The “Three A’s” No Longer Lead to Success

The “Three A’s” No Longer Lead to Success

December 23, 2020

When I was a resident in the 1990s, I was told by many staff surgeons that success in my career would be dependent on my mastery of the “three As.” Being polite (and a bit of a suck-up), I would usually feign lack of awareness of this advice (and interest in it) so that the attending’s delicate feelings would not be hurt as he recited this well-worn trope.

For anyone lucky enough to have never received this advice, the three As are: ability, availability and affability. The advice goes, “If you, as a surgeon, are competent, make yourself available to referral sources and patients, and get along with those populations well, you will be successful.”

Maybe that was true in the health care system of old; the one where patients had a wide network of orthopedic surgeons they could see, where some surgeons were incompetent and where the only devices anyone had to facilitate communication were a phone and a pager, but that is not the health care system that I see now. We have moved farther away from that environment slowly and surely in the past 15 years.

First of all, I don’t know any incompetent surgeons in my market. We are all board certified, which counts for something. There are precious few valid and non-gamed quality measures by which to discriminate true quality. Who is competent and who is not? Who really knows?

Second, I probably wouldn’t be aware of any signs of incompetence if they existed, because those patients stay put. In my experience, doctors who are a little short in the competence category become good about the affability variable of the equation. They may not be a “John Charnley,” but they are smooth with the language. They hang tons of crepe with their patients, every fracture being the “worst one” they have ever seen. They ooze charm and grace, and their patients excuse every complication that occurs. The most competent doctors tend to be a more direct and less loveable; the least competent doctors get all five stars on their Healthgrades reviews. A paucity of one quality appears to me to lead to an emphasis in the other.

That only leaves one important variable in the original three: availability. Among the 26 surgeons in my group, it is true that when doctors stop taking call, their productivity tends to decline. Once they cut back to banker’s hours and stop answering their mobile phones on the weekend, they miss out on some opportunities to generate relative value units like those of us still chained to our jobs 24/7. However, while these senior non-call surgeons gain 70% improvement in quality of life, they only seem to lose about 40% of their clinical productivity. It appears to be a good deal. By that point, they are so ingrained in the market that their reputations buoy their clinic volumes for years or decades.

So, if it isn’t the three As that dictate success in 2017, what is it? What is the advice that we should give the young students and residents who rotate in our services (presuming they are interested)? I’m sure there are many answers to this question and I would invite readers to respond with their thoughts in the comments section.

In my practice, success appears to stem more than anything else from figuring out the market need and building a practice to address that. For example, after years of having a Monday afternoon clinic that was filled with 75% follow-up patients and 25% new patients, I finally realized I was missing a ton of new patients who had been injured during the weekend and were looking for Monday afternoon appointments to address that need. If they wanted to see me, but I was full, they weren’t interested in waiting a few days to see me. They would take anyone who had a spot. So, I changed my template for Monday afternoons: No return patients at all from March to November. Now, I start every Monday morning with a blank afternoon schedule and by the time I get back from lunch, there are 26 new fractures in that clinic. My productivity is astronomical.

Another change was implementing a device-agnostic appointment app that uses algorithmically driven value predictors, ensuring that my time is invested in the encounters that maximally drive my productivity. The rate-limiting step in my productivity is my time, so spending that time the most efficiently that I can ensures I do as much good as I can in my market every day. My study on this has been accepted for presentation at the American Academy of Orthopaedic Surgeons Annual Meeting in 2018 in the practice management section, so check it out in New Orleans if you want to learn more.

It’s not the three As; it’s T and A. That is “template and app.” The surgeon who adapts his appointment template to his market and uses an app to invest his time based on his known value indicators will be successful. That’s my advice to surgeons, young and old. Don’t forget to comment if you have another pearl to share.

John “Jay” Crawford, MD, is a partner at Knoxville Orthopaedic Clinic and founder of nextDoc Solutions, a software company that builds custom apps for orthopedic surgery practices. His primary interest is helping private-practice orthopedic surgeons discover and implement strategies to ensure robust and sustainable business performance in a consumer-driven health care environment.