I went light on the slides for this talk, because a lot of this is going to just be sort of friendly advice and some stories. So first year in private practice is the first year anywhere else. You need to get better at what you do, right? I mean, honestly, you need to pay attention to your endoscopic skills. I mean, you think you're good at endoscopy now? Wait five and ten years. You'll realize that you're going to get really good as you go through practice. And the difference is that when you get out into private practice, you're not going to have an attending to call in to rescue you when you're stuck in the sigmoid colon and you can't get out. You know, you might have a partner in the endoscopy room next to you. They're going to be doing 15 cases and then have time to come save you. So every time that you do a case, pay attention to what went well and what didn't go well. I mean, everything that you can think of as far as, you know, the patient's condition, the body mechanics, everything that you can think about for an endoscopy so that you're not taking 10 minutes to get to the cecum. Eventually, it'd be taking two minutes to get to the cecum on a routine basis. So you need to focus on your craft in the first year. That's really what you have to do. Also, get better at patient interviews. Start to pay attention to the quasi-clinical questions. So you get into the office and you talk to a patient with a reflux that's really gone, it's out of control, and they were also 35 minutes late for their appointment. And you said, ah, come on, send them on back. I'll still see them. I got other patients, but I'll make room. And so you see them and you just happen to ask, oh, I saw that you were a little bit late. Did you have a problem with transportation? Yeah, and my ride didn't show up. Ah, okay. Do you not have a car? Oh, you know, it got repossessed. Oh, are you having, you know, financial problems? Yeah. Yeah, I'm having financial problems. Oh, can you afford your medication? No. No, I really couldn't afford that Nexium anymore. That's why your heartburn is killing you, right? So don't be afraid to get to that level of granularity and work on that every time you see a patient when you're asking those questions. And again, this is not anything related to private practice. This is just getting to be a really good doctor when you no longer have supervision. You know, moving forward, this is what's going to make you an excellent clinician. So you guys are super smart, and you probably have more facts in your head right now than you will ever have again in your life. Trust me, as soon as you get out of fellowship, your brain's going to just start emptying, and you're going to wonder what happened to all that knowledge. So what you've got right now is knowledge. But remember, what you need to develop is wisdom. What is wisdom? Wisdom is knowledge plus experience plus judgment. And that comes with time and attention. And that wisdom is what makes a truly great physician. So work on these things. Think about these things on a day-to-day basis. Did I do everything today that I need to do to continue to progress? Because taken from all the experience of the faculty that you have here, I think we would all say, you know, we were all super smart when we finished fellowship and passed boards and made a 95 and blah, blah, blah. But I'm a way better doctor now, because I've got that wisdom. And study for boards. This is not going to be in your contract, so you don't have to put this in your contract. But make sure that your partners are not going to schedule you heavy until after your boards are done. So that's key. My partners were very nice to me for the first whatever. And then that was actually, I didn't get a two-month vacation after fellowship. I got two days after fellowship. So it was busy. But they were very nice to me until I was, and then they were not nice to me after I passed boards. But still. All right. So some day-to-day advice here. So the most important thing, and I mentioned this a little bit earlier, become efficient. Don't waste time. And it's not just you wasting time. It's finding things in your day-to-day where other people, processes, systems, events are wasting your time. So if you're in your office and you're sitting in your little area, your cubicle, and you've got five patients that are supposed to be there in the next hour, but no one's back in any of the rooms right now, you need to find out why. You need to walk up front. Where are my patients? Is Mrs. Jones here? Her appointment was five minutes ago. Oh yeah, three of your patients are all sitting in the lobby right now, and they're filling out paperwork. Okay, maybe bring one of them back and start the visit without all the paperwork. Let that happen later. Or take a look at your paperwork and say, these forms are garbage. Why are we not doing this online? Why don't we mail these to the patient or have the patient come in a few minutes early or whatever to improve that process? Same thing at the ASC. If you've got patients that are showing up late, you need to find out why. If there are no showing for a procedure, you need to find out why. Is it because of a medical reason, or did they call your office and cancel three days ago, but your office forgot to put that on your schedule, so now you've got a 30 minute gap where you could have been doing something, and now you're not doing anything, so you're reading the news on your phone. So pay attention to that from day to day, and importantly, in the hospital. So you know that your least efficient time is going to be in the hospital waiting for procedures to start, because you're not alone in the hospital. You've got other gastroenterologists and other people in the endoscopy, ambulatory surgery center in the hospital that are monopolizing the time. And other people are going before you, and other people are going after you. If at all possible, do block scheduling. Certainly you will be doing block scheduling in your endoscopy center. So you're there for an entire morning or an entire day, and you're following yourself, so your schedule is not dependent on anyone else's efficiency. So make sure that you're actually in charge of that schedule. At the hospital, it's much less likely that they're going to give you significant block scheduling, but if you can, group cases. So you start first thing in the morning, so you're not waiting for somebody who's doing a complicated ERCP and it went 45 minutes long, right? First thing in the morning, and stack all your cases in the morning. And get them out of the way, and then go back to your office. Okay, so that's just efficiency. I learned, I was not very efficient when I was a fellow. I joined my practice, it was four of us, and one of them was a woman who's still my partner, and she is the most efficient person I've ever met in my life. I learned everything that I learned about efficiency from her, and I still learn from her to this day. And she talks like crazy. Gosh, she just, it's like constant chatting, and I'm like, Barb, how can you do that? How can you chat so much? And it's because she doesn't waste any other time. That's not a waste for her. She likes to chat. That's part of her day. But she's so efficient that it doesn't impact her productivity, and she still gets home in a reasonable time. All right, so pay attention to your physical and your mental health, and this is, obviously, you know this already. So use your support systems as you get out into practice, because you're going to lose touch with some of the people who were your support systems before, like your co-fellows, your program directors, some of your mentors. You're going to move. You're not going to have them on a day-to-day basis. So make sure you've got your support systems. It might be a spouse, a parent, a friend, or your dog, but any of those support systems, you need to use those and realize them for what they are, which is things to keep you sane as you suddenly are out in the real world, and you have to grown up. And it is disconcerting sometimes if you're going into a setting where you're actually, there's not a lot of supervision, and you're on your own. And then, obviously, it helps to have a routine, and the faster you can develop a routine, the happier you'll be, and that's going to include, you know, some downtime, some exercise, and some fun. And sometimes you have to schedule fun, and that's just the way it goes, but if you don't do it, chances are it's not going to get done. Okay, so that's just life advice here. All right, don't undervalue the importance of networking. Networking is huge at all levels of your career. So number one, if you have partners, depending on what size group you join, it might be a group of five, it might be a group of 40, you're likely going to have a core group of physicians in your location that you interact with most of the time. Get to know them socially. Become their friends. Number one, you're going to spend as much time with them as you are with your spouse, and so it's important to know them and to trust them. And the more socially connected you are with your partners, the more likely you are to think alike, the more likely you are to act as a unit and look out for each other. Whereas if you've got some lone wolves going in different directions, it's going to be a little bit more of an every man for himself, every woman for herself kind of a thing. So get to know them socially. It's very gratifying as well. Importantly, get to know your office staff. Get to know your endoscopy staff. If you have a receptionist who's getting divorced and in a terrible mood, and she's clearly going to be snippy with your patients as they walk in the door, and you have to be careful of that because that sets the tone for your office visit, and that sets the tone for your Google review, and you're going to get dinged on that, and that people do pay attention to Google reviews, believe it. So it's important. It's also important to know that you, as their employer, care about them. Don't undervalue that. When you go talk, you think it's not a big deal when you go talk to your receptionist and just shoot the breeze for a little bit. To you, it's nothing. It's nothing. It's just making conversation. To them, it's, oh, Dr. Smith came up and talked to me and wanted to know about my dog. And that's a thing to them. So don't undervalue the fact that you have a doctor before your name. People pay attention to that. It's a big deal. Also pay attention to your endoscopy staff. Look for things in your endoscopy staff, not necessarily how they treat patients. Of course, that's important, but also, are they good? If you have people that, in the endoscopy department, are cutting corners, are not doing appropriate assessments, are doing something that you think is sort of not even positioning patients. If you think it's not up to your standards or it's not what you want done, you're in charge there. It's up to you to make sure that that patient experiences everything they thought it was going to be and you said it was going to be. So get to know that staff. And when you have some criticisms to make, make sure it's constructive. Make sure you're doing it in a positive manner, that you actually get them to change without forcing them to change. They want to change because they say, Oh, yeah, Burgreen, he had a good idea. Maybe we should try that. So again, life advice. Build your referral network. So that's your referring doctors, people that are coming into your practice. That's huge, because you depend on it. Now, it was more back in the day that you really had to have really good relations with internists, with family practitioners, with OBGYNs, etc., because that's where you were getting almost all of your patients, that and friends and family. That is still true, but not to the same degree. Because what we're seeing right now is about 40% of our patients are coming in through the Internet, through Google reviews, etc. Now they might have a panel where their insurance company says they have to go to this group of physicians, but most panels are fairly inclusive. So you're going to be one of many on that panel. Just make sure that you build that network of referral docs, and your network now includes Google. So pay attention to that, because that's going to directly relate to how busy you are and what type of patients you're getting. Also, you're in private practice now. So you don't have the benefit of a hospital system, an employed model of doctors that are all under one roof. So you have to find out who you're going to refer out to when you have a rectal cancer that needs to be resected, when you have a patient that needs radiation, an oncology visit, even something like a dermatology visit. You happen to find a worrisome mole, and you have to send people out. So make sure that you build that network and that you know who's good. And by good, I don't just mean medically good, I mean also good at communication, okay? Because you're going to send this person out, and you're going to need a system to make sure that you got a response from the person you sent that to. In a closed hospital system, that happens pretty routinely. When you're in private practice, these people are in different groups. Their communication to you is entirely dependent on their systems, and you don't know how their systems function. So you need to make sure that you get a response to that referral, because number one, your patient doesn't get good care, and number two, you're liable. If you send a patient somewhere and they never went, or you didn't follow up, then you probably have an issue there. So make sure you know who's good and who's good at communicating. And then finally, call your colleagues. Call your colleagues. When I started out in practice, they say how to build your practice, how to get your reputation out there, and you should try all these, this, that, and the other, bring lunch to your referring doctors. I'm like, bring lunch. Call them. See one of their patients. Hey, I got a patient of yours that has bad Crohn's disease. I know you sent him over. I just want to let you know what I'm doing with him and what the plan is. And it's remarkable how well-received that is, because then that takes the pressure off of them to follow up with you if they didn't get a letter. So call them. Just chat with them about the patient. They love it, by the way. It makes their life easier. And then finally, so make sure that you are paying attention to your reputation and your community, and that is multifaceted, as you can imagine. It means doing a good job for every patient, every time. And even if you didn't do a good job, recover from it. Call the patient and say, you know, and I've actually done this, too, Mrs. Jones, I don't think that visit went very well. I don't think I asked the right questions. I got the impression that you had more questions or were not satisfied. I've done this on multiple occasions, and boy, it is well-received. They're like, wow, I've never had a call like that before. I'm like, well, I felt that I didn't answer all your questions. I didn't address the problems. Am I correct? And they'll go, oh, yeah, you know, it was this, and by the way, then the next week you're seeing their cousin, because they're so happy that you called them. And people really like that. Pay attention to your small business. Remember that you are in a small business. All right, here's the story. I joined my practice in 1993. I was two years to partnership. In 1994, my partners were saying the business was in trouble. We weren't collecting payments. We were losing patients. Our staff was turning over. People were leaving, people, employees that had been there for 10 or 15 years. It took us 10 months, not me, I wasn't a partner, it took the other three of them 10 months to figure out that our office manager was embezzling from us. And it was horrible. We had 100% staff turnover. We got no payment for like three months. I was not a partner, but I got no Christmas bonus because there was no money. And that was the beginning of my journey to learn how to run a practice, because then I realized that my partners were not following the business. No one was monitoring this. And our office manager set up an account at another bank and was diverting checks. And then they left. And that was, that was ugly. That directly impacted my ability to deliver quality clinical care to my patients. Because my medical assistant, who I had trained, left. The billing that we were doing was terrible, late, and incorrect. So patients were getting statements that were making them angry. No one was answering the phones on time. The phones would get shut off over lunch, not turned over, but shut off. And people couldn't get in for appointments. This was directly impacting clinical care. So remember that your office is a small business. Run it like one. Like your career depends on it, because it does. And then finally, focus on your patients from a global perspective. Like I said, pay attention to their needs individually, not just from a clinical medical standpoint, but maybe financial, social, emotional standpoint. You'll figure it out. You're smart people. But also start to think, and this is aspirational in your first year, but start to think about the big picture issues in health care that affect your population of patients. Things like trends in medicine. Why is private equity suddenly in medicine? Why are hospitals getting so big? What government policies are contributing to the way that physicians are practicing medicine or the way the care is delivered to our patients? Start to think about those global things as a hobby in your first year, but maybe more as a significant interest as you get into your career a little bit more, because these things affect our society as a whole, our health care system as a whole, and we're in charge of that. Like it or not, we're in charge of that. So start to think about those things. So I'll stop there. Thank you.

private practice

endoscopic skills

patient interviews

developing wisdom

time efficiency