What I learned I should have asked/done in my first year of practice

If you are taking on someone else’s practice, you will also be taking on their mistakes and successes. It will take time for their patients to trust you.

Booking in Patients: Unfortunately, b/c the Ontario Government can’t get their heads out of their collective ass, you won’t have the luxury of “ramping up”.  Because the patients are going to be coming in at full speed, you will need to have a plan. I made a few hours every day my “meet and greets” where I would get families to come in to meet me and go through their health history to get me caught up. Priorities were patients with diabetes, using narcotics, with cancer, polypharmacy, etc. My staff helped flag them as they refilled their meds. 2 - 3 hours were for seeing acute patients/patients that were booked in over the past couple of weeks. At least one hour for labs, scripts and reports.

No general assessments for at least 6 months. If a patient is due for their pap, either divert to an NP or have them booked in for just a pap. Lots of your patients think they need a general assessment to see you. Have staff ask if a meet and greet will do what they want. 

Spend time with each patient’s chart updating it to fit the way you want to practice. It will save you lots of time in the future. 

Your access time in the first year is going to suck. Get over it. As long as you are treating your patients well when they come in, they will forgive you. 

Med Refills: They will be on meds that haven’t had the appropriate labs set up in ages. Set up standard labs and protocols for patients who are calling in for scripts and have your staff automatically order what you want (e.g. LFTs for statins, metabolic panel for antipsychotics, TSH for Li and synthroid…). 

Decide what your rules will be for certain drug classes (opioids, benzos, etc.). My rules were considered stringent by my patients in my first year. I was very clear about max amounts of morphine equivalents I was comfortable with (200). Anyone above that had to see the clinic pharmacist for a review and to see if there are changes that can be made, if the level of pain management is appropriate. Use the McMaster Pain Guidelines. Having the objective tool makes it easier to be firm. http://nationalpaincentre.mcmaster.ca/opioid/  I asked pain and bento patients to be in q4months. I wouldn’t renew scripts unless they came in. Drug testing was mandatory. 

Money: Get everything in writing. All the little bits and pieces that you are paying for in your overhead. Do any of your billings go directly to the clinic? Who is in charge of your billing? How often do they go for training? How do they deal with billings that get sent back? How is overhead split? Do you have to pay rent for the FHT staff or just your FHO staff? Who exactly contributes to the pot for your clinic? Is it the same people who are using the clinic? If you are working rurally - dose your ER billing go to the same billers? hospitalist? OB? 

Governance: How are budgeting decisions made? What makes a vote go through (i.e. is it majority or unanimous?) How are disagreements within the group managed? (ask for an example) What committees will you expected to be a part of? How many days vacation do you get? How does your team feel about you going on vacation? Are locums expected or will they cover your patients when you are not around? Does the team have a plan for mat/pat leave? How many hours are you expected to devote to in clinic time? Who manages your staff? How is that person evaluated? What sort of observation/probation does your team use?

Retaining your recently recruited rural doc

I. Make them feel welcome. Seems obvious, but encouraging all docs to individually welcome the new doc will make a difference. Honestly. Just do it.

II. Give them a list of things that they need to know about in town. Best place to buy groceries, list of housekeepers, electricians, plumbers, etc., restaurants, good place to go for a quick weekend with their partner, vets. Start the list now. Add to it as other ideas come up. These people are not in the yellow pages or local paper when you are in a small town.

III. Prepare a list of commonly used billing codes in your office, hospital, nursing home, wherever you tend to make your money. Each clinic has different common codes. Never assume new docs know them. They’re not taught in residency, and the codes they used elsewhere may not be appropriate. If your new recruit is making money to pay down the debt they have, they will be happier, promise.

IV. Check in frequently. Have someone who is their designated mentor that actually wants the job. Someone who will make sure they don’t feel like they are bothering the mentor. Knowing which docs to refer for what kind of issue is important. Knowing what to do when that doc then turns down all referrals is essential. Weirdness happens every day in the clinic.

V. Have regularly scheduled check ins. Both of you will be ready for the meetings and know that you are safe to say what you need to. If either of you have concerns, a regular meeting makes it easier for both of you to come up with solutions. If you just chat about a few cases, it will be time well spent.

VI. Be clear about numbers. How many days of vacation? How many months of free rent? How is overhead calculated? Everything needs to be in writing so that everyone knows the rules up front. That way when snide remarks like “but no one takes vacation in their first year” can be taken as the jokes they are meant to be.

VII. Make sure their new office and exam rooms are clean. Seriously. No one wants to work in someone else’s year’s of dust and outdated hand outs. That’s gross and indicates that your group doesn’t care about your new recruit.

VIII. Have a welcome dinner. Make spouses welcome. Spouses are the bomb for making new docs feel welcome. They know what their partners went through and will help make your new recruit feel like they belong. While you're at it, ask those spouses to add to this list.

IX. If you notice your new doc is not making it to the lunch room, it’s not a good sign. Check in to see what can be done to lighten the load. They will want to hear your advice.

X. Help them get a family doc. Know that they will NOT be comfortable with one of their colleagues doing their DRE or pap. Follow up to make sure that your friend actually took them on. You’d be surprised. It took my nurse begging a former colleague to get a doc for my partner and I.

XI. If your recruit comes to you with concerns, deal with it. While it’s true that things get better in 5 years (it’s OK to tell them that), it’s not enough. Help them through whatever is going on or you won’t see how much better they are in 5 years.

XII. Baby docs are just out of residency where they are taught that if they don’t have the answer to something, they’re useless. This will be a hard habit to break, but essential that they feel safe in stopping it. 

XIII. Consider a community meeting/doctor to introduce people in town to the new doc. Getting formally introduced may reduce assumptions and gossip that comes later, or at least keep it kind hearted.