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ACHIEVING GROWTH IN PRACTICE

Pankaj K Mehta, Reena Mehta

Family Physicians, Kalachowki, Mumbai 33.

Whenever one enters into practice, one starts dreaming of name, fame and money. But in reality one has to pay price for everything. 10% may be inspiration or good luck but 90% is hard work and good planning.

Today we live in the world full of competition. Right from getting admission to primary school, everywhere we face stiff competition. According to Darvinís rule, fittest will survive.

Achieving growth in practice is an ongoing, continuous process and does not end at any particular point of time. It is usually a slow process, depending upon many factors, including our own willingness for change.

Today we shall discuss certain general principles of growth and our own experience of last twenty years.

When we started practice some twenty years back in a small bylane of kalachowki, Lalbaug, the space was small, about 180 sq. feet. There was a small examination room, a small dispensing cabin and small common room for ourselves and waiting patients. Two doctors were working in that small place simultaneously, myself and my wife. We would take history outside and later use examination room alternately. I still remember my wife knocking at the door if I took little more time in examination.

Right from beginning our motto was to offer something more, something different, something special to our patients than what was offered by our neighbouring practitioners.

In spite of time and space restraint, we started doing some small small things, apart from our routine dispensing practice, like urine examination by simple reagents

Blood for ESR by Westergren Method

Minor surgical procedures like suturing, auroplasty etc.

PV and PS examination
PR; Proctoscopic examination
Injection treatment of piles.
Taking pap smear
Cauterisation of cervix
IUCD insertion
Menstrual Regulation
Immunisation
ECG
Fundoscopic and auroscopic examination
Use of nebuliser

In Mumbai, space is a major constraint but to perform above mentioned procedures one doesnot require extra space.

After initial period of struggle, hard work and dedication one develops good practice. He has settled down in his clinic as well as in his new apartment. His debts are paid long back, he has come extra fund to his credit. He is still young at heart and has inclination to grow. This is the right time to look for a bigger place preferably nearby, where extra facilities can be added.

From 180 sq. feet, we went to 360 sq. feet about ten years back where we could arrange for separate cabins for both of us, where we could leisurely take proper clinical history and detailed clinical examination in total privacy. Space could be spared for a cot for administering IV fluids and post procedure recovery. By timely administering IV fluids, many unnecessary admissions could be averted. Many cases of acute gastroenteritis with mild to moderate dehydration, early pregnancy with vomiting, high fever like malaria or enteric with vomiting can safely be managed in our clinic. Giving rest to g.i. tract for couple of hours and partly correcting the fluid and electrolyte imbalance changes the clinical picture dramatically. Apart from various iv fluids, many drugs can be administered intravenously for predictable results like

IV chemotherapeutic agents

Ciprofloxacin
Ceftriaxone
Metronidazole
IV Ranitidine
IV Ondansetron (Emeset)

A second hand, low powered X-ray machine, with screening facility was purchased. Initially it was used for screening but getting good response, we started taking X-rays mainly chest radiograms. I sold it off last year and got more money than what I had paid for. We purchased high power X-ray machine last year which gives better quality, as well as difficult X-rays and procedures could be undertaken.

To take good X-ray picture is neither difficult nor easy. One has to learn about basic radiology from books and radiologist friend. One has to master dark room technique too to develop films. Later one can train compounder or keep part time technician depending upon response. But there are many advantages and it is financially viable proposition. Apart from extra income from X-rays, these patients come for regular follow up and publicity it gives is tremendous. Concession can be offered to deserving poor patients, thus fulfilling our social obligation. Tie up is necessary with nearby radiologist friend for reporting our X-rays and to guide in case some technical problem arises. In return difficult X-rays, procedures and sonography work is offered.

To start clinical laboratory is very profitable proposition. It requires space as small as ordinary writing table with multiple shelves, small sink and water supply. It is advantageous to start with simple and commonly needed investigations. One may use readymade strips, kits etc. to make the work simpler. On getting good response, one can keep sophisticated instruments, reagents and even parttime technician.

If one doesnot want to enter into the hassles of all these instruments and reagents, one can start a collection centre in the clinic by having a tie - up with nearby pathologist. In the morning various samples are collected and in the evening the reports are ready on the table.

Various day to day medical problems are diagnosed accurately, quickly and confidently with the help of these investigations.

Many fresh cases of tuberculosis, tropical eosinophilia or hypothyroidism are picked up on day one. It gives a lot of job satisfaction and a lot of mouth to mouth publicity.

Last year we moved to a still bigger place on main road, measuring 1300 sq. feet. It is something like a diagnostic centre cum day-care clinic. We added four cots, separate operation theatre and sonography machine.

Sonography is very useful, handy and informative in a wide variety of medical problems seen in our day to day practice.

Certain obvious things are very easy to diagnose by USG screening. They are:

Pleural effusion
Ascites
Gall stones
Acute cholecystitis
Renal calculi
Liver abscess
For gynaec - obstetric practice, it is a boon. USG helps to come to the diagnosis very quickly.

They are:
pregnancy - its diagnosis and viability
Multiple pregnancy
Pregnancy with bleeding PV
Location of IUCD
Fibroid
Tubal pregnancy etc.

Our intention is not to become sonologist, but to detect common things. Later sonologist comes, checks our findings and adds some more. Sitting with him, we keep on learning more about the machine and technique. Our gynaec practice has picked up well after the arrival of sonography machine and with practice, perseverance and guidance from sonologist, we become more and more wise with passage of time. We should always be cautious of limitations and not overdo things.

Today is the era of computers, super-computers and printouts. According to marketing strategy, not only the product has got to be good, but it must be presented in an attractive and acceptable form to get good reward. Anything printed and attractively presented has more value than any amount of verbal talk given. Most of us are familiar with Dr. OP Kapoorís file. He uses his stationery very freely. There are several papers containing information regarding clinical examination, blood and urine tests, fundoscopic exam. PEFR, dietary instructions, investigations asked, treatment advised etc. All these papers are neatly typed and filed properly. A common man get highly impressed and does not mind paying him high fees. To use file in our practice is highly desirable. Apart from better record keeping and follow up it is an excellent way of ethical advertisement. Apart from name, degree, address, hours of attendance, it also contains various other services we offer in our clinic. File is seen not only by the patient and his relatives but ten other people at his neighbourhood and place of work. One can imagine the amount of publicity it gives for less than ten rupees per file. It is advantageous to mention about the services we offer on our sign board as well as in the waiting room. We had good response to BCG vaccination, once it was put on the signboard. Another ethical way of advertisement is to print on the backside of the prescription paper about our extra services in the clinic. It should be of good quality paper and given in proper sized plastic folder for longer life. One may also send postcard reminders for follow up of diabetics, ECG or immunisation.

Only routine dispensing practice is neither satisfying nor very much rewarding because of many factors including competing with quacks, chemists, TVs and print media, not to talk of self medication. But if one has class practice i.e., he diagnoses using electrocardiograms, delivers drugs using nebulisers, then quacks and chemists are out of the picture, and we are one up on our neighbouring practitioners.

In our experience, patients are very happy and easily submit themselves for various investigations if they are carried out by us in our clinic. It is convenient and cost effective. It is common experience that patients take their own sweet time before undergoing tests after requisition form is given, thereby wasting precious time before the specific diagnosis is reached or correct treatment prescribed.

So far we have narrated all advantages, but there are certain disadvantages too. One has to learn to accept rose with thorns. We need more helping hands, preferably from qualified assistant doctor and qualified nurse. With other staff members, like compounder, technician and typist, we should have cordial relations. Important thing is to pay them well and to give them incentives like overtime, gifts and bonus. We must learn to become good administrator. We should develop the quality of delegating various duties and supervising them. We should be like coconut, tough outwardly but soft within.

We must have the working knowledge of all the instruments. In case of emergency, we may have to play the role of technician or a typist. We should keep good relations with our pathologist and radiologist friends on whom we are partly dependant.

Lastly we have to depend upon our own patients for Laboratory, X-ray or ECG work as references from neighbouring practitioners are negligible.

Before I end, I would like to quote,

"Take time to work - It is the price of success.

Take time to think - It is the source of power.

Take time to read - It is the foundation of wisdom."



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