In the last of our seven-part series, it's time to move from planning to running your new practice. Your biggest challenge: building a patient base.

This is it. The moment you've been working toward for months. Your office is equipped and ready; your staff is in place. Like a Broadway producer you're awaiting the people who, if they like what you're offering, will not only return—they'll tell their family and friends about you. This seventh and last installment of our series on starting your own practice spotlights how to make your presence known in the community, impress your first patients with your practice's proficiency, and set the stage for a long, successful run.

Reaching out to referral sources and patients

On the day he opened his solo practice, FP Ivan M. Filner of Peoria, AZ, faced a moment of truth: His daughter looked at the empty chart rack and said, "So, Dad, where are all of the patients going to come from?"

Where indeed? An "if you build it, they will come" philosophy might pay off if you open the only thermal underwear outlet in Siberia—or, more to the point, if you're the only physician in an underserved area—but not if you're the new gal or guy in a busy town. You have to help patients find you.

"Start by courting referring physicians," says Ginny Martin, a consultant with Jasin-Martin & Associates in Perrysburg, OH. "That might mean giving a talk at a medical staff meeting, writing an article about your specialty for the local newspaper, or going out of your way to meet local physicians and their employees. The key to referrals is that personal connection."

"If you're a primary care doctor, get to know the surgeons in your community and tell them that you're available for medical clearances," says Michael J. Wiley of Healthcare Management and Consulting Services in Bay Shore, NY. Build bridges with other healthcare professionals, too. Dentists, nurses, pharmacists, hospital social workers, and chiropractors come into contact with many people and can refer some of them to you. "You'd be amazed how many people ask their neighbor who's a hospital receptionist to recommend a physician," Wiley says.

Then reach out to potential patients by placing an ad in the local newspaper or mailing announcements. "Mailing services are listed in every Yellow Pages book," says Keith Borglum, a consultant with Professional Management and Marketing in Santa Rosa, CA. "Not only will these companies process mailings using their bulk postage permit, most of them have targeted lists of homeowners, senior citizens, new parents, families, and other groups within a geographic area. You can have any cross-sort you want."

Borglum recommends sending a well-designed postcard to potential patients, as well as to pharmacists and other physicians (see the example). "Postcards are more likely to be read because recipients can see the message without opening an envelope. And they're cheaper—about 50 cents each, counting printing, sorting, and mailing, for a batch of 5,000," he says. "The larger the mailing, the greater the price break. If you're short of cash, your hospital's marketing department might be willing to cover mailing costs."

To attract attention, offer an opening week "special." When internist Laurie LeMauviel of Asheville, NC, began her solo practice, she placed ads in the local paper offering flu shots for $14.95, which was about $5 less than area pharmacies and grocery stores were charging. "I knew I had scored when people walked in with my ad in their hands," she says. "I gave the shots myself and handed out my brochure. For each person who left my office I was now 'on the map.' A few even made appointments."

Getting the word out needn't be pricey. LeMauviel contributed to an "Ask the Doctor" column in the local newspaper, and she arranged for her bio and photograph to appear in a regular newspaper feature that marks professional comings and goings. She also volunteered at the local free clinic, which, she points out, "is a great networking opportunity—as well as good karma."

"It's important to realize that the daily paper isn't the only medium around," LeMauviel says. She put ads in the university newspaper, a monthly regional paper, and a local arts and entertainment weekly favored by young adults. Perhaps the most effective promotions for your practice are word-of-mouth endorsements—something that FP Bobby J. Newbell of Hazel Green, AL, relied on when he began a solo practice because his budget didn't allow for much advertising. For more on Newbell's startup, see "My first year: Tough but I made it."

Online advertising is rarely cost effective, Borglum says, because the Internet has national—even international—visibility, and people tend to find their doctors from local sources. But Borglum and other consultants recommend that you have your own Web site ready by Day One. "For most primary care practices, a Web site is like an online brochure—you send the patient there rather than the patient finding you through it," says Borglum. "A Web designer can build you a nice site for under $500."

Welcoming your first patients

Order magazines for your waiting room in the weeks leading up to opening day, so you don't start out with a rack full of out-of-date publications. Subscriptions often won't start for six to eight weeks, though, so you might want to go to the newsstand the day before you open and stock up. In addition to standard fare—weekly news and entertainment magazines, as well as journals keyed to your patient population (such as Parenting, if you're a pediatrician)—include patient education materials. The American Academy of Family Physicians, for example, recently published a waiting room book, Family Doctor: Your Essential Guide to Health and Wellbeing. The book, which addresses a wide variety of health concerns, was distributed free to AAFP members. It can be purchased online at www.familydoctor.org/x6973.xml.

As patients make appointments, mail them a "welcome" letter telling them about your practice and the services it offers, says Will Latham, a consultant in Charlotte. Include your telephone number, Web site address, and directions to the office. On a separate, different-colored page, include a checklist of items to bring when they come for a visit—insurance card, copayment, referral forms, and so forth.

From the get-go you'll want to impress patients with your practice's professionalism, and projecting that image may take some practice. "Uncover your operational problems before opening day by staging dry runs," Wiley advises. "Ask family members and friends to serve as 'patients.' When they arrive at your office, have staffers greet them, give them the requisite paperwork, take them into a room where they're seen by you, escort them to the billing desk, clean up the room, and so forth. Do this several times, until you feel certain that your team won't come across like disorganized rookies."

You'll need to have patient registration packets on hand when patients start arriving. According to Lawrence W. Vernaglia, an attorney with Hinckley, Allen & Snyder in Boston, the packets should include:

• A HIPAA Notice of Privacy Practices, and an acknowledgement of receipt for the patient to sign.

• An authorization to disclose medical information to the patient's insurer or other payer. "While HIPAA doesn't require such authorization for payment purposes, state law might," Vernaglia notes. (For more information on HIPAA requirements, see "The lowdown on HIPAA and OSHA".)

• A general informed consent form describing the kinds of services that you provide and the risks associated with them. More specific forms will be necessary as you undertake different kinds of procedures.

• A medical and family history form.

• A form to acquire contact, demographic, insurance, and billing information.

• An authorization to release medical records from the patient's prior physician.

• Any other disclosures your state requires. For instance, some states mandate disclosure of certain antidiscrimination policies and fee schedules. Check with your state medical licensing board or a healthcare attorney about the rules in your area.

"Consider putting forms that take some time to complete, such as history and demographic forms, on your Web site so that patients can download them and bring them to the office when they first see you," says Michael Wiley. "This saves time and speeds patient flow through the office. Mail the forms to patients who don't have Internet access—especially if the patient has a long health history and might have to look up dates of surgeries and other procedures."

Preparing your practice brochure

Consultants advise against putting a brochure about your practice in your patient registration packet. "Patients pay more attention to the brochure if it's handed to them by the physician during their first visit," says Will Latham.

A polished brochure projects a professional image and gives patients something to show others whom they refer to you. Most brochures contain:

• The practice's name, address, office hours, and phone numbers.

• Directions to the office, including a small map.

• Details on when the phone is answered, how to schedule and cancel appointments, how to renew prescriptions, and how the practice handles routine medical situations and emergencies. For instance, "To make an appointment, call 555-6789 during office hours. If the practice is closed, our answering service will contact me in case of an emergency."

• Health plans in which you participate, and whether you accept Medicare assignment.

• Your photo and personal profile—including training board certification, hospital affiliations, and areas of special interest. Ginny Martin advises against including profiles of staff members, because if someone leaves you're faced with having to redo your brochure or give patients one that's out of date.

• The practice's financial policy, forms of payment accepted (i.e., cash, check, credit card), and how payment is handled. You might indicate that you'll file insurance forms, and that copays and other uncovered charges are due at the time of service. Martin recommends that you also include a copy of your financial policy in your patient registration packet, or mail a copy to patients when they first make appointments.

Putting together a brochure needn't be cumbersome or expensive. Laurie LeMauviel took the do-it-yourself route, and printed the finished product on cardstock at home until she decided this wasn't the best use of her time. "I finally paid a printer to do them," she says. "Comparison shopping revealed huge differences in rates of local printers. And experience taught me that I can't reread a proof too many times or have too many people check it."

"Coordinate your brochure, business card, appointment cards, letterhead stationery, and envelopes so that the paper, colors, and graphics match," Borglum says. "Your fellow physicians can recommend a graphic artist or local print shop. To keep costs down, use different shades of one color, like light gray, dark gray, and black, rather than four-color graphic design."

Opening Day and beyond

For the big day itself, Judy Capko, a consultant in Thousand Oaks, CA, has two words of advice: Stay calm. "Give each patient a small gift, such as a mug with your logo on it. Have cookies, lemonade, and coffee available the entire first week. Put fresh flowers in all rooms. From Opening Day onward, make pens and memo pads with your name and phone number on them available to patients."

Even if you're fortunate enough to begin with a full patient load, Borglum suggests scheduling every other appointment slot for the first few days, then jumping it up to two-thirds the next week and to full speed the week after that. "You don't want to make patients wait, especially if you're depending on referrals to build a patient base," Borglum says. "We've found that happy patients might tell one other person; unhappy patients tell as many as a dozen people."

"Write out your telephone and scheduling protocols so that everyone knows from the beginning how these should be handled," says Will Latham.

You'll build patient loyalty if you make follow-up phone calls to see if the patient is feeling better or if the medication is working. "But be careful what you implement early on, because if you ultimately get too busy to continue the service, patients will perceive that as something lost," Ginny Martin warns. If you make follow-up calls a regular part of your practice—and Martin recommends doing so—staff members can assist you with the process as you get busier.

Judy Capko likes the idea of sending a note to new patients after their first visit, with a stamped response card that asks if you met their needs and if they have any suggestions on how you can improve patient service. "Above all," Capko reiterates, "try to relax and enjoy it. This is a time when you can focus on the details, get used to working with the people you hired, and realize your vision of being at the helm of your own practice."

Checklist for starting a practice

Checklist for starting a practice   Getting ready for opening day Check off as completed: Place announcements in community newspaper and other local publications. Mail announcements to patients, physicians, and pharmacists. Develop practice Web site. Select and order magazines and other publications for reception room. Assemble patient registration packet. Prepare practice brochure and have it printed. Stage "dry runs" to iron out operational problems. Begin accepting appointments. See your first patients.

All seven articles in this series can be accessed on our Web site, www.memag.com

Gail Weiss. Starting a practice: The final steps. Medical Economics Sep. 3, 2004;81:58.