Eyeworld

committed to developing or joining a large practice may be better suited to stay small. Others who are at- tracted to working in a modest, bou- tique practice would do better to overlook the challenges of scale, get out of their personal comfort zone, and gravitate toward building or joining a large practice. 1. What size practice team makes you most comfortable? The answer to this may be obvious from your personal history. If you played large-scale team sports back in school (football, baseball, basketball) you're probably going to be comfort- able jostling in a crowded board- room or at a meeting with a hundred support staff in attendance, and vice-versa. If, like most ophthal- mologists, you revel in a quiet din- ner party with two or three couples but can't stand plunging into a rau- cous New Year's celebration, that may be all you need to know about your happiest practice scale. 2. How well can your personal time availability rise to meet the constant baseline commitments— and periodic sky-high demands—of large practice ownership? If you em- ploy 50 staff, you will have 10 times the personnel headaches of a tidy solo practice, 10 times the absen- teeism, 10 times the job-site drug abuse, and 10 times the exposure to customer service gaps. Some relish the larger playing field, some shrink from it. 3. What's the best fit with your personal lifestyle and competing in- terests? It's no secret that eye sur- geons in their 30s and 40s today are a bit less workaholic than doctors from previous generations. Physi- cians who are simultaneously prac- ticing and raising a young family or juggling other outside interests (teaching, research, a budding art ca- reer perhaps) would do well to con- sider the proper practice setting to fit with their other demands. A suc- cessful, entrepreneurial private prac- tice of any scale obliges 50- and 60-hour workweeks, more in the early years. Happily, given the signif- icant and growing number of open- ings, employing practices are more flexible than ever before in granting a creative template. 4. What's your risk tolerance? Is the safer bet in these challenging times being part of a larger or a smaller practice? Actually, the an- swer is more braided than the ques- tion suggests. The risk of being an ophthalmic business owner was once negligible. Today, more prac- tices falter and fail than ever before. While a small boutique practice may seem more fragile and risky, such businesses can make faster changes, reducing costs or entering new serv- ice lines with little notice. While large group practices may seem less risky, some become ossified, unable to adjust to fast-changing condi- tions. Bottom line: You have to eval- uate every setting differently and especially examine the second-order variables beyond practice size: local population-to-provider ratios, the age distribution of patients and pay- ers, managed care penetration, and the strength and unity of the own- ers. 5. How do you feel about time off from practice? In a large practice, coverage in your absence is no prob- lem. In fact, in a few large practices partners are encouraged to enjoy larger sabbatical breaks, something that is nearly impossible to accom- plish in small-enterprise practices. 6. Are your physical and emo- tional energies and reserves in line with the demands of leading a larger or smaller group? As you can see, leadership demands rise at a faster pace than practice scale. To some ex- tent, these higher demands can be laid off to a growing cohort of mid- dle management staff. But at the root, as a large practice leader you simply have to exert yourself more, physically and emotionally, than in a small practice. Meetings run later into the evenings and there are more of them. Since the stakes are higher, arguments can be more heated and stresses rise, which obliges the fortitude to withstand (ideally, even relish) conflict. 7. How high is your demand for personal control? Running a solo practice board meeting is pretty sim- ple—all decisions are unanimous and you always get the vote you are looking for. This is not so in group practice. A consensual style of prac- tice decision-making works with two or three owners, but "kumbaya man- agement" breaks down with scale. Eventually, majority voting is obliged. If you aspire to a jumbo practice scale, your new favorite say- ing has to be, "I can live with that." 8. Are you concerned about get- ting your investment out when you retire? Selling a practice was rela- tively easy a generation ago. Amer- ica was making nearly 3% more ophthalmologists every year, and a flood of new grads were all too happy to pay a premium to buy in. Now, however, we're not graduating enough new eye surgeons to cover the existing retirement pace of baby boomer doctors, much less take care of the roughly 3% annual growth in the number of new American sen- iors each year. These stark demo- graphics mean that your practice— any practice of any size—will proba- bly be worth a little less in the years ahead. When selling, however, the edge goes to larger practices. A soloist has to find a doctor to take over; a 100% shift in professional labor is needed to accomplish the transaction. A 10-doctor practice has a lot more flexibility with the same succession event: Nine doctors can buy out the retiree painlessly and probably absorb his patient base. Or the large group can simply hire a new grad (who may be easier to coax into a large group in today's envi- ronment), splitting the cost and risk nine ways. Without advance plan- ning, an increasing number of peri- retirement soloists in the years ahead will simply be closing their doors, getting little more than sal- vage value for their tangibles. EW Editors' note: This is an excerpt from John Pinto's upcoming 2012 ASCRS•ASOA book, Ophthalmic Leadership: A Practical Guide for Physicians, Administrators and Teams. EW Ophthalmology Business February 2011 89 ABOUT THE AUTHOR John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979 with offices in San Diego. He can be contacted at 619-223-2233, pintoinc@aol.com, and www.pintoinc. com. He is the country's most-published author on ophthalmology management topics. Seven recent books, John Pinto's Little Green Book of Ophthalmology (3rd Edition), Cash Flow: The Practical Art of Earning More From Your Ophthalmology Practice, Ten Practices: Benchmarks for Success, Turnaround: 21 Weeks to Oph- thalmic Practice Survival and Permanent Improvement, The Efficient Ophthalmolo- gist, Legal Issues in Ophthalmology: A Re- view for Surgeons and Administrators, written with Alan Reider, and The Women of Ophthalmology, written with Elizabeth Davis, M.D., are available from ASCRS• ASOA and may be ordered by calling 703- 591-2220. Figure 1

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