who you know very, very well that really cares about you—may be more willing to go above and beyond and to do things without having to be constantly directed. There are tasks that need to be done that somebody who cares will understand.

If you don't have that right person who is vested, then you can recruit and hire very talented people—but likely at a high cost. Good people need compensation. You either have to pay them well or make them feel as though there is some reward for being in this practice. And when somebody feels vested in a practice, your practice will grow.

5. BELIEVE IN YOURSELF

The first year in your own practice takes persistence and belief in yourself. No matter how talented you are as a surgeon or a caregiver, succeeding in practice requires a whole different set of skills. Those skills are not taught to us in training or in residency or in medical school or even college. Skills are different than knowledge. An individual with a business administration background or even an MBA may have knowledge, but that doesn't ensure effective real-world application.

When you're actually in a situation, you see the problems that you need to address and become more adept at handling them. The challenges can come in any form. For example, dealing with pharmacy boards at first seemed overwhelming. There were so many things that we needed to show and we needed to develop a process for managing inventory and documentation of prescriptions. It took time to map it all out, to create the protocols and set things in motion. Now we have a pharmacy license and are in our second or third year of dispensing prescription products like topical tretinoin. It's a routine now.

GIVE IT TIME

I firmly believe the first year is the most challenging. The bumps in the road start to seem smaller as you go along. Be patient. Don't get frustrated. Take time for yourself. Get away from it for a while, take a weekend trip, go for a hike, visit with family. Avoid burnout. Exhaustion and pessimism are probably your worst enemies and when you want to defeat an enemy, its best not to feed them well.