Grand Rounds-Starting a New Job: Part III-Business Development

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- Hello, ladies and gentlemen, this is the third part of the three part series, discussing the principles of starting your new job and business and development. Thank you for joining us.

- Business development is usually very important to a young surgeon success. Oftentimes I get this objection to people who start their practices and they are slow, they say, I don't wanna do business development, I just wanna operate. And of course you just wanna operate, but the cases don't normally just fall from the sky and into your O.R, so going out, shaking hands, meeting people and letting them know that you are ready and open for business is often an important part of the job.

- So you want to make a good impression when you first start, and this is gonna be vitally important to show that you're not there just to see what the practice is going to hand you, but you wanna show that you want to contribute to the growth of that practice and it will require going out to beat the bushes a bit, to get it done.

- I have had a candidate who is very successful in a business development, and he actually found out how to make these very cookies, which you see a picture of and if you Google a brain cookie, you can actually find directions for these right on the internet where he found them. He these fancy brain cookies around to the offices of referring physicians. Everybody remembered the brain cook sheets, and you know, the cookies, are more for the, you know, the staff at the office, but it makes an impression to bring some kind of you know, a little gift of food when you go visiting. Make sure that you that the people that you are talking to, the referring physician and whoever's at the front desk, make sure they have your cell phone number. Sometimes I have seen enterprising people not put their cell phone number on their business card, not have it printed on their card, but instead they have handwritten it on their card, on the front of the card because it makes the person receiving the card feel a little special, right? Oh, that physician, he gave me his personal cell phone number and they very intentionally left it off of the card, which seems, you know, maybe a little salesy, but I actually think it's the nice thing to do. It's really important to thank people for every referral that they send you, including the low and the no-pay patients. I have had people make this mistake before, a surgeon called me and he told me that he wasn't very busy. And I asked him to tell me what he was doing to develop business, and he says, well, you know, these guys, they only send me the low pay and the no pay stuff. And so I called him and I hassled him about it. I told him, you know, you send me all the junk and I would like to be the physician for all of your patients. And I said, wow. When you told him that the patients you sent they were junk, I wonder how he felt about that . It's really important to always say thank you for referral. Just like you say, thank you for a job offer. Even if it's not exactly the referral that you want, because every time you get to handle a referral, you have then an opportunity to develop a relationship with the referring physician. And even if it's not the referral that you most want, if you say thank you for the referral and you follow up with the referring physician to let them know how the patient is doing, you will make a great impression on that doctor. And then the referring physician will be more likely to send you patients in the future. It's also really important sometimes to know if there is a third party, that is in charge of deciding who gets what referrals. Some hospitals use referral services, basically phone people, who decide which doctor gets called. And if you're in that situation, it's important to get to know those people and to be really nice to them, because they may help determine whether or not you get referrals of patients or not. And ask your employer if a meet and greet reception could be arranged. Recognize it costs money, acknowledge that to the practice, but tell them there's nothing that you would love more than to meet some of the referring physicians in the community and if a little wine and cheese could be arranged, it would be a great idea for you to be able to shake some hands.

- So that's all good advice. I think it's what many have heard before, about the three A's of a successful practice, especially when you're first starting your practice. First 'A' being Availability. You have to be available when someone calls to refer you a patient and the answer has to be send them over or I'll see him tomorrow. If you get a hospital consult, you don't want to say, well, is it okay if I see that patient tomorrow. Until you've established your reputation, you have to be Johnny on the spot and be available. The second 'A', from Availability is Affability. They have to like you. You have to be somewhat outgoing and social with these people, when you talk to them with referring doctors, and as you mentioned, their office staff, because frequently the office staff is the one making the referral more than the doctor. And then the third 'A' is Ability, so you got Availability Affability and Ability. So you'd like to have some early successes in your practice and then, you know, word will get out that you're providing good care to the patients. And those three things I think will make you successful.

- That's great advice. Success in your practice starts at home. If your spouse or children are not doing well in the community, chances are you will wind up looking for a new job. And it's often really easy to lose track of the people that love you, that you take for granted and rely on for support or sometimes who are depending on you, you know when you move. It's important even in the very stressful time of starting a new practice, to make sure that you talk to your spouse about how he or she is feeling, how his or her new job is going, make some time for each other, don't let the marriage fall apart. Don't let the kids develop problems because you are so focused on that practice.

- Agreed

- Something that is really increasing is hospital employment. We certainly believe it's increasing tremendously in neurosurgery and to be successful as a hospital employee requires that you understand something about corporate culture. And I'm gonna go out on a little bit of a limb here and talk about some of my experiences with neurosurgeons who are in employed arrangements and who aren't always successful and the things that make people less successful and what we can learn from those lessons to make sure that we are successful. One of them is to know that it's critically important that all of the people at the hospital at the administrative level perceive that you are a team player. That you share their vision and their aspirations for the practice. And one of the things that I see very commonly is that neurosurgeons are born and bred as problem solvers. They don't want to make promises that they can't keep, there're very data-driven. You know, as a breed, you all are very precise and nobody wants to say, yes, let's develop this great practice, if they don't actually think that step-by-step, they can accomplish each of these things that they're talking about within a year. Whereas hospital administrators, I find are often more aspirational, when they're talking about what they wanna do. And I'm not saying that they don't have goals in mind and that they don't have a strategic plan for accomplishing those goals. But I do find that neurosurgeons often take a much more serious approach to is that goal achievable? And if not, I have to make an objection. And sometimes in the process of making those objections, the administrators go, whoa, that person is not on the same team as me. They don't share my goals, that I'm saying that I wanna develop this great practice and that person's saying it can't be done for a hundred different reasons. And it's very important to recognize the difference between an aspirational personality or culture and a problem solving personality or culture. And to know that when you are working with hospital administrators, it's important to know that you can share their aspirations and then still share with them some of the challenges that you may you know have or faced in making all those big dreams come true, while being very reassuring to them that you share those aspirations and you wanna meet those challenges together. So I think that's a very important thing for people to know, when they're thinking about an employed position, is how to deal with hospital administrators who may have you know big dreams for a program or program development. When there may be challenges along the way, you can be both aspirational and focused on problem solving, but you have to be very reassuring while you're looking at the problem solving piece that your aspirational as well. It's also important to come into any workplace quietly. I mean, there are some CEO positions where, you know, the rule is, is that when a new CEO comes in, you're not allowed to make any changes for the first six months. And I think it's good for neurosurgeons to think about their jobs much the same way. Come in quietly, listen a lot, when you come into a position. One of the trickiest positions to come into is this situation where the administration is hiring you to make big changes and you come in and you're gonna make big changes, and the hospital employees who are accustomed to working in a very certain way go, whoa, I'm really surprised by this guy. He wants me to do this and this and this and God, we've never operated that way. I've never worked this hard and now I'm really tired, and I don't think I like this person maybe I'm going to report them to HR for being abusive. It's important to come in very quietly and to recognize that the people who are working for you, are not really working for you. They're working for the hospital, they have an HR department that they can go to if they find you troublesome or problematic. And if the HR department has a negative report about you, then all of a sudden they have to come with their notepad and play check the box. And make sure that they follow the procedures that they have to follow, when they get a complaint about another employee. And it's important to know that, you know, that is the environment of working in a hospital. It's not all negative, but you have to be very sensitive to the people around you and understand that you might not have as much control over the people that you're working with or over your practice environment, as you might have, if you are your own boss and working in your own practice.

- Well, I agree with all those points. I think that one more thing I would say, regardless of whether you take a job with established group or become a hospital employed neurosurgeon, when you're first starting, no matter what happens, do not criticize other doctors. I have seen people out of training come in and they start a new job and they start telling the nurses, oh, I wouldn't have done it that way. They sure do things differently, I never learned to do it that way. And if you come off as being critical of the doctors, who've been practicing there for years, you're not on the right foot, you're gonna have a lot of problems.

- Boy, that is really good advice. I could not agree more. What do you do if you have a problem in your practice, there are some very common problems that people face. One is that you get assigned all of the low pay or no pay patients, or at least it feels that way. Sometimes there was not a clear cut agreement. You might've thought there was a clear agreement, but maybe there wasn't about getting, who gets credit for the money that you're bringing in, when you take call. Is that part of your, you know, considered part of the money that you bring in? Does it go towards calculating your bonus or does it just belong to the practice? Sometimes people feel that they have a senior partner who's trying to take advantage of them sometimes. And this is the most common problem that you don't have enough cases. What do you do if you have a problem? It's important to talk to your partners, and it's critically important when you do talk to them about the problem, that you don't put them on the defensive or make them feel that they're to blame in any way. Because as soon as somebody feels that they're on the defensive, they stop listening. Instead, it's real important to be objective instead of laying blame for something or accusing somebody for the problem, even if you think you know why the problem is the way it is or why you can't do what you wanna do, it's important to be objective. Don't say I'm getting all the low pay and no pay cases, say you know, I noticed that last month I had this many cases and this many of them were uninsured. Just state the facts, give other people the benefit of the doubt when you're dealing with them. Sometimes you think, you know the whole picture but you really don't. And if you give other people the benefit of the doubt, it may give them an opportunity to explain or to correct your assumptions which may not be correct. So when you state a problem if you state it while giving the other person the benefit of the doubt, you'll state it in a non accusatory kind of way. That gives them an opportunity to explain things or to help you come up with a solution rather than being on the defensive.

- I think that's good advice. You listed some of these common problems, and I think that people listening to this, should put some of these issues, back into their contract negotiations. You know the way the money is distributed should have been established before you started the job. And I think you should also, I mean, you can make sure to a degree that the senior partner's not taking advantage of you if you negotiate the contract properly. Obviously people can go against what's in the contract, but at least you have a precedent for bringing those issues up. If you negotiated them in advance.

- Troy, can you suggest how somebody could prevent a situation where they feel they're being taken advantage of through contract negotiation. What kind of term would you suggest to do that?

- Well, it depends what you mean by how they're taking advantage of. sorry. Give me an example of what you mean, they're not being paid properly, or what, what issue are you referring to?

- I guess it could be any of a number of things. You know, it could be that this senior guy is dumping all of his call on you, or I could be that he's cherry picking cases and sending all of the stuff that he doesn't want to you, that seems to be more common complaint that I hear. Again, whether or not it's actually happening is often a matter of perception, important to give people the benefit of the doubt. But, you know, these are people you know seem to seem to complain about problems.

- So if you join a practice, there's only one other person senior to you, it's gonna be a different scenario than if you're joining a group. But if you get there and suddenly, you know, most likely you will have discussed how often you're gonna be on call, before you get there. And then suddenly you get there and you find out you're on call every other day, then you have to have that discussion. Say, my understanding was that I was gonna be on call this many days. How has this changed Or why has this changed? I understood that I was gonna be given access to patients regardless of their insurance, they were you're gonna be distributed based on whatever, diagnosis or availability, I'm very available, but I'm not getting patients. And I think you just need to lay it out on the table and have that discussion in a honest, and non-confrontational way in a non-threatening way. You don't come in there and say, oh, you guys are screwing me, I'm gonna quit. You say you know what, when we met before and we've negotiated this terms and I agreed to come here, it was my understanding that X, Y and Z were gonna happen and those things aren't happening. So what has changed and how can I work with you to correct these problems? And maybe you'll get them corrected and maybe you won't, but I think you have to have that discussion. And sometimes it's also, if there's a larger group is to find an ally. Other than that senior partner, to find an ally in that group, that's already an established neurosurgeon who can kind of advocate for you rather than you being the new guy coming in and complaining. If someone else in the group can take your side as well, I think that's gonna help you.

- I think that is great advice as well. Worst case scenario, you have the wrong fit. It's important not to panic. It's especially important while you are not panicking and it's not fitting that you're not bad mouth, all of the people that you're working with. Do your best to maintain good relationships, communicate in a non-confrontational objective way about whatever issues there are. see if you can resolve them. And if you can't make sure, that you are closing on a good note. That you leave with good relationships on your way out the door, because a reference from your prior employer is really important for your future career success. Even if you're successful landing another job, because you can get references from your residency program for example. It's still very important to know that 10 years from now you may need to look for a job again, and people will definitely want to talk to the people that you've never worked with in the past. So no matter how angry you are, even if you think that the guys absolutely took advantage of you, did not live up to their promises, you know, completely backed you into a corner, and were not trustworthy or were dishonest. Even if you really feel that there were major problems and they were all somebody else's fault, it's very important that you do your best to make sure that you maintain a good relationships on the way out the door. There's no reason to blow up, you can just leave.

- So that's a good point. And it gets back to contract negotiations again. If you join a practice and it works very well, and you're happy there, and they're happy with you, but you missed something in your contract, you're gonna have a pretty good chance of correcting that problem. If it's not working, the terms for your departure will be held to the letter. And if you signed something that said, you're gonna pay them back some money that they've paid you, if you haven't collected enough to cover your expenses or whatever, they're not gonna let up on that and you're gonna leave, owing them money. So I think even though you join a practice expecting it's gonna work well, don't forget the section on termination. And what happens if you leave, because that's where the contract is gonna be held most strictly and if it ever unfortunately gets to court, they're gonna just go by what's written. And the terms of your departure as written in the contract are what you're going to be held to. And if you agreed to pay money you're gonna pay.

- I totally agree with that. And I'd like to share a story about a neurosurgeon I know, who had a provision in his contract, where he was to repay his signing bonus, if he left the practice within a certain period of time. And it was a significant amount of money, and he had already used the money. He didn't have it sitting in the bank and he had already paid taxes on it as income. And, you know, that's a very tricky situation, you're required then to repay money that you don't necessarily have, which means you have to borrow it. Fortunately for him, he maintained such good relationships with everybody, even as he was on his way out the door, that he was able to not quite exactly renegotiate that term on his way out the door. But he said, you know, here's the predicament that I'm in, and I definitely wanna make good on my agreement with you. He worked to understand the perspective of the other party, He said, I understand you would never wanna set a precedent by letting me out of this because if you let me out of it, you let a lot of other people out of it and they've signed the same thing, but could I possibly work it off by doing locum tenens for you over the next several months? And you know, the money that I would make for locum tenens instead we'll go to paying down basically that IOU that I owe you. And they let him do it, because he maintained good relationships on the way out the door.

- And I suspect that was a scenario where he chose to leave and not one where they were trying to terminate him.

- That's exactly right. There were things that were not working for him, and he did choose to leave. He was definitely not terminated, Boy, they wished he would stay, he was terrific.

- I'm sorry, that's why he was able to renegotiate, but again worst case scenario, obviously you plan for the best case, you hope for the best case, you plan for the worst case. And that's why it's important to pay attention, and a good lawyer will do that for you. Pay attention to the terms of your departure, termination clause and what happens, who owes who what. And what happens to your accounts receivable and what happens to your signing bonus, and what happens to your salary guarantee. Those things will all be hidden in there, and it's important to review that just for worst case scenario. Most of the time, it never gets to that, but if it does, you have to be protected.

- Well that's exactly right. Well, we're at the end and I'm probably, I'm guessing that everybody might be glad cause it's been a long time. But hopefully you've gotten a lot of good advice that you can take to your job search and use to help you be successful in your interviews and make sure that you don't botch anything up unintentionally with a practice that you've really liked to impress, and with people that you'd really like to work with. Hopefully the material in this seminar, will give you the best chance of getting the job that you want. The takeaway points to remember are that the purpose of a job interview is to actually obtain an offer. Once you've made a good impression on them, you can decide yourself whether or not you like to practice. But you don't want to love them and not have them love you back. The way to get an offer is to focus on the needs of the practice. And it's important to focus the first site visit, just on getting to know the people. Getting to know the needs of the group, getting to know the culture. Say, thank you even if you don't like the job offer itself, or if you've decided that you're not interested. Let the other party save face, maintain your dignity even if you reject them, just like in dating. Bear in mind that the contract is the beginning of a long-term relationship and make sure that your lawyer knows this as well and behaves accordingly. A contract really can't force anybody to do anything, it only gives you the right to sue or other penalties if the other party breaks their promise. So choose the people that you contract with based on who you trust to live up to their agreements, cause nobody wants a lousy job and a lawsuit. When you get started, go to the offices of referring physicians, introduce yourself. Bring a little gift to the staff usually food. Recruit patients, you are now in the recruiting business, when you are in practice, you're recruiting patients in order to help develop your business. If you do experience problems, talk to your partners and administrators, and be sure not to put anybody on the defensive cause that's when they will stop listening to you. Give them the benefit of the doubt and try to get them to be part of the solution.

- That's very good , I wanna thank you very much for all of this information, I hope it is helpful to people. I think it is good advice. Obviously we had covered a lot of material and this is a good overview, so thank you very much.

- Thank you very much.

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