CareerPhysician

I've been advised by my program director to nail down an employment contract - negotiated and executed - many months prior to completing my training? What's the rush?

admin — Mon, 07 Nov 2011 11:02:00 GMT

There are some very good reasons to work toward the goal of having an employment contract executed 12-6 months prior to completion of training. For instance, if you are moving to a new state, you will need to obtain a license to practice in that state. The amount of time and effort required for the licensure application and approval process will vary from state to state, but you should allow at least 3-4 months. Once you have obtained a license, you may then apply for hospital privileges and for provider status with various health plans. It can take 1-2 months to be granted hospital privileges and another 6-12 months for approval from health plans.

I'm always uncomfortable using notes during a presentation. Any tips on how to successfully pull this off?

admin — Mon, 24 Oct 2011 21:08:00 GMT

Unfortunately, it is easy for notes to become a crutch for the speaker and a distraction for the audience. Following are some tips to creating effective notes and using them properly:

-- Use multiple colors – this will make it easier to find the next point to present
-- Print or type with large fonts
-- Write key words only
-- Set the notes down (where they are accessible but not overly so)
-- Pause when glancing at notes – avoid talking when referring to them
-- Glance at notes only as a final resort

Be cool, calm and collected!

Doctors to see slight salary increases in 2012

admin — Thu, 20 Oct 2011 02:26:00 GMT

Doctors to see slight salary increases in 2012

October 18, 2011 | Stephanie Bouchard, Associate Editor

PHILADELPHIA – Doctors can expect to see salary increases in 2012 but they’ll be smaller than those in 2011 says a physician compensation survey released this week by global consulting firm, the Hay Group. In 2011, physician salaries increased by 2.7 percent but expectations are that in 2012 they'll increase only by 2.5 percent.

The size of the salary increases is impacted by organization-specific things such as the salary increases provided to other employees, and, more importantly, reimbursements, said Jim Otto, senior principal in Hay Group’s healthcare practice. “The primary influences on these increases are likely to be flat or minimal increase in reimbursement for services rendered and flat or minimal increase in actual services rendered that result in reimbursement,” he said.

Doctors working in group-based practices are expected to see pay increases of 3.2 percent in 2012 but hospital-based doctors are only expected to see increases of 2.5 percent. More specifically, physician specialists working in hospitals may expect an increase of 2.4 percent and those in group practices may expect a 4.5 percent increase. Primary care doctors in hospitals may expect a 2.9 percent salary increase in 2012 while their peers working in group practices may expect a 3.3 percent increase.

The differences in salary increases between hospital-based and group-based doctors are likely the result of three things, Otto said: group income from ancillary services that are part of a practice’s business lines and which are not part of a hospital-employed physician’s compensation; sharing in profit after expenses for physician owners, which is also not part of a hospital-employed physician’s compensation; and employed physician increases being influenced by budget and salary increases for the other employees of the hospital.

With the demand for primary care physicians up, it’s not as surprising that they are expected to have larger salary increases than specialists in 2012. “The expected increases to primary care physicians is a reflection of the importance of their role in the healthcare reform environment – for example, accountable for integrated patient care models – the increase in reimbursement that is being paid by insurance companies and the government for primary care services, and the decreasing reimbursement for other specialists,” Otto said. “This does not mean that the pay differences that you see in the market between primary care physicians and specialists will evaporate quickly, but over time these differences are expected to shrink.”

Other findings from the physician compensation survey include:

• When determining base pay structure, 50 percent of organizations set physician pay on an individual basis, 28 percent establish formal salary ranges, 18 percent use market rates and 1 percent use step-rate progression.
• The prevalence of annual incentive plans decreased slightly among all physician participants in 2011.
• Measures for determining incentive payouts continue to be dominated by quality and patient satisfaction.

Physician Comp Incentives Shifting

admin — Tue, 18 Oct 2011 02:22:00 GMT

Physician Comp Incentives Shifting

Karen Minich-Pourshadi, for HealthLeaders Media , October 13, 2011

Changes in Medicare and Medicaid reimbursement, healthcare reform, and market competition are all driving change not only in how hospitals and health systems approach patient care, but also in how physician compensation models are taking shape, according to a new HealthLeaders Media Intelligence Report, Physician Compensation: Shifting Incentives.

Medicare and Medicaid reimbursement were named by 76% of respondents as the No. 1 influence on their organization’s physician compensation structure.

“As Medicare goes, so, oftentimes, goes the commercial payer—physician rates generally change not long after. So people will make tweaks to their compensation models to be ready for the future,” says Jeffrey D. Limbocker, lead advisor for the report and CFO for Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, one of the largest private medical centers in the state, with more than 700 licensed beds.

Healthcare reform came in second, cited by 59% of respondents as the major influence on compensation models. Next was market competition, noted by 49%. The local economy remains a factor, with 38% of respondents noting it influences their compensation models; region is frequently cited in national physician compensation surveys as an explanation for compensation disparities. And, although accountable care organizations and the medical home fall under the healthcare reform umbrella, 38% and 27% of respondents, respectively, broke them out separately as having an effect on their models.

Perhaps due to the influence of government mandates, healthcare sources say, compensation models are also under review more frequently. Forty-one percent of respondents are changing their models every year or two, while 38% are adjusting it every 3–5 years. Just 21% of respondents maintain models for more than five years.

Salary plus incentive, along with productivity-based models are the dominant compensation structures (40% and 34% respectively), according to the survey; 14% of physicians are earning straight salaries. Healthcare
leaders say this may be due to the shift toward an ACO care model in which physicians are put on salary to allow them to focus on quality of care over volume. However,it may also be the result of patient volume issues.

“There are certain specialty areas where hospitals need the coverage; however, there may not be enough patient volume to use a productivity model, so they may offer straight salary in order to retain those services,” explains Suzanne Anderson, senior vice president, CIO, and CFO for Virginia Mason Medical Center in Seattle. The nonprofit, integrated health system includes a multispecialty group practice of more than 440 employed physicians and a 336-licensed-bed acute care hospital.

With the fee-for-service reimbursement model still firmly in place at hospitals nationwide, it’s not surprising that productivity ranks highest (75%) as a compensation model incentive or that work relative value units dominate as the productivity measure (66%). However, 57% of respondents now prize quality as an incentive measure, and another 50% are also using patient satisfaction scores to motivate physicians.

Five years ago, our sources agree, those last two measures wouldn’t have seen such high percentages. The shift toward incentivizing for quality and patient experience are likely tied to healthcare reform, which is causing healthcare leaders to reassess the carrots and sticks used to motivate doctors. But, as fee-for-service is replaced by pay for performance, could productivity incentives go by the wayside?

“I believe there will always be productivity measures [for incentives]; however, there will continue to be a growing use of quality and patient satisfaction scores as incentives in compensation models,” says Alan Kaplan, MD, vice president and CMO at Iowa Health System in Des Moines. With annual revenues of $2.3 billion, Iowa Health System is the sixth-largest nondenominational health system in the United States.

Additionally, 47% of survey respondents are incentivizing physicians for participation in administrative duties, and 23% are doing so for chart completion.

“These days, physician leadership, particularly in integrated systems and hospitals trying to integrate, is a key to accomplishing organizational objectives. You need their leadership and partnership,” says Anderson.

Physicians are not only being incentivized to participate in administrative time, for nearly half of survey respondents it is part of the overall compensation package: 47% count administrative time as a separate pay rate or bonus, while 48% of healthcare leaders don’t factor this time into the compensation model but still expect physician participation.

“We are finding more frequently that we [administrators] need physicians to participate in administrative discussions because they help us drive our goals to meet the future demands of healthcare reform,” says Limbocker.

He notes that prior to the demands brought about by healthcare reform, hospitals used perhaps 2%–3% of a physician’s time to assist with administrative discussions, something they wouldn’t have incentivized.

But now key initiatives on leaders’ priority lists are no longer organization-driven but tied to mandates that affect future reimbursements for the organization—such as value-based care incentives for quality and patient satisfaction. Physician insight is now crucial to the success of these programs and the overall financial health of the organization.

The shift in priorities has caused administrators to call on as much as 10%–15% of the physician’s time, Limbocker says, and “that materially cuts into the physician’s schedule, thus the need to reimburse them for that amount of time needs to be considered.”

Though quality, patient experience, and administrative time are being factored into compensation models, it doesn’t mean that physicians will see large pay hikes in 2012. Just 6% of respondents expect to give pay increases of 10%–20%, while 65% of physicians will likely see their paychecks stay the same or have a moderate cost-of-living increase of 1%–4%, according to survey respondents. On the flip side, 4% of respondents expect to have compensation decreases of 1%–4%. About one of five physicians will see a 5%–9% compensation increase, a boost that report advisors say may be the result of practice acquisition “catch-up,” physician demand, or market conditions.

“Right now primary care doctors, under healthcare reform, will be the most valuable asset we have because we need them for an ACO to work … They are a huge asset for an organization, but there is a shortage of them nationwide. It’s the law of supply and demand, and their salaries will reflect it,” says Kaplan. He notes that when hospitals compete to acquire a practice, compensation levels go up. To maintain parity with previously acquired practices, hospitals may adjust the compensation levels of the other physicians within the same specialty.

“In some local markets,” Anderson says, “there may be competition for physicians—including competitors’ poaching some of your employees. In the past, we’ve increased salaries in a substantive way due to local market conditions.”

Limbocker, Kaplan, and Anderson agree that as healthcare reform directives continue to unfold, and incentives and penalties from these mandates take hold, physician compensation models are likely to continue to morph.

“With all of the uncertainty in the current environment, how we compensate physicians is going to see a lot of change over the next several years. I’m not sure exactly what to predict, but we should all strive to be nimble and to create a culture that will be ready to adapt to whatever is thrown at us,”
says Anderson.

Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media. She may be reached at kminich-pourshadi@healthleadersmedia.com.

What sort of tips can you offer on how to research a prospective employer before my first interview?

admin — Mon, 17 Oct 2011 09:44:00 GMT

Prior to attending the interview, you should thoroughly review the company’s website to gain valuable information about the program. If you have received a list of individuals with whom you will be interviewing, use the website to read about these individuals. This will enhance your ability to make “small talk” during the interview. Be sure to read any articles that your interviewers might have published. It would be very wise to make contact with a resident who is already in the program. Current residents are usually more than willing to give you priceless information about how the interview process will work, types of questions to expect, and other helpful hints. Finally, as the saying goes, “practice makes perfect.” Know yourself, your CV, your accomplishments, and your goals. Practice answering mock questions with peers so that you will be able to naturally articulate yourself during your interview.

Are there professional credentialing services to help me in the process? Are there any for non-US, international residents?

admin — Mon, 10 Oct 2011 14:12:00 GMT

The Federation Credential Verification Service (FCVS) from the Federation of State Medical Boards is one, and The Universal Credentialing DataSource system developed by the Council for Affordable Quality Healthcare is another. The AMA also has a fairly inexpensive service, but does not cover all specialties. Foreign or international residents may find it well worth the investment to enlist a credentialing service because getting to sources of information may be more complicated.

We have our share of conflict in the office and we also suffer from high staff turnover. What's the connection?

admin — Mon, 03 Oct 2011 14:44:00 GMT

Unresolved conflict manifests itself in a myriad of ways that have an enormous, negative impact on job satisfaction, the level of patient care and the bottom line. It's not just the patients who get fed up when conflict goes unchecked. High employee turnover is the frequent result, says Chris Simms of Internal Medical Associates of Lee's Summit, Missouri. "People get mad and they become unhappy with their jobs, which starts the wheel rolling" for them to look elsewhere. "With so many shortages in physicians' offices right now, it's not that hard to find another job. You hear that someone left because she 'found a better job,'" but no one questions why the employee was seeking employment elsewhere in the first place.

Physician Belief About Fair Compensation Varies Widely by Specialty

admin — Thu, 29 Sep 2011 02:04:00 GMT

Physician Belief About Fair Compensation Varies Widely by Specialty

Written by Bob Herman | September 09, 2011

Of physician specialists in the United States, general surgeons are least satisfied with their compensation while dermatologists feel they are most fairly compensated, according to Medscape's 2011 Physician Compensation Survey.

In total, 15,794 U.S. physicians across 22 specialty areas responded to the survey. The following are the top and bottom five physician specialists who think they are fairly compensated:

Top Five:

•   Dermatologists (71 percent)
•   Radiologists (69 percent)
•   Emergency medicine physicians (65 percent)
•   Anesthesiologists (63 percent)
•   Psychiatrists (58 percent)

Bottom Five:

•   General Surgeons (44 percent)
•   Pulmonologists (45 percent)
•   Endocrinologists/diabetes specialists (45 percent)
•   Nephrologists (45 percent)
•   Cardiologists (46 percent)

http://www.beckershospitalreview.com/compensation-issues/physician-belief-about-fair-compensation-varies-widely-by-specialty.html

There never seems to be enough time in the day to achieve everything I set out to do. Am I simply over-scheduling or doing something wrong?

admin — Mon, 26 Sep 2011 15:01:00 GMT

Each physician's situation is unique and must be addressed individually. Since one cannot do everything at once, setting priorities is key and conscious choices must be made. For example, you may need to be more selective in your journal reading, opting to focus on the most relevant material rather than trying to scan every page of every publication you receive. You may need to postpone some activities. It may be unwise, for example, to take on new outside commitments when you are in the middle of major changes in your practice setting.

When doctors communicate effectively and respectfully with their patients, the patients are less likely to do what?

admin — Mon, 19 Sep 2011 14:19:00 GMT

Patients are not likely to sue physicians with whom they have developed a trusting and mutually respectful relationship.

Burnout, Dissatisfaction Seem Rampant Among Medical Residents

admin — Mon, 12 Sep 2011 22:22:00 GMT

Burnout, Dissatisfaction Seem Rampant Among Medical Residents

One-third dissatisfied with work-life balance, nearly half emotionally exhausted, study finds

September 6, 2011

By Kathleen Doheny
HealthDay Reporter

TUESDAY, Sept. 6 (HealthDay News) -- The medical resident of today -- possibly your doctor in the future -- is exhausted, emotionally spent and likely stressed out about debt, a new study indicates.

"About 50 percent of our trainees are burned out," said study leader Dr. Colin P. West, an associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn.

Higher levels of stress translated into lower scores on tests that gauge medical knowledge and more emotional detachment, among other fallout.

The study is published in the Sept. 7 issue of the Journal of the American Medical Association, a themed issue devoted to doctors' training.

West and his team evaluated results of surveys and exams given to nearly 17,000 internal medicine residents, who were said to represent about 75 percent of all U.S. internal medicine residents in the 2008-9 academic year. The participants included 7,743 graduates of U.S. medical schools. They were asked about quality of life, work-life balance, burnout and their educational debt.

Among the findings:

Nearly 15 percent said their overall quality of life was "somewhat bad" or "as bad as it can be."
One-third said they were somewhat or very dissatisfied with work-life balance.
Forty-six percent said they were feeling emotionally exhausted at least once a week.
Nearly 29 percent said they felt detached or unable to feel emotion at least once a week.
More than half said they had at least one symptom of burnout.

The more educational debt the residents had incurred, the greater their emotional distress, the researchers found. Those with more than $200,000 of debt had a 59 percent higher chance of reporting emotional exhaustion, 72 percent greater likelihood of suffering burnout, and an 80 percent higher chance of feeling depersonalization.

Perhaps more alarming is the finding that greater stress was associated with lower test scores, and those students who were academically hurt by stress never caught up with their peers.

West said he can't explain why those more laden with debt are more stressed out. One possibility is that they may be more prone to stress to begin with.

Medical residents' stress has made news for years, and efforts are under way to improve their working conditions. However, West said, "to our knowledge, this is the first national study of residents' distress issues. And it's also the first national study to connect those issues to other important outcomes like medical knowledge."

As for solutions, he said "we have not yet identified the best ways to reduce burnout and promote well-being for residents, or for physicians in general."

He hopes that this new data, now gathered nationally, will help lead to solutions.

The findings come as no surprise to Dr. Peter Cronholm, an assistant professor of family medicine and community health and also a senior fellow at the Center for Public Health Initiatives of the University of Pennsylvania.

Cronholm, who published a study on resident burnout in 2008, said the residents of today may put more emphasis on work-life balance than previous generations.

One disturbing finding, he said, is that a stressed-out resident has less empathy over time. Already, close to one-third said they felt detached emotionally at least weekly.

However, he said, it's difficult to balance obligations to patients and get sufficient sleep and personal time. "Those two things sort of continue to compete with each other," he said.

Solutions aren't available yet, as "the problem is not yet totally understood. This is part of the conversation about health care reform," he said.

More information

For information on picking a good doctor, visit the American Academy of Family Practice.

Under the theory of negligent credentialing, Managed Care Organizations (MCOs) are responsible and can be held liable for what?

admin — Wed, 07 Sep 2011 14:10:00 GMT

MCOs are responsible and can be held liable for exposing an injured subscriber to an unqualified provider by failing to conduct a proper credentialing review. They also undertake the risk that subscribers can look to collect damages when the subscriber is injured due to the malpractice of a provider deemed later to be unqualified. An MCO that exercises reasonable care in credentialing and monitoring its providers reduces its risk of liability of a malpractice suit by one if its members.

Report casts doubt on cost benefits of physician hirings

admin — Tue, 30 Aug 2011 01:48:00 GMT

Report casts doubt on cost benefits of physician hirings

Written by Editorial Staff

August 19, 2011

As healthcare reform and cuts to Medicare have forced many private practices to close their doors, a brief issued Aug. 18 by the Center for Studying Health System Change (HSC) questioned whether the rise in hospital employment of physicians is actually as beneficial as some think in terms of quality and cost savings.

“In a quest to gain market share, hospital employment of physicians has accelerated in recent years to shore up referral bases and capture admissions,” according to HSC. “Stagnant reimbursement rates, coupled with the rising costs of private practice, and a desire for a better work-life balance have contributed to physician interest in hospital employment.”

Hospitals look to employ physicians to gain market share through service-line agreements and as a way to prepare for possible payment cuts. Additionally, hospitals see physician employment potentially leading to increased admissions, diagnostic testing and outpatient services.

“While initial hospital moves to employ physicians generally focused on hiring specialists to build targeted service lines, such as cardiac or cancer care, hospitals increasingly are hiring primary care physicians to capture referrals for their employed specialists,” the report stated.

These hirings don’t help just the hospitals; physicians also benefit. Because of low reimbursement rates and growing overhead costs, physicians look to hospitals as a safety net to protect them from upcoming cuts.

Despite the belief that hospital employment will improve care coordination and quality, it does not guarantee clinical integration. “Hospital employment of physicians theoretically can improve quality by encouraging better integration of care and communication among clinicians, but respondents indicated that clinical integration does not occur automatically once physicians become employees,” the report stated.

Additionally, the report pointed out that while many look toward hospital employment as a means to cut spending, costs may actually increase in the short term. These hikes may be due to the fact that physicians continue to practice in the fee-for-service environment, which provides incentives to increase the volume of services delivered, and they may feel pressured by the hospital to perform and order more expensive care.

The report noted that patients may gain in the end. “Increased hospital employment of physicians appears to affect patients’ access to care in a variety of ways,” according to the report. “From the patient perspective, physician employment by a hospital may be invisible as many employed physicians continue to work in the same offices they occupied when independent.” However, physician-hospital alignment will facilitate access to specialists, especially for low-income or disadvantaged patients.

“While the potential of hospital-employed physicians to improve quality and efficiency has received attention, the potential for higher costs has received less attention,” according to HSC. “The existing fee-for-service payment system that encourages hospital strategies to use employed physicians to increase referrals and admissions, coupled with the market power of hospitals to gain higher payment rates, risks overshadowing potential quality gains.”

Unless payment systems are reformed, HSC concluded that hospital employment will continue to raise costs and not improve care.

Last updated on August 22, 2011 at 6:04 am EST

Seven Reasons Family Doctors Get Sued and How to Reduce Your Risk

admin — Fri, 26 Aug 2011 21:04:00 GMT

Seven Reasons Family Doctors Get Sued and How to Reduce Your Risk

By adopting a risk-management mind-set, physicians can avert not only malpractice claims but also patient injury.

Richard G. Roberts, MD, JD, FAAFP

Fam Pract Manag. 2003 Mar;10(3):29-34.

With medical malpractice insurance premiums rising sharply across the nation and at least a dozen states facing an insurance crisis, physicians and policymakers are debating vigorously how best to respond. Tort reforms that would cap awards are among the proposals and have proven effective at moderating premiums in several states. [See “Understanding the Physician Liability Insurance Crisis,” FPM, October 2002, page 47.] But while physicians await legislative action or an upturn in the economy to soften the impact of insurance hikes, there is something doctors can do: better manage risk.

Risk management involves more than just reading a journal article, listening to a lecture or filling out a workbook. It is a style of practice that endeavors, first and foremost, to prevent patient injuries; second, to avoid malpractice claims; and third, when a claim does occur, to reduce malpractice claim losses.

First prevent patient injury

A while back, I was involved in the care of a four-year-old boy who was admitted with status asthmaticus. He was very ill, requiring intubation and ventilatory support. We were at his bedside literally breath by breath through the night. The child bounced back, fortunately, as children often do, and within three days he was home.

The following week at grand rounds, the senior resident presented the case. I opened the question and answer session that followed by asking the group, “How did we fail this boy?” A long silence ensued. One of the second-year residents responded, “I don’t understand what you’re talking about. You saved this kid’s life. At every turn you made exactly the right decision.”

And I said, “Yes, but how did we fail this boy?”

Finally, a first-year resident raised her hand and offered, “Well, he shouldn’t have been in status asthmaticus in the first place.” And that’s the answer.

One of the things physicians need to ask whenever a patient is admitted to the hospital is “How did the outpatient management fail?” In this instance, should we have spent more time with the child’s mother, emphasizing how important certain environmental changes were for her son? Was this a medication compliance problem? Develop a routine of reviewing the sequence of care for unexpected or unwanted outcomes. While we weren’t negligent for anything we had done in the care of this boy – indeed, our hospital care was excellent – we had failed to prevent an avoidable condition, status asthmaticus. Our failure violated rule number one of risk management: prevent patient injury.

KEY POINTS

To prevent, first and foremost, patient injuries and, secondarily, malpractice claims, physicians should:

Follow their patients complaints to full diagnosis,
Prepare themselves mentally before procedures,
Know when its time to consult with a colleague or make a referral.

Why FPs get sued

Patients sue their physicians for many reasons. Here are the seven most common ones for family physicians and tips for avoiding them.

1. Failure to diagnose or a delay in diagnosis. The most common allegation is failure to diagnose in a timely manner; the most common disease for this allegation is breast cancer. A frequent reason for a failure or delay in diagnosis of breast cancer is excessive reliance on a falsely negative mammogram. A palpable lump or breast complaint should be taken to diagnosis. Mammography may be an adequate screening tool, but it is a poor diagnostic tool with false negative rates of 20 percent. Diagnosis may mean simply following the patient for a month and determining whether the lump resolves with the next menses; or it may require needle aspiration; or it may need excisional biopsy. Whatever it takes, the lesion should be followed to diagnosis.

2. Negligent maternity care practice. Two things that often get family physicians into trouble are 1) the use of oxytocin, especially when a baby is distressed while the physician continues pushing the drug, and 2) the failed handoff. The classic story of the failed handoff is the Friday night catastrophe that occurs while the patient’s usual doctor has gone away for the weekend and the covering physician is inadequately informed and has no prior relationship with the patient. Developing a routine of signing out pregnant patients, especially those near term or with problems, can go a long way toward reducing the risk of a failed handoff. Sign-out need not be in person; voicemail systems and electronic methods can facilitate such communication.

3. Negligent fracture or trauma care. Patients with wrist “sprains” and snuffbox tenderness should be assumed to have navicular, or scaphoid, fractures until proven otherwise. A thumb spica cast is a reasonable approach until symptoms resolve or later X-rays resolve the question of fracture. Another situation to watch for is the patient with a popliteal fossa injury, usually resulting from impacting the knee against the dashboard during a car crash. Check and document that the patient’s distal circulation is intact with palpable pedal pulses. Popliteal artery embarrassment can easily go unrecognized, and the limb is placed in jeopardy.

4. Failure to consult in a timely manner. I try to follow the rule of three: If I haven’t figured out and corrected a patient’s problem within three visits, I enlist someone to help me. It may be my partner across the hall, a specialist down the road or someone else. Why do I use three as my cutoff? Because it’s as good a number as any, and it keeps me from temporizing forever while the patient continues to have problems. In primary care, it can be a challenge to diagnose vague symptoms for early-stage disease at the first visit. By the second visit, the story becomes better clarified. By the third visit, a clear diagnosis and plan should be decided. The main point is to set a plan for diagnosis, treatment and expected improvement; when these have not occurred as planned, then get help.

5. Negligent drug treatment. Drug-related iatrogenic injuries cause thousands of hospital admissions each year. Many of these injuries are related to the use of warfarin, perhaps the most dangerous prescription drug in America. Because of the drug’s very narrow therapeutic window, the clinical care team needs to use a protocol to ensure that patients are well educated about using warfarin and are getting their International Normalized Ratios checked regularly. [See “Improving Anticoagulation Management at the Point of Care,” FPM, February 2002, page 35, and “Reducing Risks for Patients Receiving Warfarin,” FPM, July/August 2002, page 35.]

6. Negligent procedures. The most common problem family physicians face with procedures is not that they are doing procedures they were not trained for, but that they find themselves doing procedures when they’re not at their best – when they’re tired or mentally distracted – and then the procedure goes badly. Although this may sound basic, the best way to prevent these types of injuries is to be prepared physically, mentally and emotionally for the procedure. Sleep depravation increases the risk of poor performance. Distractions such as pressing personal problems might be good reasons to reschedule or have another physician perform the procedure.

7. Failure to obtain informed consent. If failure to obtain informed consent is the only allegation a plaintiff makes, it usually suggests a weak case on the merits, and the physician has a good chance of winning the claim. Still, it’s best to avoid this risk by documenting that discussions with patients included expected outcomes, potential risks and reasonable alternatives to the proposed care plan.

MYTHS ABOUT MALPRACTICE

1. This is a new problem.

The first malpractice case recorded in the United States was Cross v Guthery, a 1794 Connecticut case in which a man sued his doctor over his wifes death following surgery. Since only appeals court decisions are usually recorded, the first malpractice case may well have occurred before the founding of the country. Historical accounts from the Civil War era document instances of surgeons refusing to do certain procedures because of concerns about being sued.

2. The current legal system works well.

Some would argue that the United States has the best legal system in the world. However, if the goals of the tort system are to make the injured whole, to punish those who commit negligence and to deter future negligence by others, then the current system is not working well.

3. It’s about money.

Many doctors believe that patients sue primarily because of money, but for the vast majority of patients, money is not the primary motivation. Instead, patients often sue because they want to prevent similar incidents from happening in the future, want an honest and clear explanation as to how and why the injury occurred and want the staff or organization to be accountable for their actions.1

4. The number of lawyers is the root of the problem.

The number of lawyers in an area does not predict the number of medical malpractice lawsuits. It is the number of doctors that predicts the number of suits.2

5. Lawyers decide the standard of care.

In every jurisdiction, a lawyer is able to file a medical malpractice suit only with a statement from an expert that negligence occurred. That expert has to be a physician.

6. Frivolous suits are the root of the problem.

A General Accounting Office report showed that less than 10 percent of the time does the plaintiff have an injury that would be regarded as insignificant.3 In the majority of cases, plaintiffs have serious problems that no one would want for themselves or their loved ones. Whether the bad outcome was the result of doctors negligence may be debatable, but medical malpractice suits for frivolous reasons are uncommon.

7. There is nothing one doctor can do.

Perhaps the most powerful predictor of the likelihood of being sued is how well the doctor relates to patients. The more honest and empathetic a doctor is, the lower the likelihood of suit.1

8. Judges and juries favor plaintiffs.

In fact, judges and juries generally favor doctors. In 2000, defendants won 62 percent of all medical malpractice cases brought before a jury.4

9. All tort reform is good.

Some kinds of tort reform have proven effective, such as Californias 1975 Medical Injury Compensation Reform Act (MICRA); others have not and, in fact, may make things worse.

1Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. The Lancet. 1994;343:1609–1613.

2Danzon PM. The frequency and severity of medical malpractice claims: new evidence. Law Contemp Probl. 1986;49:58–84.

3Medical Malpractice: Characteristics of Claims Closed in 1984. Washington, DC: General Accounting Office; 1987.

4Medical Malpractice: Verdicts, Settlements and Statistical Analysis. Horsham, Pa: Jury Verdict Research; 2002.

The four Cs of risk management

Developing a risk-management style of practice involves four Cs: compassion, communication, competence and charting.

Compassion. When patients do not pay their bills, it may be a signal that they were not happy with their care. Our practice sends three dunning letters to patients who don’t pay. The first letter is fairly mild, the second is more blunt in tone, and the third says, “We’re sending you to a collection agency.” This third letter isn’t sent without the doctor being made aware, and we endeavor to speak personally with the patient before the third letter is sent. It is surprising how often the reason that patients aren’t paying is because they are angry – angry about the way the nurse acted or something the receptionist said. For these patients, not paying the bill may be their last chance to express their displeasure. Take advantage of these risk-management opportunities. Patients appreciate the chance to have their grievances heard and addressed. Once heard, they are often more willing to work out payment terms. At the least, they are usually happier. Happier patients are less likely to sue.

Communication. Physicians practice as part of a care team. Communication across teams can be a challenge. It is sometimes tempting, for example, to engage in jousting in the chart: A nurse writes one observation, a physician notes a conflicting observation, and a consultant offers yet a third observation. Stay away from those kinds of games because no one wins except plaintiff’s lawyers who seek to divide and conquer. Instead, be honest and open yet discreet with communications, not only with colleagues but with patients and staff as well.

Competence. Physicians are keenly aware of the need to stay up-to-date on the latest evidence and clinical recommendations, yet no one can remember everything that is needed for the care of every patient. Flow sheets, protocols and other tools can reduce the chance that important factors are overlooked. A low threshold for consultation can be enormously helpful when the patient isn’t getting better as quickly as expected or wanted; when the patient or the patient’s relative expresses dissatisfaction with the care; when the patient’s presentation is atypical or the diagnosis obscure; or when the patient is critically ill or dying.

Charting. The greatest charting mistake physicians make is that they fail to note what is important. Often, doctors believe that there is a need to write volumes. Write what’s important. I recall one instance where I dictated a history and physical for a patient with chest pain admitted to rule out myocardial infarction, and the transcriptionist clocked me at 250 words a minute with gusts up to 350. When I later reviewed the transcribed note – and I do read every single transcribed note – I realized I had forgotten to mention anything about the heart! This can happen to anyone, and courts will forgive such clerical mistakes so long as they are detected and corrected.

We’re not expected to be perfect scribes, but we are expected to be honest and thoughtful in how we approach documentation. Follow these simple rules:

Be honest. Never go back and surreptitiously alter a record. I was once an expert witness in the case of a pediatrician caring for a child with H. flu meningitis. The care the pediatrician provided was excellent, but the patient had a terrible outcome and his family sued the physician. Because one normal white blood cell count result had not been incorporated into the patient’s chart, the physician got nervous and rewrote the entire two years of well-child and other visits to include this white count. The plaintiff’s lawyer obtained the original records and saw they were all written, without a single error, in the same colored ink. The lawyer had the ink analyzed and proved that the ink was not even manufactured until after the patient’s claim had been filed. The physician had a perfectly defensible case but panicked and ruined her credibility. Be honest with record keeping. Recording errors, when they occur, are best managed by a single strike through line that is initialed, dated, timed and identified as an “error.” More extensive or significant errors (e.g., “wrong patient”) may require more detailed explanation.
Be objective. Write the record as though the patient will read it. For example, avoid adjectives such as “drunk and obnoxious’ to describe a difficult patient. Instead, use more diplomatic language: “Patient is combative; ethanol-like odor noted.” In this case, the patient may be in a state of diabetic ketoacidosis, not alcoholic intoxication, and our description of early impressions will be less likely to haunt us later should our care be challenged as inattentive. The point here is not to sidestep the truth but to choose language that is descriptive, objective and respectful.
Be legible. Some physicians actually believe that illegible notes are a good way to prevent lawsuits because they hide any evidence of wrongdoing. In reality, illegible notes provide no protection and are viewed by juries as reflecting sloppy writing and, perhaps, sloppy care. Years later, when the case finally gets to the jury, the medical record can be the doctor’s best, and often only, friend as memories fade over time. Legible and logical notes detailing thoughtful care provide the best malpractice defense. Best is to use an electronic medical record system (it brings a wealth of information to the point of care); next best is to have notes dictated and transcribed. If notes must be hand written, make certain they are legible.

Bottom line

No one can promise immunity from lawsuits. However, developing excellent relationships with patients; promoting good communication with patients, colleagues and other members of the care team; maintaining clinical competence; and producing accurate and legible charts can go a long way toward reducing liability risk.

If a career counselor advises me to have a signed employment agreement early in my final year of residency, then I should be looking for a job almost two years before I complete my training, right?

admin — Wed, 24 Aug 2011 04:03:00 GMT

The majority of residents and fellows believe that they should begin their practice search when they begin their final year of training; anytime before that is just too soon. That’s not so! This common misconception can cause a hurried search and limits the job seeker’s ability to fully assess an opportunity. By proactively beginning your search with a career assessment 24-18 months prior to completion of training, you increase the chances of finding a position that’s right for you. Ideally, you should know where you are going to practice 12-6 months prior to completion of training, and, during that time, finalize your employment agreement. Residents, even if you are considering a fellowship, it should be lined up 6 months in advance.

2011 Medical Group Compensation and Financial Survey Finds Continued Financial Losses in Most Regions, Average Increase in Physician Compensation at 2.4%

admin — Tue, 23 Aug 2011 03:13:00 GMT

Newswise — ALEXANDRIA, VA-According to findings in the American Medical Group Association's 2011 Medical Group Compensation and Financial Survey, many provider organizations continue to operate at a significant loss, and although nearly 70% of specialties saw increases in compensation in 2010, increases were marginal.

The section of the survey that examines financial operations found that medical groups were still faced with significant financial challenges, and operating margins are increasingly thin. In 2010, only organizations in the Western region were nearing break-even (-$27 per physician). All other regions were operating at a loss: the Eastern region averaged a loss of $1,597 per physician; the Southern region averaged a loss of $1,870; and the Northern region continued to experience significant losses (-$10,669 per physician in 2010, compared to -9,943 per physician in 2009).

"In the face of the current economic climate, these medical groups continue to rise to the challenge of delivering the highest quality, coordinated care to the patients they serve," commented Donald W. Fisher, Ph.D., CAE, president and chief executive officer of AMGA. "Much of the losses we see in 2010 are supplemented by other non-clinical revenue sources and/or funding from health systems with which groups are associated. Our current volume-based reimbursement system is largely indifferent to the efforts of medical groups to elevate the standard of care in the U.S. Currently AMGA is working to address the inequities of the current payment model as part of overall healthcare reform and to develop a model that incorporates a substantial component reflecting achievement of quality results and value for patients and payers."

The compensation portion of the survey found that 69% of the specialties experienced increases in compensation in 2010, with the overall average increase around 2.4% (in 2009, 76% experienced an average increase around 3.8%). The primary care specialties saw about a 2.6% increase in 2010, while other medical specialties averaged an increase of 2.4% and surgical specialties averaged around 3.8%. (The primary care and surgical specialties saw about a 3.8% increase in 2009, while other medical specialties saw 2.4%.) The survey reports that during 2010, the specialties experiencing the largest increases in compensation were allergy (6.38%), emergency medicine (6.37%), and hospitalist – internal medicine (6.29%).

"The survey indicates that compensation continues to fluctuate only marginally for most specialties," said Fisher. "The modest increases seen this year reflect the negative impact of declining reimbursements, competition for specialists, the cost of new technology, and other factors on practice revenues in most parts of the country."

The AMGA 2011 Medical Group Compensation and Financial Survey gives a complete financial picture of medical group operations in one volume, providing compensation, productivity, and financial operations data from approximately 49,700 healthcare providers throughout the United States, including 124 specialties, 32 other healthcare provider positions, and 28 administrative positions. The data represents responses from 239 medical groups, representing 51,700 providers (55.6% of groups report more than 100 physicians). The survey data includes starting salaries by specialty; medians, means, and percentiles; compensation/productivity ratios; and comparative data from previous surveys, as well as providing analysis by group size and geographic region. In the financial section, profiles are provided per physician FTE, square footage, and work RVU. In addition to staffing profiles, the financial data includes medians, capitation impact, accounts receivable analysis, and department level analysis. A section examines data specific to the academic/faculty practice environment. The 24th annual AMGA compensation and financial survey was conducted by the national accounting firm of McGladrey.

McGladrey is the brand under which RSM McGladrey, Inc. and McGladrey & Pullen, LLP service clients’ business needs. Together, they rank as the fifth largest U.S. provider of assurance, tax and consulting services with 7,000 professionals and associates in nearly 90 offices. The two firms operate as separate legal entities in an alternative practice structure. McGladrey & Pullen is a licensed CPA firm that provides assurance services. RSM McGladrey is a leading professional services firm providing tax and consulting services. Both firms are members of RSM International, the sixth largest global network of independent accounting, tax and consulting firms. For more information, visit the McGladrey website at www.mcgladrey.com.

The American Medical Group Association represents medical groups, including some of the nation's largest, most prestigious medical practices, independent practice associations, and integrated healthcare delivery systems. AMGA's mission is to improve health care for patients by supporting multispecialty medical groups and other organized systems of care. More than 117,000 physicians practice in AMGA member organizations, providing healthcare services for 110 million patients in 49 states (nearly one in three Americans). Headquartered in Alexandria, Virginia, AMGA is the strategic partner for these organizations, providing a comprehensive package of benefits, including political advocacy, educational and networking programs, publications, benchmarking data services, and financial and operations assistance.
www.amga.org

A limited number of copies of this year's survey are available for working press. For press copies, contact Tom Flatt at tflatt@amga.org. Surveys are also available for purchase for $325 to AMGA members and $650 to nonmembers. To order, visit www.amga.org or contact Stefan Rozga at (703) 838-0033, ext. 326. Survey data is also available in a subscription-based, interactive, online database. For details, contact Stefan Rozga or visit www.amga.org.

When may I treat a minor without parental consent?

admin — Tue, 23 Aug 2011 03:02:00 GMT

A person under age 18 is considered a minor and generally may not consent to their own medical treatment without authorization from a parent, guardian or custodian. There are exceptions to this rule. In an emergency, the physician should try to obtain consent from a minor’s parent or surrogate, whenever possible; if that consent is obtained from a surrogate, then it should be documented.

Minors may consent to their own treatment in several situations, including when a married minor consents to treatment for him/herself and for his/her spouse, when a minor parent consents to treatment for his/her own minor child, and when a minor treats for his/her own venereal disease, drug abuse or any illness arising from these.

Special attention should be given, when a female patient treats for pregnancy, the prevention of pregnancy or childbirth. In these circumstances, treatment may be rendered regardless of age or marital status. However, particular attention should be paid to specific Georgia laws not discussed here that address the consent requirements for sterilization and abortion procedures.

How much importance should I place on preparing my presentation? Should I do some sort of pre-presentation rehearsal?

admin — Mon, 15 Aug 2011 09:06:00 GMT

Rehearsal is preparation time devoted to the most crucial and difficult parts of the presentation while simulating the actual speaking conditions as closely as possible. Practice should not be going through the presentation time after time. Instead, rehearsal time should be spent on the opening and closing of the presentation, pacing and delivery, and smoothing out rough spots. Public speaking is much like flying a plane. Once the plane’s in the air, the flight is usually smooth and on "autopilot." It’s getting the plane into the air and landing it that are the most difficult tasks. Therefore, most of your rehearsal time should be spent on getting your presentation "launch" and "landing"—the first 60-90 seconds and closing 2-3 sentences. Script out the opening and closing of the presentations to help prevent getting "tongue tied" during these crucial times. Practice smooth transitions from one slide to the next as well pauses, where appropriate, for dramatic effect. When rehearsing, simulate the actual speaking conditions or worst-case scenario you are likely to encounter as closely as possible. When a professional football team is going to be playing in a noisy domed stadium, they conduct some of their practices with a public address system blaring crowd noises at the same or higher decibel levels they are likely to encounter. Demonsthenes, the renowned Greek orator, overcame his inarticulate, stammering pronunciation by practicing with his mouth full of pebbles.

Why would an insurance carrier include personality assessment tests as a condition of policy renewal?

admin — Tue, 28 Jun 2011 21:42:00 GMT

There are many things that contribute to lawsuits being filed against physicians, but there have been several studies in recent years that connect personality with lawsuits. Researchers who have studies physician personality traits expect to see more insurers turn to personality assessment testing in this current tough medical liability market. At least one liability insurer is now asking doctors to complete a three-page communication skills assessment as a condition of policy renewal. Tranquil," "meticulous," "sympathetic," "opinionated," "devoted," "agreeable," "tense" and "perfectionist" are among the 81 word choices physicians contemplate when asked to describe how other people would describe them. Next, physicians are asked to check the words that they would use to describe themselves. Several studies in recent years connect communication and personality with lawsuits. The physician liability insurance market is a hard one, and companies are trying to get a handle on risk assessment.

Reform efforts have spurred dramatic drops in malpractice lawsuits in Pennsylvania, Texas

admin — Thu, 23 Jun 2011 10:37:00 GMT

Reform efforts have spurred dramatic drops in malpractice lawsuits in Pennsylvania, Texas

Publish date: Jun 15, 2011
By: Michael Levin-Epstein, JD
Source: Medical Economics eConsult

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Two significant rule changes implemented by the Pennsylvania Supreme Court have had a dramatic effect on the number of medical malpractice lawsuit filings, according to a recent report from the Administrative Office of Pennsylvania Courts (AOPC).

Since the “baseline” years of 2000-2002, statewide malpractice claims have declined 45.4%. In Philadelphia, Pennsylvania, the state’s judicial district with the largest caseload, the drop over 10 years has hit 70%.

What’s behind the big decline? Two rule changes are making all the difference. First, attorneys now are required to obtain from a medical professional a certificate of merit that establishes that the medical procedures in a case fall outside acceptable standards. The second rule change put a damper on “venue shopping,” requiring medical malpractice actions to be brought only in the county where the cause of action takes place and not where attorneys think juries might be more sympathetic. The baseline years used in the AOPC report are the period just prior to the two rules changes.

So, has the drop in filings led to a drop in malpractice insurance premiums for physicians? Unfortunately, insurance companies in Pennsylvania have not lowered liability premiums, according to the Pennsylvania Medical Society. Also, the state’s legislators have refused to limit the size of noneconomic medical malpractice awards, which tort reform fans favor to help lower the cost of insurance. Thus, while the decline in malpractice lawsuit filings is good news for Pennsylvania physicians, the bad news lingers.

Meanwhile, in Texas, as part of comprehensive tort reform in 2003, Proposition 12 placed a $750,000 cap on noneconomic damages in medical malpractice lawsuits and limited an individual physician’s liability to $250,000.

That, concludes a study recently reported in the Journal of the American College of Surgeons, is behind a nearly 80% decrease in the prevalence of surgical malpractice lawsuits at one academic medical center.

Researchers at the University of Texas Health Science Center at San Antonio conducted the study using data extracted from two hospital databases. They reviewed malpractice suit prevalence and associated costs across an 18-year period, from 1992 to 2010, and found that the prevalence of lawsuits decreased substantially following tort reform. During the pre-reform period, prevalence measured at 40 suits per 100,000 surgeries. After tort reform, it dropped to eight suits per 100,000 surgeries, showing a relative reduction of almost 80%.

The study also showed that tort reform brought about reductions in legal costs and malpractice insurance premiums for individual surgeons. In 2002, malpractice insurance premiums were $10,000 per surgeon. By 2010, the premium had dropped to $2,700.

Ronald M. Stewart, MD, FACS, the study’s lead author, touted the benefits of tort reform for surgeons and other healthcare providers. He also pointed to benefits for patients, noting that fewer lawsuits and lower associated costs lead to reduced healthcare costs overall and improved quality of care.

www.medicaleconomics.modernmedicine.com

Given the economic climate, what's the risk of accepting a job with the first quality practice that makes me an offer?

admin — Mon, 20 Jun 2011 10:07:00 GMT

Every job opportunity that presents itself to you is not a good one. And every practice you talk to will present itself as a quality practice. Practices that know how to recruit are only going to show you the good parts. And even when the practice is an ideal fit, the community may not be. Remember, by researching potential opportunities, you can weed out those that might not be a good fit for you. And by interviewing effectively, you can eliminate additional opportunities that might not meet your needs.

If I'm acquiring a practice am I generally better off in an assets purchase or a stock purchase?

admin — Mon, 13 Jun 2011 07:52:00 GMT

It's usually more desirable to purchase the assets only (excluding the liabilities or equity) rather than the stock in a practice acquisition, since the assets can be depreciated but the stock cannot.

Under Murphy's Law, what can I expect to go wrong during employment agreement negotitations?

admin — Wed, 08 Jun 2011 10:21:00 GMT

Twelve of the most common negotiation mistakes that might jeopardize a deal are: 1. Recruitment package is not finalized, but the candidate is ready to talk seriously 2. Letter of intent is not finalized 3. The final working agreement (contract) is not drafted 4. Disagreements about offer 5. Indecision among key players 6. Poor response time 7. Lack of understanding of what the candidate really wants 8. Lack of knowledge on how to negotiate 9. Opening offer is too low 10. One or both parties have a win-lose attitude 11. Offer description lacks flexibility 12. Emotion replaces good business sense and the eye loses sight of the ball.

Besides a copy of my CV, what else should I take on the interview?

admin — Tue, 31 May 2011 09:51:00 GMT

When it comes to your accoutrements, less is more in an interview setting. The only item necessary to bring into an interview setting is a leather portfolio, preferably black, that contains a notepad, pen, several copies of your CV, and several copies of your reference listing. {Note: Industry specific guidelines may indicate that additional materials such as a transcript, portfolio, copies of articles, etc. should be included in the portfolio. Adjust as necessary} The materials inside your portfolio should fit neatly inside the pocket – avoid stuffing your portfolio with research, notes, and information from other programs with which you might be interviewing. In addition to a portfolio, women may take a small purse or handbag into the room. Under no circumstances should backpacks or large tote bags containing anything from magazines to water bottles accompany you into the building. Finally, make sure that your cell phone or pager is turned off. It is a serious mistake to interrupt an interview with a ringing phone.

Malpractice fears hamper communication between ED physicians and PCPs

admin — Tue, 24 May 2011 20:55:00 GMT

Malpractice fears hamper communication between ED physicians and PCPs

Publish date: May 12, 2011
By: Michael Levin-Epstein, JD

If one of your patients is treated in a hospital emergency department (ED), chances are you engage in very little communication or coordination of care with the doctors who provided the care. So says a new study conducted by the Center for Studying Health System Change (HSC) for the nonprofit National Institute for Health Care Reform (NIHCR).

The result, the study’s authors conclude, is compromised patient care. It’s a problem for which no simple solutions are evident.

“There are no easy answers to the coordination issues between emergency and primary care physicians,” says Emily Carrier, MD, MSCI, HSC senior researcher and coauthor of the study. “Policymakers will need to examine a broad range of ways to address the problem. Pieces of the puzzle include payment reforms, standards for health information technology and malpractice liability reform.”

The researchers conducted 42 phone interviews with 21 pairs of ED physicians and PCPs, case-matched so that the perspectives of both specialties were represented. The key findings:

Real-time communication could be useful in many cases, but would be particularly time-consuming.
Faxing patient information could be helpful, but has limitations.
Sharing information via interoperable electronic health records would overcome some barriers. However, this option doesn’t offer a rapid overview of a patient’s case, limiting access to the kinds of detail an ED provider might need to direct care.
Insufficient time and lack of reimbursement are significant barriers to communications between the two groups.
When cross-covering physicians are involved, an ED physician is less likely to speak with a PCP who has direct knowledge of the patient.
The increasing use of hospitalists and larger primary care groups decreases the interactions between office-based providers and prevents PCPs from fully participating in care coordination.

Researchers concluded that even if these barriers to communication and coordination were removed, vexing liability concerns would remain. ED and primary care physicians face different constraints and have “fundamentally different assumptions regarding patients’ reliability and resilience,” according to the study.

Unlike PCPs, ED physicians do not have the opportunity to develop long-term relationships with patients, which are considered to be the most effective protection against being sued in the event of a misdiagnosis or bad outcome. ED physicians generally are much more concerned about being sued than primary care physicians, say the researchers.

Failing to address emergency providers’ concerns about their malpractice liability will limit attempts to encourage ED physicians to coordinate with PCPs, the study concluded. Moreover, even if an ED physician could reach a patient’s PCP and even if the PCP proposed an alternative to testing or admission recommended by the emergency provider, that provider would likely have to accept the full legal responsibility should there be a bad outcome following the patient’s discharge.

So what can you do? At the very least, let your patients know that you want to be able to follow up after any hospital visit. Ask patients to notify you themselves and to list you on the follow-up note at the ED.

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