From the Mailbag



"I'm a Rheumatologist in solo practice in the DC Metro area. I enjoy reading your blog when I can, it is always very informative. I've been in practice for about a year and a half and I'm still trying to wrap my head around the management aspect. I was thinking of having a small practice management firm have a look at my books but the first estimate I got was completely out of my budget. Do you think I need to do this and how else can I approach it? I'd appreciate any suggestions you might have."



This email came from Jennifer, and I want to thank her for taking the time to write. Of course, I completely empathize with her situation, but I am left wanting to know more. How large is her staff? What is nature of her concern--legal? Financial?



It's an important decision to involve a consultant, and if I may speak informally here, I'd say the fact that you want someone to look at your books and help you better understand "the management aspect" means you do need to seek a professional opinion. Not because you are doing anything wrong, but because the uncertainty you mention needs to be addressed.



Of course, the problem is finding an affordable solution. I am unfamiliar with your area, but have you asked around? Perhaps some colleagues might have a better suggestion? Inquire with any professional associations you might belong to and see if you can find a good management firm via networking.



A good, reliable firm will be worth your investment. It's a lot of responsibility to practice medicine and run a business, Jennifer, so I wish you luck. If you have more specific questions, don't hesitate to ask.



As always, I invite any readers who have advice to please leave a comment. We're all in this together. Perhaps someone in the DC metro area might have some names or contacts which might be useful?

Risk Management



Recently, I read about a bride who was suing someone for a botched flowers on her wedding cake. When people start seeing lawsuits in the wrong frosting, what chance do those of us in the medical profession have?



While I'm not a lawyer, I've learned a few practical tips on how to practice risk management. Really, what it boils down to is common sense.



For example, physicians in our practice are very specific when it comes to follow-up visits and refills. Their instructions to the patients are clear, so that there can be no misunderstanding regarding treatment.



When we have to discontinue treating a patient due to nonpayment, we provide them with ample warning. We also word our intent in a polite and gracious way. There is no point in antagonizing a patient during such a stressful time.



Another potential landmine is patient privacy. Physicians and staff never discuss medical information with a patient in an open area. Any time an insurance company or third party requests information, we ask for it in writing, and verify it with the patient-in-question.



Of course, my main concern is with how my staff conducts itself during interactions with our patients. They are under strict orders to never offer an opinion, and only to relay information that they are given. Anything more, they are instructed to refer the patient to their physician.



I remember a woman who once worked with me. She was very pious, and after a short time on the job, started to proselytize to patients. When one of them complained to our manager, the employee was fired on the spot. It was a lesson I never forgot.



I've often noted the importance of communication as a way to avoid many pitfalls in running a medical practice. When it comes to potential litigation, a paper trail is vital. If anything, erring on the side of excess never hurts. But another key is common sense and respect for others. I'd say everything I've suggested here falls under that general category.



Of course, there's no telling what some future patient will find worthy of a lawsuit. If we're lucky, it won't be the equivalent of bad frosting!



Naturally, I'm curious about your opinion. What stories or words of caution might you offer?

The Direct Approach



In my early years as a manager, I had a serious problem. The bookkeeper I had hired and supervised had embezzled a lot of money. We'd been having problems paying bills, and an accountant friend of mine audited our books on his own time as a favor.



Needless-to-say, I was mortified. I remember sitting at the kitchen table with my husband, beside myself with worry. I was certain I would be fired for this person's misdeeds. There was no way to tell the physicians this news and make it less awful.



My husband was in the Marines, and he can be less than subtle. He looked me straight in the eye and said the only way to deal with the situation was to be direct, and to tell the doctors first thing in the morning. He pointed out that I had already fired the bookkeeper and would have to call the police anyway.



The important thing, he said, was how I told them. He said it's important to make it clear that I was dealing with the situation in a pro-active way. "Doctors don't tell their patients, 'you've got diabetes, too bad.' They say, 'you've got type 2 diabetes, you'll need to meet with a nutritionist, and we'll discuss some exercising options.'"



It was great advice. Not only did I keep my job, the doctors applauded my efforts to investigate the problem.



As the years have gone by, I've had many other occasions to give physicians bad news. Recently, a doctor's poor bedside manner caused a patient to lodge a serious complaint. I told him about it without hesitation, and he admitted that his workload had been stressing him out lately. When he next saw the patient, he made amends.



It is never fun being the bearer of bad tidings, but when you're a manager, it's your job to tell it like it is. To do otherwise is to risk the trust of your colleagues and your own self respect.



Addendum: Recently, I invited readers to offer topics for blogs, and Rochelle was gracious enough to reply that she wanted to know how upcoming Medicare cuts would impact group practices. In the interests of accuracy, I think this article addresses that issue better than I ever could.



Thanks, Rochelle, for your question. As always, I welcome all comments and inquiries.

The So-S0 Employee



As many readers of this blog know, I am something of a softie when it comes to my employees. It has taken years for me to build up the self confidence necessary to project the right mix of manager and friend. (Mind you, I don't necessarily mean "friend" in the literal sense, but rather as a person sympathetic to the needs and goals of my employees.)



Recently, my mettle was sorely tested by a staff member who seemed in a slump. They had been extremely efficient and reliable when they first started, but over the course of their first year, something seemed to change. They lost the fire.



Mediocre employees can come in a variety of stripes. Some have a great interviewing technique and references, but a horrible work ethic. Others wind up over their head and unable to keep up due to lack of experience or ability. But when an employee starts out wonderfully and tailspins into a less satisfactory work routine, it can be painful. You know what they are capable of, and it's difficult to see them settle for less.



Worse, it can poison office morale. The slacker employee can become a leader by default, encouraging their co-workers by example. Why worry about coming in late when someone else is doing it on a regular basis?



So I had to do something about this particular staff member. They had just had their annual review and gotten a decent increase in salary. We had discussed weak spots and areas of concern, and I thought by offering a raise above cost-of-living, I'd sent a positive message for change. Unfortunately, the employee seemed to treat it as incentve to do even less, likely since the next review wouldn't be coming anytime soon.



The first thing I did to assess the situation was examine my own behavior as manager. I had allowed some sloppy mistakes by this employee because they were having a tough time in their personal life. I also looked the other way when they were tardy consistently. Clearly, I was enabling her habits.



I called her into my office and told her enough was enough. That she was to be in work on time and that if her carelessness continued, there would be consequences. I then asked her why she was continuing to slip. What was her perception of the problem?



She wound up pooring her heart out about her personal problems. It was like a floodgate had been lifted. I listened patiently and sympathetically, but I ended our meeting by telling her that while I completely understood what she was going through, she would have to step up and do her job. I gave her some concrete goals for improvement, and since then she has made great strides. She also apologized to some of her co-workers, who were relieved that the problem was out in the open. Morale in the office has never been better.



There's a part of me that feels for anyone who works for me, and cares deeply about what they're going through. I think that is partially my strength as a manager. It's knowing the boundaries for that kind of empathy that make me an effective professional. It can seem like a fine line sometimes, but I pride myself on knowing the difference.



Of course, I'd love to hear your opinion. How do you motivate mediocre employees? Do you have a zero tolerance policy for such behavior? I'd love to hear from you!

Do-It-Yourself

First I would like to start by apologizing for falling off the map recently. My professional and personal life have been a bit demanding lately, and unfortunately I feel my blog has suffered a bit. Second, given that my schedule is still quite full, I will most definitely continue to post my musings, however I would like to extend an invite to any of my readers who may be interested in doing some guest writing. Feel free to let me know if you have any topic suggestions, or would like to borrow my soap box! Ok, back to the blog...

As I've discussed before, the internet and computers are offering modern medicine a chance to interact with patients in a way that previous generations could only dream about. Recently, I read an article in the New York Times about an innovative new program by Microsoft called Health Vault (http://www.healthvault.com/) that allows consumers to create free personal health records on the web:



"The personal information, Microsoft said, will be stored in a secure, encrypted database. Its privacy controls, the company said, are set entirely by the individual, including what information goes in and who gets to see it. HealthVault searches are conducted anonymously, Microsoft said, and will not be linked to any personal information in a HealthVault personal health record."



Of course, I support any attempt to make the patient more responsible in the maintenance of their health care. Often, it can be difficult for various offices, with different levels of technical know-how and cooperation, to properly coordinate medical care. What a boon it would be to have one resource that everyone could access, and that's controlled by the person-in-question.



The Health Vault site is very simple to use, but while I think it's a good innovation from a leading computer company, I also have some doubts about it. For one thing, it's Microsoft, and even the article notes that it is an attempt by the company to make sure it is the dominant platform used. Could this be a case of something be offered to increase a market share without considering the actual consequences?



Another recent article I came across eloquently discussed the problem of patients not following their prescribed drug regimens:



"On average, half of patients with chronic illnesses like heart disease or asthma skip doses or otherwise mess up their medication, says a report being issued later this week. It calls the problem a national crisis costing billions of dollars."



The article mentions the famous example of former President Bill Clinton going off statins and later needing heart surgery. Apparently, this epidemic of carelessness crosses lines in terms of income and education; no one is immune.



Of course, this is old news to those of who work in medical offices. We know how difficult it is to get patients to properly care for themselves. Sometimes people need a major setback to realize that they are not invincible, or that a problem like high cholesterol is real.



So, naturally, this leads me to wonder if people can't be trusted to take their medicine, how on earth can they be trusted to create and maintain their own medical records? Will they omit information detrimental to, say, their chances at getting insurance? Or something which might embarrass them?



There will always be patients who are scrupulous with their care, and who will be able to build a solid personal database for health professionals to access, but I fear that the vast majority are not up to the task. I say that honestly, and without cynicism. Believe me, nothing would please me more than to see a world where patients were in complete charge of their health. It's just that my professional experience tells me the reality will always be otherwise.



I'm deeply curious about your opinion on this. As fellow medical professionals, what do you think of Microsoft's Health Vault? Should patients be trusted to create and maintain their own health records?