And so my wife Janny and I started the practice early February 1980. We received our first patient at Carolus Hospital on a Monday morning at 8:30 a.m. I had been used to start at 8 a.m. in Groningen, but no one wanted to attend before 8:30. If I remember correctly, in the beginning, at Willem-Alexander Hospital (WAZ) we only had consultation hours on Monday, Wednesday and Friday afternoons and every morning and the other afternoons at Carolus. This soon backfired, because the consultation hours at the WAZ were full and waiting times were getting longer, while there was plenty of room at Carolus. Then, after a renovation of the practice at WAZ, practice hours became Carolus  Hospital Monday all day, Wednesday all day and Friday morning, and Willem-Alexander Hospital Tuesday all day, Thursday all day and Friday afternoon. This was the most efficient for contact allergy testing, my favorite topic and area of expertise: performing the patch tests on Monday  (Carolus) and Tuesday (WAZ), removing the patches on Wednesday (Carolus) and Thursday (WAZ) and second reading on Friday morning (Carolus) and Friday afternoon (WAZ). It also had as advantage that we only had to go from the Carolus to the Willem-Alexander hospital once a week at Friday noon, from one side of Den Bosch via the four-lane Zandzuigerstraat (a 45 mile/hour road) to the other side of town, where WAZ was located.

Minor surgery at the outpatient clinic with Janny. In case you are wondering about my long sleeves (because of increased infection risk): the management allowed that because I had an active psoriasis on my elbows at the time. This did not so much embarrass me, but I was sure that many patients would notice and start talking about it (especially the patients who consulted for their own psoriasis) and that would take too much time off my busy schedule. I was not fond of performing surgical procedures and referred many patients to the (plastic) surgeon. Fortunately, the procedures that I performed myself almost always went well, although I did make some scars (but I also saw those from the surgeons). One time I made a misjudgment when removing a basal cell carcinoma on a patient's forehead: I couldn't get the wound closed properly. But I remained calm, explained the situation to the patient and said I would find a surgeon to help me. Ten minutes later, surgeon Erik-Jan Carol closed the wound without diffuculties. The patient was very content with how I had handled the situation.  

I can say without hesitation and immodesty: it went by storm. At the end of 1980, the revenues were already much higher than those of my predecessor in 1979. So I was becoming an Albert Heijn branch manager and I liked it! Partly this was due to a sharp increase in the number of new patients and partly it was the result of a completely different practice management. My predecessor was a product of his time: an old-fashioned dermatologist who diagnosed from behind the desk and prescribed an ointment: 'see you next month.' But I had allergy tests and sclerotherapy of varicose veins in my repertoire and minor surgery for malignant tumors (skin cancer) and benign tumors, such as moles (which led to chagrin of the plastic surgeon). Back then, the health insurance companies allowed all this and reimbursed the patients for what were (at least some of them) essentially cosmetic procedures. I had also learned from a colleague that it was best to order and pay for the materials for allergy testing myself and not order these from the hospital. The reason for this was simple: the expense reimbursement from the health insurance funds for the materials was higher than for performing the tests themselves! Sclerotherapy was also very generously reimbursed at that time. In those days physicians were still allowed to treat the very smallest red-blue veins (in fact not varicose veins) with sclerotherapy and I was more than happy to do so.

New secretary wanted

As the practice soon became increasingly busy, only 2 months after the start we had to hire a secretary. You can imagine that it was impossible for Janny to simultaneously perform the allergy tests, help me with sclerotherapy, apply bandages to leg ulcers and in addition manage the phone for appointments and other matters. That secretary was hired and Janny then became my physician's assistant. She has worked full-time in our practice until the end of December 1983, so almost 4 years. Then a new assistant came, but she soon acquired Pfeiffer's disease and Janny took her place up to a few days before she gave birth to our daughter Elleke in April 1984. It was especially hard for her to apply bandages to leg ulcer patients with such a big belly. Afterwards, Janny would fill in regularly when my assistant or secretary was sick. In April 1999, at which time we practiced solely at Carolus Hospital, she was employed by the hospital for one day a week and in 2000 for 0.32 fte. And from 2000 to June 2002, when we stopped practicing, Janny has worked full-time for extended periods of time. I read in the annual reports of 1998, 1999 and 2000 that in all 3 years there was a vacancy for either physician assistant or secretary, and there was also quite a bit of illness among them. Janny was fortunately able to fill both positions.

Janny filling in was possible then, because by now the children were older and they could take care of themselves. Speaking of staff, we were not always very lucky with them. Many dropped out for short or longer periods of time due to illness. Some stayed (quite) long, like the secretaries Els, Corina, Hanny, Marijke and Barbara, and the doctors' assistants Erica and Marlies. One of them was always nervous and quickly went on the defensive ('yes, but I didn't know that') and another one regularly dropped out due to a back hernia or something else and then Janny had to show up again (outsourcing children was not always easy, our parents lived 65 and 135 miles north, respectively). We had to fire a few employees during their probationary period because they didn't live up to expectations. One physician's assistant was so strict with the patients, we called her 'The General.' One secretary made an awful lot of typos and another, I soon noticed, had the habit, when I would open the hatch between my consulting room and the secretarial area, of stretching with her hands behind her head, protruding breasts forward, right in front of me. This was not much appreciated by Janny. The secretary apparently did not know that Janny and I, who was also there at the time, were married. Needless to say that the exhibitionist didn't last long .....

The boss was a bit strict 

However, there were also secretaries and physician assistants who resigned after a relatively short time on their own. This was undoubtedly partly due to me. I have always been an authoritarian person and I knew exactly how I wanted things arranged and runing in our practice and the employees had to stick to that. I could also sometimes get angry or react a bit irritated if they didn't do their job properly. It was actually always terribly busy. To make sure that I could go on continuously, it was their job to get the patients to an examination room on time and, if necessary, to ask them to partially undress and to remove bandages from patients with leg ulcers. If I could not proceed because a patient had not been brought to a room, was not yet undressed or still had bandages on the legs, and especially when this happened more than once, I would sometimes vent my irritation. When Janny was there, she usually got the brunt of it (even if she hadn't made the mistake herself, fortunately she could take it pretty well), but otherwise the secretary or doctor's assistant herself. So I was a rather demanding and certainly not easy boss and not everyone can cope with that. For some, the hustle and bustle (we undoubtedly had one of the busiest, if not the busiest, outpatient clinic in the hospital), was reason to look for another job after a (relatively) short period of time. All in all, besides Janny, I have had 10 physician assistants and 15 secretaries in 22.5 years; that does give one pause for thought! But the long-term cooperation between Janny and me has done our bond a lot of good. We've never really had an argument and we've never had any disagreements in the presence of patients.

Facilities

The facilities at Carolus Hospital were good (enough), but at Willem-Alexander Hospital they were limited. I practiced there in a so-called portacabin, comparable to a shed of a construction company. It was attached at the end to a side wall of the hospital, in which, of course, a hole had been cut. When you entered, it immediately started cracking, because the whole thing was made of wood and rested on beams. To the right was a small table with the secretary behind it, continuing through, there was an examination/treatment room on the right and at the end my consulting room. It was not suitable for the large quality practice I wanted to develop. Apart from the creaking, it was all far too small. There was barely room for allergy testing and certainly no room for the 'tilt table,' which I needed for injecting varicose veins. I believe that after only a week or two I made an appointment with the medical director of the hospital Rudolf Spittuler to talk about a more adequate practising area. He took me to his home in Nistelrode on a Friday evening (i.e., I drove behind him with my car), where we sat and dithered over the possibilities, for example, 2 portacabins side by side. We spent hours drawing and trying it out, but it didn't work out.

Moreover, one was always left with the problem of the crackling and - certainly not unimportant - the fact that it was so noisy that a patient in the treatment room could hear what I was discussing with another in my room and vice versa. This  of course was not acceptable, even though the 'privacy watchdog' did not exist yet back then. So the conclusion was that a new practice area had to be added on to the hospital, there was no other way. Because we had had a few drinks together, I spent the night at his and his wife Lydi's house. We have always gotten along very well ever since.

Of course, it took a while to get everything arranged with construction plans, permits and financing, but I think the construction started in the summer and was finished after a few months. In the meantime, we could use some rooms in the emergency department. There was only one examination room annex treatment room available, which often caused great problems when elderly patients came in short succession to be undressed or bandaged. But after a few months, the outpatient clinic was ready and we had access to a reception, a fairly large treatment room, an examination room and my consultation room. All (the treatment room excepted) quite small and somewhat narrow, but it was all right.

All beginnings are difficult

In retrospect, I must say that practicing was not easy in the first 2-3 years for a couple of reasons. First of all, everything was new to me and I had to discover it all on my own, which someone entering a partnership does not have to do. During my dermatology training in Groningen, there had been no attention at all for practice management. The workdays were very long and the consultation hours very busy. I'm not complaining about that and I have no right to, because I wanted it that way myself. Of course, I could have scheduled fewer patients per hour, but then the access times would have increased which would be bad news for my patients. We were so busy that when Janny and I drove by car from Carolus to Willem-Alexander on Friday, she would first hold a patient file in front of my nose and then a dictaphone so that I could speak in a letter to the referring general practicioner. And then halfway down the Zandzuigerstraat we would eat some currant buns while driving. Totally irresponsible, of course, but we did it in our youthful hubris and fortunately it always went well.

The dermatology training had been inadequate

Furthermore, my knowledge of and experience with dermatology was a problem in the first few years of practice. The training in Groningen had been completely unstructured, and except for Johan Nater, none of the staff, including the chef de policlinique, dr. Edze Kruizinga, from whom we largely had to learn the trade, did his best for the trainees. Kruizinga, although an amiable man, was an old-fashioned and ageing dermatologist (he was 61 when I started training), who had been brought to Groningen from the Achterhoek by prof. Klokke and had absolutely not the knowledge nor the didactic skills to adequately teach us modern dermatology. None of the staff members had any surgical experience, we had to learn the basics of derma surgery some senior dermatology trainees who previously had gained experience in the tropics. For learning sclerotherapy I traveled several times to the 'Heilanstalt für Beinleiden' in Hamburg, Germany. However, I only got to inject varicose veins of actual patients 2 or 3 times, that was my entire experience!!! In other words, formally I was a licensed dermatologist, but with very ramshackle training, experience and knowledge. I still had to learn a lot and gain experience in the practice itself and look up a lot of things to diagnose and treat patients correctly. This often resulted in very long drawn-out consultation hours, where patients sometimes had to wait up to an hour and a half or even longer. I know colleagues who don't care about this in their practice, but I hated it. Not only was this bad for my reputation, but also extremely annoying for the patients: after all, the doctor is not the only one who is busy. Also, there were always many  consultations of patients admitted to hospital for other medical specialists. I sometimes had more than 10 of such patients, who I had to visit at the hospital wards after finally finishing the outpatient consultation at 18.30 hours or so. Often I wasn't home until 20, 20:30 hours or even later. There was also always much work to be done during the weekends, notably with practice administration. Janny and I, especially in the beginning, when we did everything together, always took home a large number of patient files and then we both typed letters for GPs, which I first spoke into my dictaphone. Janny had an electric machine (which we brought home from the practice), I typed on a mechanical typewriter!

And finally: I consciously chose for a solo practice, but during those first years I did miss colleagues around me whom I could ask something, with whom I could consult or with whom I could share examining patients who had interesting or 'beautiful' skin disorders. Later I would always call in my secretary and physician's assistant when there was something nice to show and I would give some information about that particular disease, of course after having asked approval from the patient. After having practiced for 3 years or so I felt I had gained more grip and control over all medical and non-medical aspects of the practice. From that moment on, I could start paying more attention to improving all the processes, which would help me build a quality practice and acquire a very good reputation as dermatologist.

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