Getting assistance and providing assistance in private practice

Getting assistance and providing assistance in private practice.

“Private practice is a lonely place”

You work for yourself and by yourself. Patients who see you expect you to know everything. You are not expected to say things like “ I am not good at this”. The patient will immediately think that you are incompetent and move on to a colleague. You must always have poise and look confident, even if you are not familiar with the patient’s medical condition. It is also not common practice to send your patient away to a colleague who may be better skilled at handing the condition. You try to keep a patient as long as possible until the patient starts questioning you.

When I started private practice in 1994, I was young and full of clinical knowledge but without much experience. When I was unsure of a condition; instead of discussing it with my colleagues at the hospital I worked in, I would call friends in other parts of the country, to seek advise. I would rather send a patient away for a second opinion in another city, then asking her to see a colleague in town. This was because of my insecurity of loosing patients. Being older and more confident of myself now, I am able to tell my patients if I am not good at certain aspects of my field. I am also confident enough to send patients to colleagues if I think they are better qualified.This attitude only comes with experience and maturity. As a young specialist, it may take some time for you to develop this attitude.

There are many situations in which you will need assistance from your colleagues or a specialist from another specialty. When and how to get assistance can be tricky. There will be situations where a colleague will ask you for assistance. You will have to decide whether you want to provide that assistance and the consequences that follow. I will discuss my experience in this area.

1. When I encounter a patient whose case I think is going to be difficult in surgery , I usually inform my 2 “bodyguards”: my favourite general surgeon, who will deal with all the bowel problems; and a urologist who will take care of the bladder and the ureters. This is the easy part because working in a multi specialty hospital both are available and willing to help me perform the surgery. The only problem will be to decide how much they are going to charge for assisting me. With insurance patients, it is easy but with cash paying patients, I have to make an intelligent estimation. The patient will then decide whether she can afford the charges. This can sometimes be tricky and difficult. Fortunately, both my fellow surgeon and urologist understand my predicament. They usually give a big discount and sometimes even waive their charges. However, it is totally unfair to the surgeon and the urologist to come and operate with me on every case. This is an abuse of their generosity. Moreover, they will think that I am an incompetent surgeon. I have seen this happening throughout the country and the patient is unaware since she is under anaesthesia. The outcome is usually good because of the assistance received. Is this what you would like be?

In some countries, especially in gynaecological laparoscopic surgery, the surgery is completely performed by another surgeon and these surgeons are called “ghost surgeons”. The patient is unaware that the surgery was actually performed by someone else. It appears unethical, but it benefits all concerned. The primary surgeon can keep his patient and the ghost surgeon has an income.The patient goes home thanking and praising her gynaecologist for having performed this wonderful keyhole surgery.

2. The situation becomes more difficult when there is an unexpected intra operative problem or complication. My usual surgeon or urologist may not be available. I may need the assistance of another surgeon or urologist. Most of the time they will come in to assist but since they know that I called them to help because my favourite surgeon is unavailable, the situation can be uncomfortable. In one instance, when I was in distress with an unexpected difficult situation, all 3 of the urologists in my hospital were unavailable. They were either busy or refused to come. I was lucky to get a urologist from another hospital who was kind enough not only to come to help me and save me from future litigation but also waive all his fees. I am eternally grateful to him. Charges in these situations can be more difficult. If it is an insurance patient then the insurance company can absorb the surgeon/urologist’s charges but if it is a cash paying patient the bill will escalate. Most of the time my friendly surgeon and urologist will again give a large discount and sometimes have even waived their fees, making it easier for me. Sometimes, I too have to give a large discount so that the bill will not be too high for the patient. As a specialist venturing into private practice, if you are a gynaecologist, it is a good idea to be good friends with surgeons and urologists. Call all of them to assist you and don’t have a favourite. Pay them well. They may save your day. I am sure this applies to other specialities as well.

3. What if another gynaecologist calls you to help him/her when in trouble? I have been called in to assist on numerous occasions. I usually drop everything I am doing to help. I did not charge anything on almost all occasions. This is because it is impossible for 2 gynaecologists to charge the same patient for the same procedure. I consider it a privilege to help a colleague who is in distress. However, the only problem is that one should not take advantage of this goodwill. A friend of mine who works in another city has mentioned that he gets called in to help in situations where the decisions can be difficult. I will give you an example. If a young woman with an ovarian cyst is put up for surgery and during the surgery the cyst is malignant, what do you do? The decision as to the correct surgery at that time can be difficult because proper counselling had not been given to the patient prior to the operation. After being called in to help in numerous situations, he refused to go in anymore because of medico legal problems. You have to try not to place your colleagues in such uncomfortable situations, when you call them for help.

Therefore, when in private practice, it is important to be able to work with other doctors. Your colleagues are also your competitors but as someone said “ we work in an environment of friendly competition”. We are competing yet helping each other. Some of us may be good in one aspect of our field while others may be good in something else Without revealing our incompetency to our patients we try to keep our patients by getting help from our colleagues, without insulting or angering them. This could be a very delicate situation. This is especially so when you are a young specialist trying to survive by keeping your patient and not losing them to your competitors. If you can’t understand what I am saying, you will when you move to private practice.


Sevellaraja Supermaniam


(Exactly 61 yrs old)


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Dr. Selva

Dr. Selva

Dr S. Selva (Sevellaraja Supermaniam) is a Consultant Obstetrician and Gynaecologist and a subspecialist in Reproductive Medicine at a private hospital in Melaka, Malaysia. He heads the O&G unit and the IVF Centre at the hospital.

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