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HomemifeatureThe Eagle Eye Journey: Opening an Ophthalmology Clinic

The Eagle Eye Journey: Opening an Ophthalmology Clinic

ZEISS refractive laser suite with the MEL 90 excimer laser and the Visumax 800 femtosecond laser.

After listing all the reasons  not to open their own practice, ophthalmologists Dr Erica Darian-Smith and Dr Mitchell Lee took the plunge anyway. Here, Dr Darian-Smith provides a personal perspective on what can be a long and tortuous journey.

Opening Eagle Eye Surgeons in 2024 was a daunting undertaking. The economy was close to recession. Building prices were at record levels. Rent was expensive and purchasing a site even more so. Ophthalmology equipment was costly, and there is more equipment required to run a comprehensive practice than ever before. Plus, there is always new technology around the corner. There were high levels of employment across job sectors and finding staff was difficult. The Reserve Bank continued to threaten to raise interest rates to ‘tread the narrow path’ (although many small business owners would argue that was lost in the woods some time ago). The spectre of higher-than-average inflation continued to loom in the background.

Perhaps these are all reasons not to start a practice! Despite this, in a decision that some may say defied logic and reason, in 2023 Mitchell Lee and I decided to throw caution into the wind and do it. After misquoting the field of dreams for 12 months (build it and they will come), Eagle Eye Surgeons opened in August 2024 in Mosman, Sydney. We are a general ophthalmology practice, as well as a refractive laser clinic, with an on-site refractive surgical laser suite.

Our situation was far from normal. We set up our practice while both completing our subspecialist fellowships and opened one month after our fellowships finished. During planning I was pregnant and in the middle of a two-year corneal and refractive surgical fellowship in Toronto, Canada (thankful for the invention of Zoom meetings). Mitch was completing a vitreoretinal fellowship at Westmead Hospital, Sydney. Neither of us had experience setting up or running a business, and we had no established referral base in Sydney. In addition, having just finished our training, we had significant financial constraints to overcome.

At this point readers may be forgiven for thinking we are straight out insane.

EXISTING OR GREENFIELDS?

There are two ways to start an independent practice: purchase a pre-existing practice (and possibly rebrand) or start your own ‘greensite’ from scratch. There are advantages and disadvantages to both.

To purchase a practice, of course, there needs to be someone who wants to sell, and you need to be in a financial position to buy. The advantages are the goodwill that comes with an existing business, the associated referral base, and the fact that the business is already functional. It is clearly a lot less work. The disadvantages are that you need to pay for the goodwill and, if there are things you don’t like about the practice, they may be hard to change.

The principal advantages to starting your own practice from scratch are that you have a blank canvas to paint any way you like, and that you are not paying for goodwill. The disadvantages are the lack of a referrer base, and the complexity of starting a business from scratch.

Our site was a greensite, and the remainder of this article will focus on starting a brandnew clinic from scratch: the why and the how, what we did, what worked… and what didn’t. Hopefully our experience will provide some useful pearls for colleagues who are considering starting a practice, which would have been useful to us 12 months ago.

THE WHY

Aside from myriad technical and business elements, the critical cornerstone considerations in setting up a practice are your own motivations and goals. The fine details can be worked through, but to succeed you need a broad and clear idea in your mind as to why you want to do it. To say setting up a business is challenging is an understatement; there is financial stress, and planning and executing your strategy is effectively a second full-time job. It requires a skill set that most of us have no formal teaching in.

Without strong motivation, we couldn’t have pushed through the endless challenges to get to this point. For our part, we wanted to establish ourselves as an independent practice, call the shots, and create a productive and enjoyable working environment for ourselves, our staff, and importantly, our patients. To get there, we set ourselves stepwise tangible goals to complete (e.g. obtaining finance, equipment purchases, fit out, staffing, operational management) – endless small building blocks that needed to be stacked on one another to achieve our most important goals – practice opening, building referrer and patient relation levels, financial independence, and job satisfaction for ourselves and our staff.

Our ultimate long-term goal is to establish a prosperous practice providing subspecialty ophthalmology care in our respective fields, laser vision correction, and a general clinic for our patients and our local community. It is perhaps too early to say whether this has been realised; we opened our doors just a few months ago, but things are steadily progressing, and I think we are on our way.

Dr Erica Darian-Smith and Dr Mitchell Lee at Eagle Eye Surgeons in Mosman.

THE HOW

Having decided what sort of clinic you ultimately want to have, and what services you will provide is a start. After this, you need to identify an appropriate target market.

Then comes the ‘how’. This is more complex and there are too many individual steps to comprehensively cover, but I want to give some broad insights and a brief framework.

Pre-Opening

Undoubtedly, the three most crucial elements to this stage of the process are:

  1. Business planning and finance,
  2. Site procurement and planning, and
  3. Staffing.

A comprehensive business plan is essential, and not only important for obtaining finance – hopefully it should convince you that your idea is a good one. If things do not stack up, you may need to reconsider.

Engaging an independent finance broker to assist is an option. Ultimately, to confirm finance, you will need a secured lease or premises, quotes for equipment you require, and cash projections over at least 12 months to demonstrate that your business will likely be solvent. Expect this to be a prolonged undertaking and start dealing with financiers early. You may wish to involve an accountant with experience in medical practices to assist with financial projections, as banks will often want this as a sign of accuracy in your plans.

A further critical component of planning your business is also having the right structure for your plan. Will you be a sole practitioner? Partnership? Company or trust? You need good accounting assistance from the outset to set up these structures.

Consider how many practitioners you need to realise your plan and what contingency you can put in place from the outset to ensure survival if business is slow (which it almost certainly will be initially). How long can you tread water before referrals start to come through? Is it long enough? In business, the secret to success is survival.

At this point, site selection and planning is worth a mention. Consider multiple potential locations; this provides some flexibility rather than having a single fixed location in mind. Leasing and real estate negotiations are complex, so having flexibility in terms of location may protect you from getting trapped in a bad deal.

You may consider using an architecture firm to help select a site. It is crucial that you provide a good brief on what you need to ensure they help select a suitable space to suit your requirements. Also consider patient parking and accessibility; these are important.

A word of caution, be wary if you are negotiating a lease yourself. These documents are generally over 100 pages long, and the devil really is in the detail. Seek independent assistance if you are not familiar with these negotiations. Read contracts to the letter and obtain good independent legal advice; do not fall for the false economy of going it alone. Remember that walking away is always an option, the quality of the deal is just as important as the quality of the site itself. A poorly negotiated deal may doom your project before it even starts.

Once a lease is secured and these components are all well underway, you will need to plan the fit out. While we discuss our site planning in greater detail further on, it’s critical to mention that a good architectural firm can make all the difference at this stage. Good planning means getting it right the first time, saving time and money. You will also maximise clinic efficiency and patient flow.

The final point to mention regarding major tasks before your doors open is staffing. Consider the minimum staff pool you can manage initially, but keep in mind the staffing levels you think will eventually be needed.

We engaged a consulting firm to assist with staff employment. For our situation, this was invaluable in helping find and select staff and with the administrative tasks required to comply with employment legislation. With this assistance we were able to put together a fantastic team. Having an independent firm assist with professional processes also helped legitimise our business (when we didn’t even have a site built at that stage); without this our staff may not have put their faith in us and the business.

The team we have started with is very small – a practice manager, receptionist, and optometrist, supporting two ophthalmologists. We even trained one of our parents as a technician, to provide casual assistance if it was needed. In part to assist with cashflow during the start-up phase, as ophthalmologists we both work part-time in the clinic and consult at other sites. All of this has meant less contingency to cover leave and that we are stretched if busier than anticipated. However, we were upfront with our team at interviews, advising that we would expect a degree of flexibility in roles early on, as we would all have to help each other out. We are all prepared to roll up our sleeves to do whatever task needs to be done.

It’s important to remember that as much as we were taking a risk in starting a new practice, our team members were taking a risk in leaving secure roles to join us. By looking after your staff well, they will continue to repay you with dividends. Strong workplace relationships are good for business, and can be some of the most rewarding aspects of running a business. The quality of working environments tends to be dictated by behaviour from those at ‘the top’ and it flows right through to the patient experience. If you ensure that you provide a safe and friendly working environment and remunerate your team competitively, you will be well on your way there.

MS39, which has been described as “The slit lamp of the 21st century” by Professor Dan Reinstein (United Kingdom).

OUR CLINIC

Full disclosure, our site was a previous medical practice. This heavily influenced our planning and design. As mentioned, we had significant financial constraints, and preserving as much of the pre-existing layout improved our budget considerably.

The existing clinic had a ‘round robin’ layout, with offices at the perimeter around a central island. The main corridor opened into the waiting room at both ends, which we preserved as it was conducive to good patient flow. There was more office and storage space than we needed, most likely a vestige from the time of physical patient file storage, so we turned these spaces into more usable clinic space. This gave us enough working room to convert the central island into a laser suite, sterilisation room, and additional room for our YAG/retinal laser. We also added a small recovery area to the back of our waiting room.

The outcome of our reconfiguration was the same number of consulting rooms as previous, with sufficient space for our diagnostic devices, and the added laser suite. Considerable structural work was required, but significantly less than had we started with a ‘cold shell’.

We were heavily involved throughout the design process, ensuring our architects had a very detailed brief. We found that as long as we were clear on our needs, our design team was able to facilitate them. Our architecture and build teams worked closely with our vendors/ suppliers and our IT team during fitout to ensure things went to plan and that small details were not forgotten. We took the opportunity to ‘freshen’ the site with painting, new flooring, and nice finishes, and put considerable thought into the aesthetic we wanted to achieve. While you can always expect a few hiccups along the way, they can be minimised. It is amazing what a difference a few simple adjustments can make to the feel of a place.

OUR TECHNOLOGY

State-of-the-art technology was crucial for our practice. Refractive surgery, in particular, requires meticulous planning and high-quality data. As a greensite started by ophthalmologists early in their careers, we also wanted to ensure our equipment would last for many years to come before requiring an upgrade. Some people have been a little surprised that we have purchased such highquality equipment at the outset, but our belief is that as a new practice we must provide the highest standard of care in all aspects.

When considering the equipment to purchase, it’s vital to plan ahead. Depending on your budget, it is likely that you won’t be able to buy everything on your wish list up front. Decide on what the bare minimum is to run your practice (and your subspecialties) and build from there. By planning ahead you minimise the risk of having to replace equipment early (at associated extra cost), and of ending up with expensive devices that overlap in function or miss key functions. While Mitch, our vitreoretinal surgeon, is generally happy as long as there is good optical coherence tomography (OCT), a bright indirect ophthalmoscope, and enough scleral depressors to cover the inevitable disappearing act these small instruments pull, the refractive surgical suite required a great deal of planning and investment. Deciding to commit to purchasing our refractive femtosecond and excimer lasers from ZEISS locked us into the ZEISS diagnostic environment to a degree, but also enabled us to seek a competitive deal in terms of equipment costs.

We were careful, though, to ensure that despite this decision, each piece of equipment was evaluated on its merits and against its competition. For example, the diodebased ZEISS Visulas combi was chosen as it combines capsulotomy/iridotomy, selective laser trabeculoplasty, and retinal laser (SL-based and BIO-based) in a single platform with significant cost saving over purchase of separate conventional YAG and argon lasers. Of note, we have supplemented our anterior segment diagnostic suite with the MS39 anterior segment OCT device and an Osiris aberrometer. These two devices came at significant expense but have enabled us to achieve phenomenal surgical outcomes for our refractive patients immediately upon opening the practice.

AFTER OPENING: THE EXCITEMENT

There is so much that we are excited about in our practice. Not least of all, it is the fruition of over a year of hard work. We take immense pride in what we have built, from the bricks and mortar, through to our team and our relationship with the local community and referrers. And we are particularly proud of the laser clinic that we have built. We run an onsite laser suite and are thrilled with the results we have been delivering for patients and the feedback we have received. Our treatments are photorefractive keratectomy (PRK), laserassisted in situ keratomileusis (LASIK), small incision lenticule extraction (SMILE), and Presbyond laser blended vision. We are the only clinic in Sydney performing Presbyond and it has been an excellent treatment for our patients with presbyopia. The preoperative workup and management are more rigorous than required for regular laser refractive treatments, but this is well worthwhile for the visual outcomes that can be achieved.

AFTER OPENING: THE CHALLENGES

Of course there are many ongoing challenges since opening our doors, but the most important ongoing challenge is to build referrals, without which there is no practice. This is the scariest aspect of starting your business. When we opened, we didn’t know whether we would have a single referral in the first week, first month, or first six months. One bank’s credit team was equally pessimistic, refusing to assume any patients would visit in the first 12 months in its risk assessment. The key elements to building referrals are:

  1. High quality patient care, and
  2. Building relationships.

The variables contributing to these pillars are not all controllable and – as an aside – supply and demand will also be an important factor in determining how quickly referrals build, which ties back to site planning and selection.

We believe (and it would have been remiss of us to open a practice if we didn’t) that as surgeons we provide high quality clinical care. The whole patient journey is part of this, from meeting our receptionist through to the end of the appointment, and we are fortunate to have staff that share this philosophy.

Building trusted relationships with local optometrists, general practitioners, and the community is crucial. We endeavour to be available for our referrers when needed, and provide a 24-hour service for advice. Fitting in emergencies, opening limited weekend clinics, and promptly sending referrers clinic letters are also important elements of our practice. These things matter. We need to be available. Luckily our team expected this and has really taken it in their stride, helped along by the shared excitement in what we are building. I really can’t speak highly enough of our staff and what they all bring to our business every day. It has been much more of an adventure for everyone than working in an established practice and the willingness of everyone to pitch in no matter the task, whether or not it falls within the traditional remit of their role, has been a lifesaver for us. These are the kind of staff you need.

Day to day running of the business remains a large challenge for us. There is no doubt it would have been much easier to join an existing practice, both financially and in terms of personal effort, or perhaps to start a business later in our careers when better resourced. As a startup business, we remain responsible for a large portion of the business, operating logistics that fall outside the traditional remit of a doctor, and our staff also contribute in many ways that may fall outside the traditional responsibilities of their roles. We expect with our team this will become easier as things become more routine and ‘worn in’, and as we can expand our team over time.

A REFLECTION

Would we do it again? Yes. Setting up this new business has been a nerve-wracking experience. It is complex and difficult, allconsuming, and tense at times. It has taken a great deal of effort to reach the stage we are at now. The fruit of our efforts is a clinic that we are proud of, that we believe provides a valuable service to the community in Sydney, and that we can call our own. We have built a team we enjoy working with and we also believe our staff take pride in the work we all do. There is the satisfaction of building strong relationships with a variety of people from different walks of life.

Finally, there is the often-surprising assistance that is volunteered from friends and family, as well as professional colleagues.

It is enormously satisfying to follow your career dreams and this far outweighs the downsides. We are looking forward to getting over the new practice ‘hump’ and eventually having the benefit of hindsight, which is 20/20.

Dr Erica Darian-Smith MBBS MMed GradDipRefCatSurg FRANZCO is an ophthalmologist who specialises in refractive, cataract, and corneal surgery. She is a Director at Eagle Eye Surgeons in Mosman, Sydney.

Dr Mitchell Lee BSc MBBS (Hons) MMed(Critical Care) FRANZCO is an ophthalmologist who specialises in vitreoretinal surgery, as well as complex anterior segment, cataract, and lens surgery. He is a Director at Eagle Eyes Surgeons in Mosman, Sydney.

The inaugural Eagle Eye Surgeons Team.

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