Starting out in surgical practice

1. Starting out in surgical practice Malcolm Steel - Box Hill Hospital TC Nguyen - Dandenong Hospital

2. Timing of commencement • Once you start you can’t go back • Ensure full and adequate training for what you plan to do • Preferable bring back something new • Job availability • Area of need

3. Scientific evidence free zone • Practice good medicine • Service community • Work in a personally satisfying way • Manage workload • Generate income • Maintain quality of life • Recruit future partners • Succession planning

4. General considerations • Site • Colleagues • Scope of practice • Research • Teaching • Marketing • Financial • Public versus private practice

5. Colleagues • Ideally people you know and have worked for • Need to feel comfortable asking for help • Trust • No major personality clashes • Establish basis of collegiate relationship – clinical, practice management

6. Site of Practice • Public Hospital • Private Hospital • Rooms • Endoscopy/day procedure • Proximity to home

7. General organization • Appropriate clinical environment to see patients • Patient information – handouts, booklets • Ease of booking

8. Public Hospital Considerations • Preferably have trained at hospital • Unit structure and mix • Colorectal / general mix • Aim colorectal only • Sessions available • Outpatients, operating, endoscopy, manometry, ultrasound • Call commitments • Colorectal , general, first or second on call • Resident staff • Fellow, registrar, intern • Meetings • MDM (oncology, IBD, audit) • Full time, part time or sessional

9. Private Hospital Considerations • Operating lists and time • Scope for future expansion • Assess extent of need • Endoscopy access • Support services • ICU, radiology inc intervention, • Colleagues • Medical oncology, radiation oncology, physician backup

10. Public hospital • Advantages • Steady hours • Guaranteed income • Administrative duties optional • Guaranteed immediate patient base • Salary packaging/ paid holidays/ CME allowance • Disadvantages • Loss of autonomy • Limited ability to increase income

11. Private practice • Advantage • Autonomy • Potential for increase in income • Disadvantage • More administrative duties • Less income initially

12. Practice development plan • Change in time allocation throughout career • Public – private • Clinical – non clinical • Major surgery, consulting, endoscopy, anal manometry and ultrasound • Anticipate and manage the transitions- as patient volume increases, improve efficiency ( staff, streamlined processes, sites) but ultimately a limit is reached • CME - additional training, visiting leading surgeons, studying book techniques/ videos.

13. Relationship with General Practitioners • Availability • Need a contact number early • Organize cover if not available • After hours contact • Continuity • Affability • Professional attitude • Ability • Ensure adequate training before starting • Subspecialty niche • Practice within scope of practice

14. Visiting General Practitioners • Advantages • GP’s like to know who they refer to • Shows that you are keen • Allows you to give contact details • Disadvantages • May be unpleasant • Time consuming • Presentations to GP Groups • Targeted visits

15. Research • Affiliation with University • Dedicated sessions • Fellows (clinical or research), registrars, residents, students • Professor / Head of Unit with research interest • Physical environment – laboratory, offices, statistician support

16. Teaching • Fellow • Registrar • Examination preparation • University affiliation • Medical students • Existing structure versus ad hoc • Dedicated sessions versus pro bono • Departmental support

17. Relationship to Gastroenterologists • Establish collegiate management • Similar principles to GP’s • Decide whether to refer back for colonoscopy follow ups • Avoid dependent alliances or closed shop arrangements

18. Relationship to General Surgeons • Avoid confrontational attitude – mutual respect • Decide on scope of practice • Emergency and elective setting • Avoid assisting general surgeons in colorectal cases • Establish roles in combined cases

19. Rooms • Hospital or stand alone • Solitary or shared • Owned or rented • Superannuation • In office procedures

20. Solo or group • Autonomy with solo practice • Combined effort in group practice should be more beneficial in long term but too many views may be conflicting. Also learning and collaborative approach. • Appraising a practice- Asset or income based? • Goodwill?

21. Setting up rooms • Rent/ buy (Review long term lease and financial responsibilities) • Staff • Business plan – lawyers, accountant – loans/ insurance • Equipment – furniture, office equipment, surgical tools • Electronic medical records • Apply for hospital privileges • Consulting and operating schedules • Policy and procedure manuals

22. Endoscopy / day procedure centre • Level of facility • Size of procedure • Patient selection • GP anaesthetists

23. Staff • Recruit early • Receptionist • Practice manager • Nurse • Outsourcing typing, theatre booking, billing • Share staff if necessary • Policies and procedure manuals • Benefit package for staff • Get professional advice

24. Advertising • Spectrum from aggressive promotion to no advertising • Direct to referring doctors • Word of mouth best • Website, medical specialist directories, phone directories, journals, social media

25. Marketing • Online presence • Send letters • GP/ gastroenterology/ lay people talks • Volunteering on hospital committees • Get to know your colleagues • Research

26. Financials • Online billing – Medicare Australia’s Eclipse • 30% of turnover? • Get accounting advice to minimize tax • Look at investing in other areas to ensure financial security in the long term

27. Lessons • Align with colleagues you like and respect • Public and private • Preferable one site • Minimize travel to distant hospitals • Work hard – be available • Communicate well with patients and referrers • Take time out

28. Lessons • Understand what aspect of the practice brings out most joy for you. High volume surgical practice versus low volume patient orientated • Respect and care for your patients - Never lose sight of it