cover story
How to Open a Practice Cold
See what this O.D. did to start a successful practice from scratch.
BY TOM MILLER, O.D., Fayetteville, N.C.

The desire to own a private practice is on the minds of many established O.D.s and new grads alike. Based on my discussions and experiences with many optometrists around the country, the overwhelming majority concede that private practice is their preferred mode of practice.

DIGITAL IMAGERY BY PHIL HOWE

In this article, I outline the methods that have helped me succeed in building a fast-growing, self-sufficient, private optometry practice from scratch in only two years. It is possible and you don't have to be wealthy, smart or unethical to do it. If you're an entrepreneurial O.D. who has a little spunk and a lot of hustle, starting a practice will bring you an incredible sense of satisfaction and accomplishment. If I can do it, then anyone can!

Survey your options

You can basically enter into private practice through one of three methods:

1. Associate yourself with an established doctor.

2. Purchase an existing optometric practice.

3. Start a practice "cold."

The third option, in my opinion, is highly underrated and many times not even considered.

I decided to plunge into the world of private practice by starting from scratch. I've been through good times and bad, but I'm convinced that I made the right decision.

The decision to open my own practice didn't hit me until I was a fourth-year student on externs. I was fortunate to extern at a successful, large practice that happened to be involved in ocular disease. This turned my attention away from the concept of only prescribing eyeglasses and contact lenses as a source of income, and showed me the great opportunities that existed, both professionally and financially, in treating eye diseases.

Do the research

I began researching for potential practice sites during my last year of school. I knew I wanted to return to the community where I grew up, which had a total population of around 300,000 with 36 optometrists and about 12 ophthalmologists.

I contacted the local newspaper to get some vital statistics on the demographics of various parts of the city including income, population, age range, percentage of people who own their own homes vs. rent them, etc. I decided on finding a place in one of the faster growing parts of the city away from the main medical area, and from most other eye doctors.

	Pictured is the entrance to Dr. Miller's office.

Find the right location

In June of 2000, I walked into a dentist's office to ask her about the area surrounding her office. As luck would have it, she owned the building and half of it was empty. I liked the idea of being in a professional complex and told her that I'd like to lease the extra space from her. The only problem was that even though I graduated in May, I wouldn't be licensed to practice until around October.

We arranged a lease agreement that was contingent on my passing my board exam and becoming licensed. Because of my crazed enthusiasm, or perhaps lack of intelligence, I began to remodel the office space to fit my needs.

My wife and I did 90% of the work from painting to putting up walls. If I didn't pass the board, all of our work would've been for nothing and we would've lost all of the money we'd spent (about $8,000, which might as well have been a million at that time).

With my location settled on, I had to tackle that small problem of finding some money.

Create a business plan

I made up a business plan with the help of an optometry practice management book. I basically copied the sample from the book and put in my own numbers, which was, at best, a rough estimate.

Armed with my plan, I headed to my personal bank. A loan officer told me that the bank just wasn't interested in doing business with "small fish." I then got the idea to ask a few other doctors in the area who they banked with. I got the name of a banker who specialized in loans for doctors. I took my information to her on a Wednesday and by the following Tuesday I had a $100,000 equipment loan with a $50,000 line of credit -- both at a great interest rate.

At the time, I had a $1,000 balance in my personal bank account and an 11-year-old pick-up truck to use for collateral. I also owed $98,000 in school loans and had a wife and three children, including a newborn. The "power-of-the-doctor" alone was enough to get financing.

Dr. Miller created an open and friendly reception area.

Prepare for practice

Now I was set. With a lot of studying and a little luck, I received my optometry license on October 8th and saw my first patient the next day -- my eight-year-old nephew who failed a school screening that same day. I had to apply to become a provider for Medicare and Medicaid, which takes months at best. I limited my enrollment in most vision-only plans except the few that also allowed me to treat medical conditions. I had to request a Drug Enforcement Administration (DEA) number, which took about six weeks to receive.

There is a fine line that an O.D. in a new practice must walk. The need to be in your office taking care of any business that might arise vs. the need to make money, which is usually accomplished by working outside your office. I always felt uneasy about not being able to give my full attention to my developing practice.

Initially, I worked three to four half days in other practices. I always made sure that they were only half days to ensure that I could be in my own practice every day.

Go full time

Not wanting to depend on the sale of eyeglasses or contact lenses in a time when commercial entities are beginning to dominate the market, I made a conscience effort to develop a practice heavily concentrated in treating eye disease.

I hated to miss even one urgent walk-in or referral. After about four months working for others, I decided it was all or nothing and I quit all outside work to concentrate full time on building my patient base. I believe in the sink-or-swim philosophy. I had many bills to pay.

My wife quit her teaching job and began to work with me full-time, bringing our newborn baby with her. I thought patients would perceive this as unprofessional, but it actually turned out to be a great asset in the slow beginning. I'd take care of the baby while my wife worked up the patient and then we'd switch when I performed the exam.

Many of my original patients still come back disappointed when we tell them that the baby isn't "working" anymore. My wife is truly my biggest asset, taking care of many of the time-consuming tasks and allowing me to do the practice building.

Market thoroughly

Seeing only five to eight patients each week and having no outside work, I had plenty of free time on my hands. I began to call on every business in my area. I simply told them I was a new eye doctor in town and that I had an office down the road. I wanted them to know who I was and what I could do.

Based on these brief, friendly visits, they began to refer a few patients initially and then more as they became comfortable with my abilities.

By far the most important thing I did to build my ocular disease practice was to visit every M.D., D.O., PA, NP, nurse, chiropractor, podiatrist and dentist around. Against most authority's advice, I made "cold-calls" to each office. Much like getting in good with the girl by getting in good with the father, I found that receptionists can be your best friend. I'd make a bit of small talk, mention who I was and that I was just in the area. They'd run to get the doctor and I'd have a productive five-minute conversation with him or her.

Most were shocked to see me. They'd never had an eye doctor stop by and visit. This just isn't what doctors do. But it made an impression. I would always apologize for "just dropping in," saying again that I was a new eye doctor in the neighborhood and that I just wanted to say "hello."

Out of the 20 or so offices I visited, I got referrals from four or five. This was a great return on my investment of a little time.

At this point, all you have to do is treat these referred patients well and communicate back to the referring doctor as soon as possible with a formal written letter on nice letterhead. This serves two functions:

1. It's just common courtesy

2. It puts your name in front of that person repeatedly.

In fact, I'll write a letter to a primary care doctor if one of our shared patients has anything remotely wrong with him systemically that could possibly be affecting his eyes.

Most healthcare providers want the same thing you want -- to have a successful practice and to take care of their patients' needs. Physicians (PAs or nurses) appreciate the quick feedback. It only takes one case of iritis that they've been treating with sulfacetamide to make you a hero in their eyes.

	Though he opened cold, Dr. Miller did not skimp on equipment.

Expand the practice

In addition to all of the schmoozing, I also visited all of the urgent care centers and small independent doctor's offices in the area. This served two purposes. I wanted to get my name out there and I was also looking for a place to set up a small branch office.

I got lucky and found a small rural medical office that had extra space. They were happy to have me rent this space from them at a fair price and I was excited to have access to a medical staff and an older patient base (with a higher incidence of disease) than I'd normally see.

This was a win-win-win situation for me, the clinic and the patients -- who now had an eye doctor on the premises. I gave lectures and presented slide demonstrations at any place that would let me -- church seniors groups, college sports teams, school parent-teacher association, nursing schools and others. I started an optometric assistants class at our local community college at night, mostly trying to find good quality employees, but also to get publicity.

The college advertised my class and my practice name in its newspaper and with brochures. I also established services at a few nursing homes. Initially, I went to the homes, but now I have convinced them to bring the patients to my office. I also secured a contract to examine patients from the Veterans Affairs Hospital in my office.

Most recently, I have been invited to join the faculty of the local physician assistant school and to teach their curriculum on eye care. So it's all paying off.

Elicit referrals

A vast number of underserved patients have eye diseases. The number of people who have cataracts, dry eye, diabetic retinopathy, macular degeneration and glaucoma is staggering. Many of these people aren't even seeing doctors. I consider it my job to find them. At the end of the exam, I thank them again for coming and tell them that if they have any problems with their eyes to not hesitate to call me.

I almost never let them leave without asking them for referrals. Sometimes I use a simple statement such as, "Now if you know of anyone else who needs his eyes checked, make sure you give him our number." This works wonders.

My goal is to get three referrals from each patient encounter. Again, with many internists and other physicians who patients come into contact with, many assume that you're booked and not seeking new patients.

I always have a large supply of refrigerator magnets and ink pens to give out to my patients. I also give out a limited number of wall calendars each year. I don't believe that this is the place to be stingy. It's more important to get your name out there.

Every opportunity I get, I put a note in the "medical news" section of our local newspaper. I announce any additional training I receive or when a new staff member joins. It's free advertising. Aside from this, I limit my outside advertising to a yellow page ad and an occasional newspaper ad -- usually about a new instrument I've acquired.

Speaking of instruments, someone once told me that it's wise to start with only the basics and to buy used equipment if possible. Here are my thoughts.

Don't skimp on equipment

I disagree with the previous advice because, like it or not, people judge by looks. I didn't want shabby equipment or furnishing. I bought a new chair and stand, phoropter, slit lamp, autorefractor/autokeratometer, autolensometer, an automated perimeter and an autopupillometer. I planned to delegate as soon a possible. True, I could've done more retinoscopy and could've used a pupillary distance ruler exclusively, but to me, that's small time.

I want to give the impression of being a state-of-the-art facility. I had the remaining equipment from school including hand-held instruments, binocular indirect ophthalmoscope and lens kit. But instead of stopping there, I purchased a digital imaging system for my slit lamp, which has been worth every penny based on excited patients who saw images of their eyes for the first time. This system generates referrals and, of course, is billable for appropriate diagnoses.

Since then, I've added a scanning laser ophthalmoscope, a pachymeter and a fundus camera. I have a wish list of instruments I have yet to buy.

Practicing happily ever after

Now, after two years, my practice is thriving with only 25% of my income coming from material sales. I enjoy having an optical because it's a great service to patients who want one-stop shopping.

But by relying on treating eye diseases as the majority of my income, I don't worry if a patient decides to go somewhere else to purchase her eyeglasses or contact lenses. I gladly give her the prescription and move on to the next patient who needs my help.

The journey is what makes this profession fun. It's an enormous amount of hard work, but for me, the perks far outweigh any negatives. I've been through good times and bad, but I'm convinced that I made the right decision -- and I wouldn't have it any other way.

Dr. Miller is in solo practice. He graduated from Southern College of Optometry in 2000 after serving in the U.S. Marine Corps from 1987 to 1991. In 2002, he was named North Carolina's Young Optometrist of the Year.