Venturing into independent private practice: looking through an optometrist’s eye

Dr Sudarshan Khanal

By definition, entrepreneur is a person who starts business, taking on financial risks in the hope of profit. Personally, I started private practice in Optometry (and my experience can equally relatable to private practice in medicine or dentistry) and by definition it is a professional business that is not controlled or paid by the government. So the most important attribute is being a professional. It would not be in our best interest if we misinterpret entrepreneurship in optometry like other regular business and put efforts in maximizing profits. Entrepreneurship in optometry is related to professional private practice of optometry where eye care needs of people are customized. So I will be sharing my experience related to private practicein optometry with opportunities and challenges. I will be sharing my things in two sections. In first section I will share about starting a private practice and in the second section I will share about opportunities and challenges. 

Starting a private practice
A common question strikes in every students or graduates, ‘When is the right time to start private practice?’  I would like to quote the rule of 10,000 hours by Malcolm Gladwell. He points out repetition of 10,000 times to get mastery in any field and gaining specific skills. He described different sport persons, musicians, doctors and politicians in his book Outliers and came to conclude rule of thumb of 10,000. 

Interestingly, an optometry student in Eye Department at Institute of Medicine during their four year time happens to consult around 10,000 patients. Out of those 10,000 around 5000 are consulted in out- patient department (which we call room no 3) independentlyand gain expertise at diagnosing, treating and managing patients. 

Diagnosis is not that straightforward as it seems. It is a great privilege to be a great diagnostician than to be an average doctor. According to Dr Groopeman, the writer of book, ‘How doctors think?’ being a good diagnostician requires recognition of the importance of language, mood, ego and bias. Differential diagnosis is based on two approach, pattern recognition and analytic. Both approaches are subject to error from cognitive biases. 
Cognitive biases can be anchoring bias where we give excessive weight to early or initial information, confirmation bias where we focus on supporting evidence for diagnosis while ignoring contradictory evidence and availability bias where we give too much weight to diagnose that comes readily in our mind e.g. conjunctivitis in any kind of red eye.
The very important thing is to analyze things very deeply and turn raw data into medically meaningful information. It needs solid foundation of basis sciences and a lot of patient base to be handled independentlywhere you analyze data, come up with differential diagnosis and final diagnosis. Final diagnosis makes it easier to prescribe treatment in the form of medicine or spectacles or surgery. 

If we follow the rule of 10,000 and handle independently that number of patient we can assume that we can become a clinician that makes less cognitive biases and come up with more accurate diagnosis. This is the first and most important step to be good at if one is thinking of starting a private practice. If this foundation is laid poorly, then there are high chances one end up doing lots of misdiagnosis that shrink patient base and shift his/her focus to optical business. 

For those who feel they do not have the necessary expertise and did not handled patients independentlyin OPD during their training at tertiary eye hospitals, district eye care centers are a great platform to gain the necessary skills after graduation. If one spends primary years in primary eye care centers and at the same time did studied cases, consulted with seniors and managed case on evidence-based practice, then they would be in an ideal position to start private practice at their chosen location.  Ideally an MD in medicine may need very short time because during residency they already see volumes of patient. The only aspect that may be missing is critical thinking and gaining ABCs of independent handling of patient. 
Personally speaking, I graduated in 2013 from Institute of Medicine, worked at Lumbini Medical College for six months, one year clinical practice in Kathmandu before moving to Philippines. I completed OD with six months rotation in different hospital and clinical setting. Later on I did clinical practice for one year before I started my private practicein 2018. 

Many graduates prefer to start immediately as soon as they graduate and presume optical business as a private practicewhich I think is a different approach if we consider ourselves as a clinician or doctor or health care professional. 

I am always intrigued by and motivated by a quote from Abraham Lincoln, “If I had six hours to chop down a tree, I would spend first four hours sharpening the axe.”  And private practice is like that. 

(Dr Khanal is an alumni of Eye Department and Department of Public Health at Institute of Medicine. Currently, he works at Better Vision Foundation Nepal that runs project on avoidable blindness and has a private optometry practice, Sewani Vision Care, at Kalanki.)

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