I saw an exhibit at a museum that demonstrated how a small vertical tile standing knocked over another larger tile, which knocked over a still larger tile, until a large brick, nearly 500 times as large as the first small tile, could tip over (see Figure). This is a metaphor for how small actions can create large results.

Figure. Example of a small domino knocking down a large domino.

How does this apply to a urology practice? I have built my career not with 3-color, trifold brochures, a website, or a social media presence on Facebook, Twitter, or Instagram. Instead, I focused on making small gestures to enhance the patient experience. My goal was to see that these small, incremental examples on my part and the work of my staff ensured that every patient had a positive experience with me and my practice.

These gestures began when the patient contacted the practice on the telephone to make an appointment. A human answered the phone in less than 3 rings. There was no phone tree to confuse patients; they could speak to a human. Patients were usually seen within 15 minutes of their designated appointment. The patient received a 3×5 card to write down what questions they would like answered during their visit. The patient completed a health questionnaire before coming to the office, reception, or exam room. A scribe met with the patient and conducted a history of present illness, a past medical history, and a review of systems before I entered the exam room. The scribe entered in the electronic medical record any comments I made in addition to what the scribe discovered before I met the patient. This process allowed me to be eyeball-to-eyeball with the patient instead of looking at a computer screen. At the end of each visit, I asked the patient, “Do you have any additional questions you would like answered on your visit today?”

The importance of patient satisfaction impacts the fall of our dominoes.

Patient satisfaction is another metric that has been studied in relation to the quality of care we provide. Patient satisfaction scores have been reviewed regarding complications, 30-day readmissions, adverse events, and medical errors. The patient experience data are collected from patient satisfaction surveys as previously described. Measures of patients’ self-reported experience may impact patient outcomes. For example, in one study, patients who reported a high level of participation in their care during hospitalization were found to be less likely to suffer an adverse event.

The expression says, “It takes a lifetime to build a reputation but only seconds to destroy it.” That is truer today than ever before. A patient with access, a mouse, and just a few clicks can go to an online review site and create a scathing comment about you and the care you provided.

When you start your clinical practice, you won’t have any credibility built up with patients and colleagues. As far as they’re concerned, you’re nobody from nowhere. You’ve got to build up your reputation, and that takes time. So, how do you do it?

Newton’s First Law of Motion states, “An object in motion tends to stay in motion unless acted on by an outside force.” It’s very difficult to change your reputation once it has been created in your patient’s mind, and that process happens quickly.

I have learned that you start creating a sterling reputation with the first patient you care for.

The reputation you build early in your career will be your reputation until you retire. If you develop a reputation for being rude or indifferent, that’s all anyone will see. However, suppose people see you as kind, caring, empathetic, helpful, and hard-working. In that case, you’ll find that people will love having you as their doctor.

Usually, it’s not the last large brick in the domino chain that solidifies your reputation with your staff and patients—it’s being excellent at small, ordinary things, or that small tile in the front of the chain that starts the chain reaction and builds your reputation.

I walked past the patient’s restroom and saw tissues on the floor and urine specimen cups on the back of the toilet. I picked up the tissues and took the cups to the lab. One of my medical assistants told me that I was the only physician that would help them clean the patient’s restroom. My example motivated the rest of the staff to take ownership of the cleanliness of the patient’s restroom. The medical assistant appreciated it and said it made them respect me more.

This emphasized how important it is to set an example, and that if you set an example, you don’t have to worry about the rule. I have tried to practice with attention to small details, like the small tile at the beginning of the domino chain, which ultimately will create a stellar experience for patients and move that huge block at the end.

Bottom line: Knocking down a large domino at the end of the chain is no accident. It requires excellence in each patient encounter, each clinic note, each business transaction, and each hiring and firing of staff. Building a sterling reputation happens one day at a time, one moment at a time, one patient at a time. If you consistently pay attention to the little dominoes, the large one will easily fall.