Private practice is a lonely place – you work for yourself and by yourself.
Patients who see you expect you to know everything. You are not expected to say things like “ I am not good at this”.
The patient would immediately think that you are incompetent and move on to your colleague.
You must always have poise and look confident, even if you are not familiar with the patient’s medical condition.
It is also not common practice to send your patients away to a colleague who may be better skilled at handing their condition.
You try to keep a patient as long as possible until the patient starts to question your management of her.
When I started private practice in 1994, I was young and full of clinical knowledge, but without much experience.
When I was unsure of a patient’s condition, instead of discussing it with colleagues at the hospital I worked in, I would call friends in other parts of the country to seek their advice.
I would rather send a patient away for a second opinion in another city, then ask her to see a colleague in town.
This was because of my insecurity of losing patients.
Being older and more confident now, I am able to tell my patients if I am not good at certain aspects of my field.
I am also confident enough to send patients to colleagues if I think they are better qualified.
This attitude only comes with experience and maturity.
As a young specialist, it may take some time for you to develop this outlook.
There are many situations in which you will need assistance from either a colleague in your own field or one from another speciality.
When and how to get assistance can be tricky.
There will also be situations where a colleague will ask you for assistance.
You will have to decide whether you want to provide that assistance and be aware of the consequences that follow.
I will discuss my experience in this area.
Ask for help judiciously
When I encounter a patient whose case I think is going to be difficult in surgery, I usually inform my two “bodyguards”.
They are my favourite general surgeon, who will deal with all the bowel problems, and a urologist, who will take care of the bladder and the ureters.
This is the easy part as working in a multi-speciality hospital means that both are available and willing to help me perform the surgery.
The only problem is estimating how much they are going to charge for assisting me as I need to inform the patient of the charges beforehand.
With insurance patients, it is easy, but with patients who are paying themselves, I have to make an intelligent estimation.
The patient will then decide whether she can afford the charges.
This can sometimes be tricky and difficult.
Fortunately, both my fellow surgeon and urologist understand the predicament.
They usually give a big discount, and sometimes, even waive their charges.
However, it is totally unfair to expect the surgeon and urologist to come and operate with me on every case. This would be an abuse of their generosity.
Moreover, they will think that I am an incompetent surgeon.
I have seen this happening throughout the country and the patient is unaware of it as she is under anaesthesia.
The outcome is usually good because of the assistance received, but is this the type of doctor you want to be?
In some countries, especially in gynaecological laparoscopic surgery, the surgery is performed completely by another surgeon, known as a “ghost surgeon”.
The patient is unaware that the surgery was actually performed by someone else.
It appears unethical, but it benefits all concerned.
The primary surgeon can keep his patient and the ghost surgeon has an income.
The patient goes home well, thanking and praising her gynaecologist for having performed this wonderful keyhole surgery.
Don’t play favourites
The situation becomes more difficult when there is an unexpected problem or complication during the operation itself.
My usual surgeon or urologist may not be available, therefore I may need the assistance of another surgeon or urologist.
Most of the time my other colleagues in the hospital will come in to assist, but as they know that I only called on them to help because my favourite surgeon or urologist was unavailable, the situation can be uncomfortable.
In one instance, when I was in distress with an unexpected difficult situation, all three of the urologists in my hospital were unavailable.
They were either busy or refused to come.
I was lucky enough to get hold of a urologist from another hospital who was kind enough not only to come help me and save me from future litigation, but also waive all his fees.
I am eternally grateful to him.
Charges in these situations can be more difficult.
If it is an insurance patient, then the insurance company can absorb the other specialists’ charges, but if it is a patient paying out of her own pocket, the bill will escalate for her.
As mentioned above, my favourite surgeon and urologist tend to kindly give a large discount most of the time, and sometimes, even waive their fees, making it easier for me.
Sometimes, I too have to give a large discount so that the bill will not be too high for the patient.
My advice to you if you are a gynaecologist venturing into private practice, is to be good friends with surgeons and urologists.
Call on all of them in turn to assist you and don’t have a favourite.
Allocate as much of a fee for them as you can too.
They may save your day.
I am sure this applies to other specialities as well.
Assisting others
What if another gynaecologist calls you to help him or her when in trouble?
I have been called in to assist on numerous occasions.
I usually drop everything I am doing to help, and I do not charge anything on almost all occasions.
This is because it is impossible for two gynaecologists to charge the same patient for the same procedure.
I consider it a privilege to help a colleague who is in distress.
However, the only thing is that one should not take advantage of this goodwill.
A friend of mine who works in another city has mentioned that he gets called in to help in situations where the decisions can be difficult.
I will give you an example.
If a young woman with an ovarian cyst is in surgery and you discover that the cyst is actually malignant (cancerous) during the surgery itself, what do you do?
The decision as to what procedure to proceed with at that time can be difficult because the patient would not have received the proper counselling prior to the operation.
On the one hand, you cannot simply remove the entire ovary that contains the cancerous cyst (not to mention the surrounding tissues in order to ensure that the entire area is cancer-free) without the patient’s knowledge and agreement, especially as it concerns her future reproductive health.
On the other hand, leaving it in so that you can speak to the patient properly later and get her consent for the proper surgical treatment, means allowing the possibility of the malignant cyst growing and spreading as long as it is in the body.
After being called in to help in numerous such situations, my friend refused to go in any more because of medico-legal problems.
So do remember to try not to place your colleagues in such uncomfortable situations when you call on them for help.
Helpful competitors
Therefore, when in private practice, it is important to be able to work with other doctors.
Your colleagues are also your competitors for patients, but as someone once said, “We work in an environment of friendly competition.”
We are competing, yet helping each other.
Some of us may be good in one aspect of our field, while others may be good in another.
But we try to keep from revealing our clinical weaknesses to our patients so that they continue to see us by getting help from our colleagues without insulting or angering them.
This can be a very delicate situation, especially when you are a young specialist trying to survive by keeping your patients and not losing them to your competitors.
If you can’t understand what I am saying, trust me that you will when you move into private practice.
Dr S. Selva is a consultant obstetrician and gynaecologist, and fertility specialist, in private practice in Melaka. This is the 12th article in a weekly series about surviving private practice in Malaysia. For more information, email starhealth@thestar.com.my. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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