“From my Perspective….The World of Solo Hospital Practice”

I am in solo practice. I’ve been at Golden Valley, 13 years now, going on my 14th year. I think what draws you to a community like this is the people and that it is a retirement community. It’s a little bit of an older population, but we also were rural. So there’s a lot of Medicare, Medicaid here. That’s a segment of the population we serve that other more private groups don’t get the opportunity to take care of. So, I think that’s a niche that we fill. Also we fill the niche for the older folks who don’t have the ability to get to the city or don’t feel comfortable driving to the city to be taken care of. They want to be treated close to home by people who they see in their community, and people who they know on a routine basis outside of the hospital. So I think that’s beneficial.

My practice breakdown is approximately 50% total joint arthroplasty of which we do knee, hip and shoulder. The remaining portion is trauma, arthroscopy and small hand cases. So, we kind of hit a little bit of everything, but we also have filled the dying breed of the small to middle sized community of general orthopedists that is really going away with specialization. There are a number of challenges being in a solo practice. The first challenge is, when I started at Golden Valley, we did not have a full-time orthopedic group or orthopedic specialty. They had somebody who would come in every few weeks do a few cases and then they were gone, and nobody followed the patients. It was just kind of a void. So, I think the first part is just digging in and getting started. You have to get your name out there. Getting patients in the door, and then I think especially in a small community, you can’t hide. So if you do a great job, wonderful. If you are not available or not affable when someone’s family member breaks their hip that weekend, and you say, “Oh no, I’m not available. Just send it.” That doesn’t take long for that community to say, “Well, he’s not really invested in the community. He’s just kind of here and he works when he wants, and doesn’t work when he wants.”

So being available as well as being affable, I think are huge parts of that, and that’s sort of how I built my practice. Initially I was available to really anything and everything. As time goes, you can narrow your scope a little bit, but you’re still going to treat just about everybody. Initially that’s how I built my practice and started to get people in the door. I think another roadblock that you run into is patients have the idea in the back of their head that the city is always better. They can think there’s more technology, there’s more availability, and there’s more things in the city that they don’t have in any small community. That is not always the case and we have two arthroplasty robots. We have a THINK, and we have a MAKO. We have as good of technology as any place in our smaller community.

Also, one thing folks don’t understand is they may go to a larger city and they may not always see the surgeon initially. They may see a nurse practitioner or physician assistant and then if their case is operative, then they get put on the surgeon’s schedule some later. When they come to my clinic, they see me. They don’t see somebody who’s a gatekeeper for me. So, in that sense, they still get to see their surgeon and get to talk about their surgery with their surgeon. So I think that’s something else; availability is huge.

There can be significant financial challenges going off and doing this completely on your own. When I came out of training it was kind of the front end of hospital employee positions. So for me, coming out and being hospital employed directly out of residency was huge because I didn’t have a huge overhead. If I was going out and trying to start my own, buy my own building, employ my own MAs and nurses, that can be catastrophic, if you don’t hit the ground running, because that’s a large investment and you’re spending years paying that off.

Now, once it’s paid off, it’s a great thing because you own it and it’s yours. For me, I felt partnered with the hospital. I don’t feel like I’m an employee, because I started the full time program, and my name is the only name that’s ever been attached to it along with the hospitals.. It’s our practice and they basically pay the bills, but in the end, I really get to make all of the decisions. I’ve got a great management group that I work with at Golden Valley that allows me to do that. Our CEO actually started as a physical therapist, and worked his way all the way up, over the last 30 years. A lot of his career and my career, we’ve kind of worked our way up together. It’s a great partnership for me. I don’t know that every place in a bigger community where you’re one of three or four different surgeons could function that way. I don’t think you could build that because you’re just one of a group of surgeons that if you’re not doing what they want you to do, they may look on to the next person. I have been blessedbecause of the way we all see each other, we go to dinner together, our kids go to school together, it’s a community and not necessarily just a job.

It is also important to mention having a wide surgical range. I think the value is twofold. It is beneficial to your practice and the community to be able to take care of a variety of different problems for the patient. They don’t have to see three different surgeons for three different problems. The patient may come in for knee pain, but during the visit they may bring up their carpal tunnel and you are equipped to take care of both. You don’t have to refer them to someone else, so it is more efficient for them. You’re not bogging down the patient and taking their time just by looking at them and then sending them somewhere else.

The other thing that I would say and I hopefully, you would agree with this is, being able to do a wide range of things really helps you in the operating room. So, if you have a complication, let’s say you’re putting in a total knee in the tibia breaks or you’re doing a reverse total shoulder in the humerus breaks, and you don’t have to immediately call somebody else to come in and help or take over. You just take off your joint replacement hat and put on your trauma hat, and you fix it and move on.

So you’re able to handle the things that come up in the operating room because it’s still in your scope. You’re not saying, “You know what, I don’t understand why or how to fix this. So let me get my partner in here to help me.” I think having a wide range of skills helps, and then I think it gives you the ability to not lose your composure in the operating room because you have the skillset. You know how to change your hat and think a little bit differently. I also think it lets you think outside of the box. So, I think by having different ideas about how to go about things, I mean we all know that there’s different ways to do different procedures, but I think if you don’t think differently, you’re not going to see it differently.
I think when I was directly out of training and trying to kind of build a practice and get my name out there I kind of took it hard, right? I was like “You know what, I think I’m as good as those guys.” You don’t really get your feelings hurt, but at the same time you like, "I think we could do just as good a job for you here. So, we kept working and said, “Okay, well, we’ll see what happens.” Then you start to take the cases that will come to you, and if you do a good job, then those folks talk to their friends. Then it starts to slowly build. It’s not putting up billboards or doing commercials. It’s word of mouth from your patients. As the patients do well, they tell their friends, that starts to build.

Then I saw about five or six years in here, those folks who would say, "Man, I’ve got to go to the city to the specialist at a bigger group. Then all of a sudden I started seeing patients begin to stay home. They just start to come in and say, “You know what, you did my neighbor’s hip or knee.” Also, in the beginning much of the practice was built on trauma. Many of those folks could choose to go amay for their elective case. They could choose to go to the city, but when they broke their hip or they fractured their forearm, they came to our ER.

That gave me the opportunity to take care of the patient, hopefully do a good job and have a good outcome and then they said, “You know what, the next time, I’m going to stay here.” So, it built that avenue of trust. Then you start seeing, like I said, the folks who have the ability to go to the city say, “Wait, we have those robots here? We can do total knees robotically here?” “Well, yeah.” So, they start to stay home. It just starts to build. Now when they leave town for their care it’s not because they’re thinking you can’t do a good job. Maybe it’s because, “Oh, my mom went there and I just want to go to the same place my mom went.”

I still refer patients out for certain things and I think those are the relationships that you cultivate over a career. I think that’s one of those things that when you first start out you don’t know a lot of folks in the area. So maybe you lean on your rep and you say, “Hey, who’s really good in the city at doing spine, or who would you recommend if you had to send your family to?” Then you cultivate that relationship. Your rep gives you the guy’s number, then you make a phone call and say “Hey, I’d love to send you this person. Would you be willing to take them?”

So, those are those relationships that you cultivate. Then when you go to a meeting you get to sit down and have a drink or discuss cases with them you become friends, and that’s the avenue you have built. You trust that you can look at your patient and say, “Hey, listen, the person I’m sending you to is good, and they’re going to do a really great job.” Because I really don’t feel comfortable just saying, “Hey, go find somebody.” That’s my patient, and when I hand them off to somebody, I want to feel like I had a plan for them when I referred them out..

I would expound on the value of high touch patient interactions in two different ways. One, I would completely agree with the high touch, and the moral fulfillment, because it’s one thing to say, “You know what, I did your carpal tunnel and yeah, your fingers are now not numb and you’re able to do more things.” Here when somebody breaks their hip, we’re a rural community, so lots of folks may fall out of their deer stand or get bucked off their horse, and they come to the ER. They’re hurting, scared and you get to come in and treat them start to finish. You don’t refer them out. You treat them at home, in their hometown. The nurses in the hospital know them. I think that can be extremely fulfilling. I think you also have now made a friend. They’re not just a patient to you. They’re a friend, and when you go to the tire store that they work at, they’re like, “Oh no, let me take care of you now.” You’ve now developed that relationship, and so I think that’s significantly more fulfilling. Now, the contralateral side of that to me is it’s also a little bit more stressful because when you do a surgery on a patient, you’re going to see them. You’re going to see them in the community. You’re going to see him at the Fourth of July parade. If they’re doing great, everybody’s happy, but if you were to have a complication, it is now multiplied because you can’t hide from them. You’re going to see them and that’s when really having that relationship with them come in. When you live in a small community your patients are everywhere. They’re here every day, and that’s where I think really caring about the quality of your work is huge in a small town because you cannot hide. If you’re not doing good work, you can’t hide from them, or if you’re not cordial and nice with your patients, you cannot hide from it, and you will get that reputation. So I think it’s both. I think having that high touch is an amazing thing, and I do think you live a happier life, and you’re more satisfied with what you’re doing every day, because you can see the difference you’re making. The downside to it is like I said, you can’t hide from anything. You don’t get the opportunity to go to the other side of town where nobody has seen you.

On the issue of burnout, as being a single surgeon in a decent sized area, you can definitely burn out from just never being off. As we all know the ER never closes. So you can just get tired. Just flat-out, get tired. So, yes you can get burnt out, but I see it differently with the idea of depersonalization. I don’t think that happens as easily in a smaller community. I think it’s harder because when you know the person on the other end of the scalpel, and they’re not just another number. That’s your friend’s grandmother. That’s the lady that you see at the church every weekend. So there’s a name attached with that and there’s a face. So I think the depersonalization aspect doesn’t happen as much, and that can be a huge problem with burnout. We had a great article a couple years ago that the academy put out, and it’s true. I also think that it helps battle it in a smaller community and I just feel like you’re going to do the best possible job you can do for anyone if you know them already in some capacity. You’re going to see them, and you know that you’re a part of their life outside of what you’re doing. I just think that there’s an extra tether to that patient that you don’t have when they just come from far and wide and they’re going to go back to wherever they came from when you’re done. I just think that there’s a face that you put with the name and with the X-ray.

I love this. This is one of the things I said I’m passionate about, and they keep asking you they’re like, “Oh, when do you want a partner?” I’m like, "Yes, kind of want a partner because of just the sheer workload, but on the other side I’m like, but I’ve got to be very careful with who the partner is because I don’t want somebody who’s going to come in here, and could hurt the reputation, but I want them to make things better. I don’t want anything to hurt the reputation of the practice or the hospital.