By Dr. Daniel G. Eichberg, Guest Writer


By Dr. Ricardo J. Komotar, FAANS, FACS, Guest Writer

White coat investors are adept at reaching early financial independence by increasing their savings rate, paying off debt, and supplementing their income with shrewd investments and physician side hustles. However, while investment dividends, interest, rent, and side-hustle income are critical components of building wealth, physicians should not neglect the importance of maximizing what is likely their largest income stream—their clinical income. The key to increasing clinical income is building a high-volume clinical practice.

Despite our emphasis on the so-called “business side” of practice building, the strategies in this article are genuinely geared toward improving patient care. The ultimate goal is producing a high-volume physician—such as a surgeon develops a vast clinical experience that generally leads to more favorable outcomes. Indeed, multiple high-profile peer-reviewed publications have confirmed that large provider caseloads are associated with improved patient outcomes. This direct relationship between large provider caseloads and patient outcomes is so well documented that it has a name: the volume-outcome effect. We want to empower as many physicians as possible to leverage the volume-outcome effect, thereby enhancing the level of care provided to their patients.


The University of Miami Hospital Story

In 2010, the University of Miami Hospital (UMH) was a newly acquired academic hospital that had seldom performed brain tumor surgeries. Yet by 2018, UMH had become the flagship hospital for one of the busiest brain tumor programs in the country. How did such rapid growth in surgical volume occur in such a short time and in such an intensely competitive market? The fundamental key is to develop an understanding of the forces that drive referral patterns—including access to care, quality of treatment, patient outcomes, referring physician satisfaction, physician reputation, and program recognition.


#1 Have Superior Clinical Outcomes

It may seem obvious, but it bears emphasis—physicians should only strive to achieve superior clinical outcomes and satisfied patients. Patients who have benefited from your care become your best referral source. Appreciative patients with great medical results will help broadcast your practice through word of mouth, posting positive reviews to online physician review websites, and recommendations in support groups for the disease that you treat. Thus, a positive referring cycle is perpetuated.

To have superior clinical outcomes, you must always make patient care your top priority. Complications can happen on even the most routine surgeries or procedures. You need to avoid looking ahead or underestimating the complexity of cases. This can be challenging, especially for a high-volume physician. But you need to make sure that when you are performing an intervention on a patient or are making an important clinical decision, that the task at hand is the only thing that matters and you are 100% focused.

Complication avoidance begins in the clinic before the patient even enters the operating room or procedure suite. Be certain that the intervention you are planning is indicated and that, in general, an intervention is the correct option. For example, when deciding whether patients should undergo brain tumor surgery, malignant tumors, large tumors, tumors that are growing, and tumors that are causing neurological deficits usually require surgical intervention, but small benign tumors that are not growing or are asymptomatic are usually better “treated” with observation and surveillance imaging.

Take the patient to the operating room for the right reasons. A complication during a clinically indicated surgery or procedure is unfortunate but is a known potential risk and is therefore considered acceptable. But unnecessary surgery, with or without complications, is completely unacceptable.

Judicious selection of patients and procedures is a must. Improper surgical indications can tarnish a surgeon’s reputation. It can be difficult to improve one’s reputation after one is branded a surgeon that will “operate on anyone.”

Decisiveness helps avert complications. When evaluating a patient in clinic or making a choice during surgery, take your time, review all the information, consider all the options, and make the best-informed decision. Barring new information, do not change your plan. If new information arises, you can change your approach, but for the most part, stick to your initial well-thought-out plan. Mistakes happen when you question yourself and lack confidence.

You must come to the operating room prepared. Chance favors the prepared mind. The more you anticipate, the fewer complications you will have. You need a set strategy before you go into the operating room. We always ask ourselves and then ask the residents and fellows, “How can we screw this up and hurt the patient?” That way, we envision and prevent these complications before they happen. Usually, there are only a few ways you can really hurt someone for each surgery or procedure. Know and anticipate these, and be mindful.

Attention to detail is critical. Every data point matters and can make a difference, no matter how trivial. Small factors are easy to miss in a high-volume practice, and they can result in major complications. To avoid missing details, make checklists for yourself enumerating the critical elements for all your surgeries. Just like an airline pilot, you must always run through your checklist to make sure you are not forgetting a critical feature.

Round twice a day on your patients. With frequent rounding, you will often be able to discover problems at an early stage, before they become major.

Communication with your patients does not end when they leave the hospital. Email is a happy medium—not too intrusive, but easy to receive and respond to when time permits. Patient communication is key to addressing complications before they become more serious.

Dr. Eichberg and Dr. Komotar are the authors of The Business of Brain Tumors

Always thoroughly explain to patients all potential risks of a surgical intervention, as well as the risks of not performing the surgical intervention. The informed consent process should not be a rote task that only results in a checked box before surgery; rather, it is the establishment of a partnership between physician and patient.

Finally, always read and keep up with the newest techniques and technology to ensure that your patients are getting the most up-to-date treatments for their conditions. Participating in continuing medical education events and conferences is an excellent way to learn of advancements in the field.


#2 Master the Three “A’s”

As a new attending, how do you distinguish yourself from your more experienced colleagues? The easiest way to separate yourself and, thus, to build volume is to become a master of the three “A’s”—availability, affability, and ability, in that order.

Availability trumps all. If you are around and if you quickly answer your phone or email, you will get cases. Sometimes it is easier for referring doctors to send a patient to the first available specialist that they can reach—once the patient has been referred, they no longer have to worry about managing the problem as it is now being taken care of by a specialist.

Availability also applies to taking hospital call. If you are on call more frequently, you will likely get more patient referrals or consults through the Emergency Department, the transfer center, and other medical specialty services in the hospital. Taking call is particularly important early in one’s career—the bulk of your surgical cases will initially come through the Emergency Department.

Affability is the second most important “A.” People have to like dealing with you. If you are abrasive, every interaction with you has a level of friction that people will want to avoid, even subconsciously. If you are rude or unpleasant, people won’t want to work with you, including sending you patients.

Somewhat surprisingly, ability is the third and arguably least important variable. Being a superbly skilled surgical technician helps your reputation, but it is actually not critical to building a practice. It is important to note that in the long term, good outcomes will keep the referrals coming due to word of mouth and physician reviews.

Obviously, ability and skill are critical for improving patient care. But from a practice-building perspective, availability and affability are imperative, yet their importance is often overlooked and underappreciated. Patients expect you to be clinically excellent—they may not be impressed with a good surgical outcome because that is what they expect. However, patients are often pleasantly surprised when a busy physician makes themselves available to answer their questions and if they have a warm personality and good bedside manner that makes them feel cared for.


#3 Expand Your Catchment Area

high volume surgical practice

A catchment area is defined as a geographic area that is served by a particular institution. For hospitals, a catchment area is usually limited to a reasonable driving radius from the hospital, perhaps 30-60 minutes for most patients and diagnoses. However, this distance can be flexible especially when it comes to more exotic diagnoses such as brain tumors. Patients will drive longer distances or even fly if the services are considered valuable enough.

Gap Zones are areas that are not in any hospital’s catchment area—there is no hospital or practice that provides a specific service within a reasonable driving distance. Gap Zones represent huge referral potential and opportunities for growth.

Always aim to expand the boundaries of your catchment area, particularly into Gap Zones. We recommend partnering with your hospital’s administrators to identify your hospital’s catchment area and surrounding Gap Zones. They will typically be happy to facilitate the growth of your practice (and thus the revenue you will bring into the hospital).

Improvements in telecommunication technology and changes in the medico-legal landscape are poised to enable further catchment area expansion. Following the onset of the COVID-19 pandemic, federal and state regulatory changes have enabled routine implementation of telemedicine visits. If a patient does not have to physically come to your office, there is no theoretical limit to the size of your catchment area.


#4 Expand Your Physician Network

Updating the referring physicians that send you patients allows you to build your physician network. Every time a doctor sends you a patient, store their contact information (personal cell phone number and email) in your phone. This makes it easy for you to send updates to the referring doctors about their patients and for them to contact you directly about future patients that may need your services. Make sure to give them your email and personal cell phone number as well. We always let referring physicians know that they can text or call us at any time on our personal cell phones so we can answer their questions quickly or expedite their referrals.

Be sure to safeguard protected health information (PHI), and use HIPAA-compliant technology when communicating electronically.

If patients make an appointment with you on their own without being sent by a referring doctor, ask them which doctor or doctors take care of them. Ask for permission to contact their physician or physicians so that you may provide them with medical updates. If a patient agrees, ask him or her to write down the name, specialty, and phone number of the physician(s).

Every referral, even those that do not result in surgery, is an opportunity to grow your physician network.


#5 Get the Word Out

Your internet presence is the face of your practice. If patients think your professional website is better than your competition’s, they often will assume you are better. This is an equation we have to accept.

Your professional website should be the hub of your online activity. It is the most legitimate of all the different online platforms, which means it carries the most clout. We recommend including a photograph of yourself, your biography, a list of your clinical areas of expertise so prospective patients will know if you treat their condition, written and video patient testimonials, your contact information, and how to make an appointment in your clinic.

Social media has become an indispensable asset to online presence portfolios. Social media accounts are no longer merely for creating status updates to alert friends that you have prepared dinner or bought new sneakers. Social media is serious business. By enabling you to continuously provide updated multimedia content, social media allows you to grow your brand awareness, promote the products and services you offer, and increase the web traffic to your website (where patients can ultimately book a clinic appointment with you). Because your goal is to sell yourself and your professional services, you should incorporate social media into your online presence.

We recognize that some institutions may be stricter about social media participation than others. In fact, there is an incredible range across institutions, with some wholeheartedly endorsing it and others harshly regulating it. Familiarize yourself with the parameters of your home institution and always be vigilant about removing personal health information (PHI). As long as you preserve patient confidentiality and obtain the appropriate consent, you can develop your presence independent of your institution if necessary.

Common social media posts that we share include pre- and post-op MRI collages, photographs of us operating, academic journal articles that we have published, and media appearances. Anything that showcases the excellence of your clinical results and aptitude as a physician makes for a good social media post.


#6 Optimize Coding and Medical Documentation

Coding and accurate documentation of a patient’s hospitalization and surgery is one of the least engaging components of medicine—most physicians understandably prefer to focus on patient care. However, reporting precise information regarding the medical complexity of the patients you care for and the surgeries you perform is absolutely critical for expanding a practice.

Do not neglect this aspect of practice growth by relying solely on your hospital’s coding specialist. Coding specialists are typically not physicians and may have limited knowledge regarding the surgical procedures you perform or the types of patients you care for. Familiarize yourself with the tenets of accurate medical documentation and take an active role in this critical area.

Payers typically reimburse the hospital for services based on the Centers for Medicare and Medicaid Services' (CMS) Medicare Severity Diagnosis Related Group (MS-DRG), as MS-DRG is the most widely used diagnostic and billing standard in the United States. A patient’s hospitalization is classified into the base MS-DRG and modified to Complication/Comorbidity (CC) or Major Complication/Comorbidity (MCC) if a qualifying secondary diagnosis is present. CC diagnostic categories reflect moderate illness severity and contribute to moderately higher hospital reimbursement than the base MS-DRG. MCC diagnostic categories reflect the most severe illness profiles and contribute to significantly higher hospital reimbursement than the base MS-DRG. Such diagnostic distinctions lead to substantially increased hospital reimbursement rates.

Reporting the correct Current Procedural Terminology (CPT) codes for a surgery is critical to ensure that professional fee billing for a procedure is accurate. Additionally, the use of appropriate CPT terminology for procedures will facilitate the hospital coder’s job of reporting International Statistical Classification of Diseases and Related Health Problems (ICD)-10-Procedural Classification System (PCS) codes.

Medical documentation and coding are the “proof” of the value that you provide to the hospital and insurance companies. Accurate medical documentation augments the hospital’s revenue stream. Your practice’s contribution to the hospital’s financials can be effectively leveraged to negotiate requests for increased salary and resources to enable you to provide better care for your patients.

What other advice do you have for creating a successful surgical practice? Did the authors miss anything? Comment below!

[Editor's Note: Dr. Eichberg, a Neurological Surgical Resident at University of Miami School of Medicine, and Dr. Komotar, Professor and Program Director of Neurological Surgery at the University of Miami School of Medicine, are the authors of The Business of Brain Tumors: A Handbook for Building a Patient-Centric Practice with Optimal OutcomesThis article was submitted and approved according to our Guest Post Policy. We have no financial relationship.]