Developing group practices: a management challenge RICHARD B HAYS* and LEONIE SANDERSON?

SUMMARY The advantages and disadvantages of forming larger professional practices are often debated. This paper reports an exploration of the issues through three case studies involving clusters of Sydney general medical practitioners who had expressed a desire to amalgamate their solo or small group practices. Their most frequently stated goals were to reduce financial overheads, to improve the range of services offered to their patients and to improve the opportunities for recreational and study leave. Several barriers to successful amalgamation were identified, and methods of overcoming these were explored. Practices can successfully amalgamate, but only where there is a group of like-minded general practitioners who are willing to invest time to achieve mutually agreed objectives. Amalgamation will not be appropriate in all circumstances. Larger group practices should benefit from the employment of a professional practice manager. These findings may be relevant to veterinary and dental practices. Aust VetJ72: 145 - 147

Introduction Professional practices in Australia tend to be comprised of either

sole practitioners or small groups of practitioners. Private practitioners like the freedom to make decisions about the best way of providing clinical services to their patients, resulting in a wide variety in practice philosophy, structure and management. As an example, the size of general medical practices varies considerably, ranging from sole general practitioners up to large multi-professional practices with 20 or more general practitioners, specialists and other health professionals (Forde 1989a). Practitioners in all situations defend their personal choices, which may have been based on a range of geographic, economic or personality factors.

There appear to be at least theoretical disadvantages to being a solo practitioner, at least in general medical practice, for which some research has been conducted. The burden of providing continuing medical care is clearly heavier when it falls to one person, with recreation, sick and study leave much more difficult to arrange. The grind of being constantly on call is not appealing to many because of the resulting disruption to personal and family life. The costs of providing an adequate medical service are often claimed to be higher in solo practice, resulting in fewer staff and less equipment, lower net income, or both (Forde 1989b) Such issues deserve careful investigation in the current economic climate. In most service industries, overheads can be reduced through provider larger service centres; supermarkets versus the comer store is a readily recognised example. Other potential disadvantages include reduced ability to provide teaching and supervision for students, lower professional satisfaction (Skolink et a1 1993) and a higher risk of professional incompetence due to the associated professional isolation (McAuley et af 1990). It is likely that similar issues confront practitioners in veterinary and dentistry practice.

Amalgamating solo and small practices to form larger practices has the potential to address these issues. For the benefit of other professions, this paper draws on the findings of research into how general medical practitioners approach practice amalgamation (Hays and Sanderson 1994) Three clusters of general practitioners who

* North Queensland Clinical School, PO Box 5394, Townsville, Queensland 481 0

t Department of General Practice, University of Sydney, 37A Booth Street, Balmain, New South Wales 2041

were interested in amalgamating their solo and small practices ic the inner west of Sydney acted as case studies. Structured interviews were conducted at regular intervals with both individual general practitioners and with group meetings of each cluster. The project was therefore based on the real experiences of general practitioners grappling with complex philosophical, legal and financial issues. Although none of the three clusters actually achieved amalgamation during the 6 months duration of the project, all made progress towards agreeing on how to proceed (in one case, how not to proceed) and we were able to learn about the trials and tribulations of practice amalgamation.

Advantages and Disadvantages Potential advantages of amalgamation identified by participants are

listed in Table 1. These include: the sharing of staff and equipment; extended clinic times; and the availability of relief for recreational or study leave. Lower practice costs per practitioner were regarded as desirable and should be achievable once the initial financial burden is absorbed. However, many existing group practices claimed that lower overheads were not automatic, but could be achieved only through developing appropriate structures and management strategies.

The concept of multi-professional practices, in which medical practitioners and other health professional share facilities, was explored. However, this appears to be an extremely complex issue, as it involves professional boundaries and legal issues surrounding the sharing of income and equipment among workers in different professions.

TABLE 1. PotenUal advantages of practice amalgamation

Sharing staff and equipment

Extended consulting hours

Improved after-hours services

Improved access to recreational, sick and study leave

Lower per-doctor practice overheads

Improved diversity of practice services

Teaching fits in more easily

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TABLE 2. Potential banieta to successful practice amalgamation

Incompatible personaliies or practice styles

Fear of ‘losing control’ over one’s practice

Initial financial burden

Difficulties associated with selling individual properties

Potential loss of patients if practi is move far

Legal complexities associated with certain models of amalgamation

Town planning requirements if building new practice premises

TABLE 3. Possible models of practice amalgamation

Physically separate but sharing seivices, for example, after-hours calls

Physically separate but jointly running a branch practice

Sharing premises only

Sharing premises and some staff or equipment

Sharing all facilities and costs but not income

Sharing all facilities, costs and income

TABLE 4. Suggested skills for practice managers

Human resource management

Communications management

Financial management

Time management

Office management

information technology management

Crisis management

Problems likely to be encountered in amalgamation are listed in Table 2. The most important early barrier was finding a group of like-minded colleagues with whom to amalgamate. It also became clear that practice amalgamation can have substantial financial im- plications, particularly where there is a need to move physically to larger premises. Participating doctors in this project were working in suburbs with high doctor-patient ratios and were concerned that patients would not follow them if they moved more than a few hundred metres. Under current local government laws, new practice premises would almost certainly have to be in sites zoned ‘commercial’, thereby raising costs substantially. Other problems included a whole range of possible legal and real estate issues, for which highly individual solutions may have to be found to take into account the variety of practice structures.

How To Do It Once anumber ofpractitioners interested in amalgamation has been

identified, the important stage of negotiating mutually agreed objectives and processes begins. It has been said that group practice is like a marriage; only too often neither the expectations nor the contract are negotiated and settled beforehand (Ellard 1984). It is fundamental that the group’s goals be explicit and, if necessary, written in even an informal document for later reference. Until there is agreement on how to proceed, attempting amalgamation is unlikely to succeed.

Once a decision is made to proceed with amalgamation, there are several possible models to consider, as listed in Table 3. These range from the simple sharing of premises through to full equal partnership; each offers particular advantages and should be considered. Because of the variety of practice structures and locations, those considering amalgamation should seek legal and financial advice specific to their needs. The Royal Australian College of General Practitioners and government business-oriented departments have produced helpful booklets on specific legal and financial aspects of business structures.

An interesting concept which emerged during the project was that of ‘trial amalgamation’ by the development of a collaborative branch practice. Through this, practitioners can test their abilities to collabo- rate without risking their present practices. This may be an option only where there is potential to increase clinical services, such as in growth areas or other locations with a lower doctor-patient ratio.

The Role of Practice Managers Historically, solo practitioners or their spouses have acted as practice

manager. This is probably acceptable in small practices because of the small size of the tasks; there is no real need for management systems to cope with one or two salaries to pay and the ordering of relatively few consumables. It could be argued that these task:j may not be done well by part-time amateurs who are usually not paid well for their efforts. However, in a small business full-time professional management is unlikely to be cost effective.

As the size of the practice increases, so too does the complexity of the management role. There are likely to be several staff in different categories, a large record system, a need for frequent monitoring of consumables and a role in financial planning. Even if a practitioner had all ofthe necessary skills and the interest, the practice would eam more through that practitioner’s clinical work and employmerit of a professional manager. While good practice managers will umder- stand the nature of the clinical work performed in the practice, they will have other skills that few clinicians can develop.

The importance and value of practice managers was explored by staff of The Graduate School of Management at the University of Sydney and formed part of the original research report (Johnson and Ellis 1993).Their findings indicate that practice management is a complex professional role, which should be performed by appropriately qualified personnel who should be paid appro- priately (at least $40 000 a year). The suggested skills of practice managers are listed in Table 4. The degree of complexity will depend on practice structures and incomes as well as the number of practitioners. A major barrier to the effective use of practice managers is the reluctance of some practitioners to relinquish sufficient authority to a non-practitioner. An important part of the development of larger practices is the acceptance by practitioners who are unlikely to be as competent as professional managers in those skills listed in Table 4.

However, Johnson and Ellis (1993) suggest that only practices with about 8 or more practitioners could justify full-time practice management at this level of expertise. Smaller practices could either employ a part-time practice manager or use an external consultant as the need arises, while solo practices will probably get by as they have in the past.

Who Should Consider Practice Amalgamation? The answer to this question depends on what is meant by amalga-

mation. In its loosest definition, all solo practitioners should develop relationships with other practices in their region, even if this involves only the sharing of after-hours work or continuing education activities. Such networks should help avoid professional isolation. Not all solo practitioners, however, need to move physically to develop large group practices. Experience has shown that not all are suited to group practice dynamics, and many of the potential benefits of amalgamation can still be achieved through networking separate practices. Some practitioners will choose to avoid complexities of

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joint ownership of property or to provide a highly personalised service. Practices in small rural and remote communities may have to be solo or small group practices because of small populations. Clearly, solo and small group practice remain necessary options.

Acknowledgments

Copyright (c) This article has been adapted from one first published in The Medical Journal OfAustralia and is published with permission (Hays RB, Sanderson L. Forming large groups practices: is it worth it? MedJAust 1994; 161: 494-496). Reprinted with permission.

We acknowledge the financial support provided by the Department of Human Services and Health through the Demonstration Practice Grants Scheme.

References Ellard J (1984) Group practice, J Gen Ptwctice 1:21-28 Forde K (1989a) Goulbum. The country co-operative clinic, Aus! Pmctice

Management, Mach:lS-l7 Forde K (1989b) What is the most efficient practice structure? Aust -!ice

Management, Octobe~6-11 Hays RB and Sanderson L (1994) Forming large group practices: Is it worth

it? MedJAus!, 161:494-496 Johnson LW and Ellis S (1993) When to employ a practice manager. In:

Group Pmctice. Finding The Right Prescription, edited by Hays RB and Sanderson L, University of Sydney

McAuley RG, Paul WM, Morrison GH, Beckett RF and Goldsmith CH (1990) Five year results of the Peer Assessment Program of the College of Physicians and Surgeons ofontario. Cm MedAssoc J143:1193-1199

Skolink NS, Smith D and Diamond J (1993) Professional satisfaction of family physicians. F m i ! ~ Pmctice 37:257-263

CASE REPORT

Sudden blindness associated with protothecosis in a dog JR BLOGG* and JE SYKESt

Introduction Protothecosis is a rare disease of animals and man, caused by

Prototheca, a genus of saprophytic, colourless algae. Prototheca are considered to be mutants of Chlorella, a genus of green algae, and because of their similarity in structure and reproduction can be confused with Chlorella in light microscopic studies. The organisms reproduce by endosporulation. Resulting daughter cells enlarge and are released on rupture of the parent cell (Migaki et a1 1982). Prototheca has been isolated from avariety of sources, including tree sap, acidic stream and lake water, marine water, faeces of various animals, soil and potato skin (Migaki et a1 1982; Font and Hook 1984). Protothecosis has been reported in many animal species including the dog, cat, human, cattle, pig, rat, mouse, deer and fruit bat.

Canine protothecosis was first reported in 1969 (Povey et a1 1969; Van Kruiningen et a1 1969). Cases have been reported in North America, England, Australia and South Africa (Wilkenson and Leong 1988). Protothecosis appears to he a sporadic disease occumng predominantly in immunosuppressed animals (Wilkenson and Leong 1988), although many cases may go unrecognised. Two species, P zopfi and P wickerhamii, affect the dog and may cause zi slowly disseminating disease of the heart, intestine, kidney, liver, brain and eye. Most affected dogs have a history of bloody diarrhoea or bloodstained faeces because of lower colonic disease, but blind- ness, renal failure and arthritis have been reported (Van Kruiningen et a1 1969). The pathogenesis of canine protothecosis is not well understood, but it is thought that the organisms localise in the colon after ingestion and subsequently disseminate via blood and lymph (Thomas and Preston 1990).

* Armadale Veterinary Eye Hospital, 547 Dandenong Road, Armadale. Victoria 3143

t Veterinary Clinic and Hospital, University of Melbourne, Princess Highway, Werribee, Victoria 3030 Macroion&, Mavlab Ply Ltd. Slacks Creek, Old 4127

We report an unusual presentation of sudden blindness associated with canine protothecosis in a dog. Light microscopy was used to confirm the diagnosis. Failure to include infectious agents such as Prototheca in the differential diagnosis of sudden blindness may lead to an inappropriate and even detrimental treatment regimen.

Case Report A five-year-old neutered Boxer bitch became suddenly blind in

Cairns, Queensland. No opacity was seen in the anterior segment by the referring veterinarian. Pupil response to light was slow. A tenta- tive diagnosis of retinal detachment was made and 1 mgkg of oral prednisolone* twice daily was prescribed.

Five days later, when examined by a veterinary ophthalmologist, blindness with semi-dilated pupils and sluggish pupillary light responses was found. Both retinas had extensive white areas where the sensory retina had separated from the underlying retinal pig- mented epithelium and become displaced into the anterior vitreous. Malaena and depression were present and gastrointestinal tract ulceration was suspected. No other abnormalities were detected on clinical examination. Blood biochemistry revealed increased urea concentration and a mild increase in alanine aminotransferase activity. All other haematological and biochemical values were within the normal ranges. Treatment was commenced with 5 mgkg intravenous cimetidineg twice daily and 50 mgkg oral sucralfatea twice daily. The dog appeared brighter and after 3 days of treatment was taken out for a walk. Half-an-hour after return to its cage the dog was found dead.

Necropsy revealed patchy haemorrhage in the gastric and intestinal mucosa, although no ulcerations or perforations were found. The heart was enlarged, with a thickened left ventricular wall and multi-

5 Tagamet? Smith Kline 8 French Laboratories, Division of SmithKline Beecham (Australia) Pty Ltd, Dandenong, Vic 3175

7 Carafate", The Boots Company (Australia) Pty Ltd, North Rocks, NSW 2151

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