The Business of Spine: 7 Steps to Balancing Patient Care & Practicalities of Medicine


Medicine has been thought of as a profession for much longer than it has been considered a business. Spine surgeons undergo rigorous training to learn how to perform the functions of their profession, but as healthcare reform continues to change how medicine is practiced, surgeons are increasingly pressed to not only provide excellent patient but to also take on the role of a business leader.

Adam Crowl, MD, a board-certified orthopedic spine surgeon with Advanced Orthopaedics in Richmond, Va., addresses the lack of business training many spine surgeons' education. He explores ways that surgeons can achieve the delicate balance of providing quality patient care while running a business.


1. Attend AAOS courses. Dr. Crowl entered private practice in 2005 with essentially no training from either his residency or fellowship in the business aspects of medicine. "We had a few morning conferences, less than five, going over coding and what the university needed to have documented to get reimbursed," says Dr. Crowl. During his training, the American Academy of Orthopaedic Surgeons also offered courses on the business of medicine, but few residents or fellows attended these sessions.


There is a great deal of pressure to achieve academically. "Most residents and fellows focus only on learning their craft and increasing knowledge in their respective specialty, trying to prepare for boards which occur about one month after residency," he says. Though residents and fellows may find the business aspects of spine surgery of little immediate importance, this knowledge becomes valuable in the day-to-day demands of a practice.


Dr. Crowl suggests that residency and fellowship directors take an active role in encouraging spine surgeons-in-training to attend any business-related courses offered through AAOS or other societies.


2. Encourage community training. Many spine surgeons assume during their training that the partners they join will teach them about the business side of medicine, but there is a great deal to learn. This assumption combined with the academic environment most spine surgeons train in creates a large gap in knowledge between practicing medicine and running a practice as a business.


"In academic centers, the economics are entirely different than in private practice and most academic surgeons have very little to offer about private practice. This is not a fault, just a fact of life," says Dr. Crowl. Community training is a practical way to breach this division between academic and private practice knowledge.


If residency and fellowship directors recommend rotations in local practices, spine surgeons can gain experience in an environment driven in equal parts by patient care and commitment to maintaining a successful business. "Private practice is mostly about volume, do more, see more; which is very different than the approach in academic medicine." Exposure to both environments will offer a greater amount of preparation for the business elements of the spine field.


3. Practice reputation building. "Many young surgeons fall into the trap of coming into a community being very aggressive and feeling pressured to bring money to the practice they have joined. Young surgeons would do well to think about reputation building first, money second," says Dr. Crowl. "Quality work is rewarded very well through word of mouth with patients and their families, which provides addition referrals and surgeries in the future," says Dr. Crowl.


Many busy spine surgeons reach out to and build relationships with potential referral sources. This builds a steady stream of referrals and provides a spine practice's patients with valuable resource. On the other hand, surgeons have the opportunity to direct patients that do not require surgery to non-operative specialists, further strengthening that bond. Another option is to hold or participate in community-based educational seminars for patients.


4. Track outcomes data. Capturing outcomes data provides a tangible way for practices to demonstrate the value they bring to their patients and communities. This also provides practices with a method of measuring performance and identifying any areas for improvement.


In addition to benefiting patient care, outcomes tracking can prove advantageous for the health of the practice. "If you can track your patients and have some of that data, it can help when renegotiating your insurance contracts," says Dr. Crowl. Data is a powerful tool for leverage.


5. Schedule your time wisely. Spine surgeons have many demands on their time — demands that are only increasing with healthcare reform mandates such as electronic medical records. Proper time management is the key to finding the right balance between quality patient care and a successful business.


Dr. Crowl suggests scheduling clinic days in half day increments. "Spine patients can be exhausting to evaluate in the clinic. Days that are half-day office and half-day surgery helps keep you fresh and more efficient," he says. Trying to cram in additional cases while battling fatigue does nothing to improve the quality of patient care.


Dr. Crowl has a full day in the operating room on Monday and then splits Tuesday and Wednesday between the clinic and the OR. He saw a significant increase in productivity and patient access. "Many patients have difficulty with access to a spine surgeon's care. Most patients who have an acute disc herniation with weakness are not going to wait two weeks to come see you in the office. Being able to capture these patients requires availability," says Dr. Crowl.


Determine the difference between reimbursable time with patients and non-reimbursable time. "Use of physician extenders is of importance to allow the surgeon to spend more time with patients and less time on the mundane documentation and paperwork, peer-to-peer reviews, insurance authorizations, phone calls and prescriptions," says Dr. Crowl. Increased time spent with patients benefits quality of care and promotes surgeon productivity that translates into profit for the practice.


6. Consider adding satellite clinics. Be willing and able to go where the patients are. "When a new surgeon joins a group, the goal is to generate additional business, not subtract from another surgeon's practice. Having satellite clinics in lesser served areas can provide a great new referral source. My group has been setting these up in primary care physician offices," says Dr. Crowl. This opens avenues to new patient groups, increases access to care for patients and generates good will with referral sources, such as primary care physicians.


7. Manage patient expectations. The most-well trained surgeons can have difficulty communicating with patients, but taking the time to properly manage patient expectations is an important part of running a successful practice. Managing expectations "has repetitively shown to be important in patients' self-reported outcomes questionnaires," says Dr. Crowl. "Giving literature and watching videos may help, however being clear about goals and expected outcomes is paramount." Careful expectation management builds valuable relationships with patients and helps build a practice's reputation.


More Articles on Spine:
7 Access to Care Issues for Spine Patients & How Surgeons Can Overcome Them
10 Key Components of On-Call Contracts for Spine Surgeons
Leadership & Innovation in Spine Fellowship Programs: Q&A With Dr. Richard Guyer of Texas Back Institute

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