User login
Want to take action on health care legislation? Here’s how
The U.S. House of Representatives recently passed a revised version of the American Health Care Act (AHCA), which the nonpartisan Congressional Budget Office concluded would result in 14 million people losing coverage by 2018 and 23 million people losing coverage by 2026.
The American Congress of Obstetricians and Gynecologists is opposed to this bill and has stated that it will leave Americans “worse off than they are today” by cutting Medicaid, eliminating Medicaid expansion, allowing states to opt out of covering essential benefits like maternity care, and weakening protections for people with preexisting conditions.
[polldaddy:9770191]
State level
At the state level, the best person to contact is your ACOG section chairman, who can then direct you to your state’s legislative chairman. The legislative chairman will provide you with information on legislative actions that have been taken by the section. If you are interested in women’s health legislation, there may be an advocacy list to join that will provide legislative alerts. You may even choose to tweet about the alerts.
Often the state legislative chairman will send out information about an upcoming bill and ask for ACOG members to provide testimony. If there is a bill of particular interest, you can offer to testify either in person or submit written testimony. Often talking points are made available to help in the preparation of testimony.
Many states also have a Lobby Day, a day when members of the ob.gyn. community meet at the state house to advocate for or oppose legislation. This action can be easier than providing testimony because the time and date are predictable, while legislative hearings may not be.
There is a great deal that can be done at the state level in support of women’s health. Perhaps your state does not have a maternal mortality committee, perhaps there needs to be funding for vaccinations, or perhaps you want to support legislation that continues to provide health care for women even if the AHCA becomes law.
National action
Legislative action at the national level mirrors that at the state level, but it is coordinated by the ACOG Government Affairs Department. Contact this department via acog.org. One option is to become an advocate and receive legislative alerts. This alert system informs ACOG members about congressional actions and gives you the option to directly contact your members of Congress through email with a specific message. Some physicians may prefer to send an email different than the one provided by ACOG, while others may tweet using hashtags like #obgynaction or #docs4coverage.
You may prefer to contact your member of Congress by phone. The U.S. Capitol Switchboard number is 202-224-3121. Phone calls typically are taken by staff members. It is reasonable to ask for a staff member who handles the issue you wish to discuss. This person may be referred to as the L.A. (legislative assistant). Inform the staff member that you are a constituent and you would like to leave a brief message for the Senator or Representative. Your comments may be as brief as stating that you support or oppose a particular piece of legislation. As with the letter, you should state the reasons for your opinion and may include a short personal story. If you do not already know it, you should ask for the lawmaker’s position on the bill.
An ideal method of interacting with members of Congress is through town hall meetings. These meetings typically are posted on the member’s website and hearing from constituents in person can have a tremendous impact on legislators. Letters to the Editor, interviews with journalists, and advocating for candidates are also options to consider. In such cases, consider contacting the ACOG Government Affairs Department. They can provide helpful dos and don’ts before an interview is scheduled or an article is written.
Health care policymaking that is not based on scientific or medical evidence is dangerous for our patients. We, as their physicians, need to advocate on their behalf. Stay or get involved to help ensure that our patients can get the health care they need when they need it.
Dr. Bohon is an ob.gyn. in private practice in Washington, and an ACOG state legislative chair from the District of Columbia. She is a member of the Ob.Gyn. News Editorial Advisory Board. Dr. Bohon reported having no relevant financial disclosures.
The U.S. House of Representatives recently passed a revised version of the American Health Care Act (AHCA), which the nonpartisan Congressional Budget Office concluded would result in 14 million people losing coverage by 2018 and 23 million people losing coverage by 2026.
The American Congress of Obstetricians and Gynecologists is opposed to this bill and has stated that it will leave Americans “worse off than they are today” by cutting Medicaid, eliminating Medicaid expansion, allowing states to opt out of covering essential benefits like maternity care, and weakening protections for people with preexisting conditions.
[polldaddy:9770191]
State level
At the state level, the best person to contact is your ACOG section chairman, who can then direct you to your state’s legislative chairman. The legislative chairman will provide you with information on legislative actions that have been taken by the section. If you are interested in women’s health legislation, there may be an advocacy list to join that will provide legislative alerts. You may even choose to tweet about the alerts.
Often the state legislative chairman will send out information about an upcoming bill and ask for ACOG members to provide testimony. If there is a bill of particular interest, you can offer to testify either in person or submit written testimony. Often talking points are made available to help in the preparation of testimony.
Many states also have a Lobby Day, a day when members of the ob.gyn. community meet at the state house to advocate for or oppose legislation. This action can be easier than providing testimony because the time and date are predictable, while legislative hearings may not be.
There is a great deal that can be done at the state level in support of women’s health. Perhaps your state does not have a maternal mortality committee, perhaps there needs to be funding for vaccinations, or perhaps you want to support legislation that continues to provide health care for women even if the AHCA becomes law.
National action
Legislative action at the national level mirrors that at the state level, but it is coordinated by the ACOG Government Affairs Department. Contact this department via acog.org. One option is to become an advocate and receive legislative alerts. This alert system informs ACOG members about congressional actions and gives you the option to directly contact your members of Congress through email with a specific message. Some physicians may prefer to send an email different than the one provided by ACOG, while others may tweet using hashtags like #obgynaction or #docs4coverage.
You may prefer to contact your member of Congress by phone. The U.S. Capitol Switchboard number is 202-224-3121. Phone calls typically are taken by staff members. It is reasonable to ask for a staff member who handles the issue you wish to discuss. This person may be referred to as the L.A. (legislative assistant). Inform the staff member that you are a constituent and you would like to leave a brief message for the Senator or Representative. Your comments may be as brief as stating that you support or oppose a particular piece of legislation. As with the letter, you should state the reasons for your opinion and may include a short personal story. If you do not already know it, you should ask for the lawmaker’s position on the bill.
An ideal method of interacting with members of Congress is through town hall meetings. These meetings typically are posted on the member’s website and hearing from constituents in person can have a tremendous impact on legislators. Letters to the Editor, interviews with journalists, and advocating for candidates are also options to consider. In such cases, consider contacting the ACOG Government Affairs Department. They can provide helpful dos and don’ts before an interview is scheduled or an article is written.
Health care policymaking that is not based on scientific or medical evidence is dangerous for our patients. We, as their physicians, need to advocate on their behalf. Stay or get involved to help ensure that our patients can get the health care they need when they need it.
Dr. Bohon is an ob.gyn. in private practice in Washington, and an ACOG state legislative chair from the District of Columbia. She is a member of the Ob.Gyn. News Editorial Advisory Board. Dr. Bohon reported having no relevant financial disclosures.
The U.S. House of Representatives recently passed a revised version of the American Health Care Act (AHCA), which the nonpartisan Congressional Budget Office concluded would result in 14 million people losing coverage by 2018 and 23 million people losing coverage by 2026.
The American Congress of Obstetricians and Gynecologists is opposed to this bill and has stated that it will leave Americans “worse off than they are today” by cutting Medicaid, eliminating Medicaid expansion, allowing states to opt out of covering essential benefits like maternity care, and weakening protections for people with preexisting conditions.
[polldaddy:9770191]
State level
At the state level, the best person to contact is your ACOG section chairman, who can then direct you to your state’s legislative chairman. The legislative chairman will provide you with information on legislative actions that have been taken by the section. If you are interested in women’s health legislation, there may be an advocacy list to join that will provide legislative alerts. You may even choose to tweet about the alerts.
Often the state legislative chairman will send out information about an upcoming bill and ask for ACOG members to provide testimony. If there is a bill of particular interest, you can offer to testify either in person or submit written testimony. Often talking points are made available to help in the preparation of testimony.
Many states also have a Lobby Day, a day when members of the ob.gyn. community meet at the state house to advocate for or oppose legislation. This action can be easier than providing testimony because the time and date are predictable, while legislative hearings may not be.
There is a great deal that can be done at the state level in support of women’s health. Perhaps your state does not have a maternal mortality committee, perhaps there needs to be funding for vaccinations, or perhaps you want to support legislation that continues to provide health care for women even if the AHCA becomes law.
National action
Legislative action at the national level mirrors that at the state level, but it is coordinated by the ACOG Government Affairs Department. Contact this department via acog.org. One option is to become an advocate and receive legislative alerts. This alert system informs ACOG members about congressional actions and gives you the option to directly contact your members of Congress through email with a specific message. Some physicians may prefer to send an email different than the one provided by ACOG, while others may tweet using hashtags like #obgynaction or #docs4coverage.
You may prefer to contact your member of Congress by phone. The U.S. Capitol Switchboard number is 202-224-3121. Phone calls typically are taken by staff members. It is reasonable to ask for a staff member who handles the issue you wish to discuss. This person may be referred to as the L.A. (legislative assistant). Inform the staff member that you are a constituent and you would like to leave a brief message for the Senator or Representative. Your comments may be as brief as stating that you support or oppose a particular piece of legislation. As with the letter, you should state the reasons for your opinion and may include a short personal story. If you do not already know it, you should ask for the lawmaker’s position on the bill.
An ideal method of interacting with members of Congress is through town hall meetings. These meetings typically are posted on the member’s website and hearing from constituents in person can have a tremendous impact on legislators. Letters to the Editor, interviews with journalists, and advocating for candidates are also options to consider. In such cases, consider contacting the ACOG Government Affairs Department. They can provide helpful dos and don’ts before an interview is scheduled or an article is written.
Health care policymaking that is not based on scientific or medical evidence is dangerous for our patients. We, as their physicians, need to advocate on their behalf. Stay or get involved to help ensure that our patients can get the health care they need when they need it.
Dr. Bohon is an ob.gyn. in private practice in Washington, and an ACOG state legislative chair from the District of Columbia. She is a member of the Ob.Gyn. News Editorial Advisory Board. Dr. Bohon reported having no relevant financial disclosures.
EHR Report: Don’t let the electronic health record do the driving
The secret to the care of the patient ... is in caring for the patient.
-Francis W. Peabody, MD1
Last month I received a call from a man who was upset about the way he was treated in our office. He had presented with depression and felt insulted by one of our resident physicians in the way he had interacted with him during his visit. I offered to see him the next day.
When I walked into the exam room, I noticed that his eyes were bloodshot and he was fidgeting in his chair. He explained that it was difficult for him to address this issue, but he had been taken aback at his previous visit to our office when the doctor who saw him, after introducing himself, proceeded to sit down, open his computer, and start typing. The patient went on to describe that the physician – while staring at his computer screen – first acknowledged that he was being seen for depression and then immediately asked him if he had any plans to commit suicide. He did not have any suicidal plans, but he felt strongly that being asked about suicide as the first question in the doctor’s interview missed the point of his visit. He was having trouble concentrating, he felt down, and he was having difficulty sleeping at night, all contributing to trouble both at work and in his personal life. Suicide was not a concern of his. He shook his head. He said he understood that we, as doctors, had to put information into the computer, but he also felt that the doctor’s main goal during that visit appeared to be to get through the forms on the computer rather than taking care of him. He admonished that physicians also need to remember that there is a patient in the room and that we should pay attention to the patient first. The computer should be second. I couldn’t have said it better myself. I told him that I would look into what happened, and then we continued with his visit.
You can already see where this discussion is going. The odd thing about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare’s quality payment program, is that, unless we are careful, the result of the program may be the opposite of what it’s intended to accomplish. By leading to an over-focus on documentation of the quality of care, we are at risk of diminishing the quality of care itself. In essence, many of the requirements appear to simply be more advanced versions of the meaningful (meaningless?) use provisions with which we have previously grappled. It is clear that we should assess the quality of care that is given and that physician payment should be influenced by that care. It is also clear that the only reasonable way to measure the care provided is by collecting data from the EHR. The problem is that the sophistication of the EHR has not caught up to the sophistication of our goals.
Our challenge as physicians who care for patients therefore occurs at an individual level for each of us. How do we provide the necessary documentation scattered throughout our digital charts to satisfy reporting requirements, yet still meet the very real needs of patients to have their voices heard and their emotions acknowledged? The Physician Charter by the American Board of Internal Medicine discusses “the primacy of patient welfare” as a core tenant of medical practice. It goes on to state that “administrative exigencies must not compromise this principle.”2 Given competing demands, how do we continue to accomplish these goals which are often in conflict with one another?
We cannot provide an answer to this question because unfortunately – or perhaps fortunately – the answer does not come in the form of a clear algorithm of behaviors or a form that we can click on. However that does not mean that it cannot be done. Simply being mindful of how important personal interaction is to our patients will help us stay focused on patient needs. In fact, one of the most exciting aspects of our digital age (and our use of EHRs) is that the need to actually connect with people is more important than ever, and prioritizing this stands to reward those individuals who continue to pay attention to patients. In a future column, we will discuss suggestions and strategies for integrating the EHR into truly patient-centered care. In the early 1920s, Dr. Francis W. Peabody said, “The treatment of a disease may be entirely impersonal: the care of the patient must be completely personal.”1 Medical competency is essential and documentation is required, but neither alone is sufficient for the care of patients.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. Peabody FW. The care of the patient. JAMA. 1927;88:877-82.
2. The Physician Charter. American Board of Internal Medicine Foundation at http://abimfoundation.org/what-we-do/physician-charter.
The secret to the care of the patient ... is in caring for the patient.
-Francis W. Peabody, MD1
Last month I received a call from a man who was upset about the way he was treated in our office. He had presented with depression and felt insulted by one of our resident physicians in the way he had interacted with him during his visit. I offered to see him the next day.
When I walked into the exam room, I noticed that his eyes were bloodshot and he was fidgeting in his chair. He explained that it was difficult for him to address this issue, but he had been taken aback at his previous visit to our office when the doctor who saw him, after introducing himself, proceeded to sit down, open his computer, and start typing. The patient went on to describe that the physician – while staring at his computer screen – first acknowledged that he was being seen for depression and then immediately asked him if he had any plans to commit suicide. He did not have any suicidal plans, but he felt strongly that being asked about suicide as the first question in the doctor’s interview missed the point of his visit. He was having trouble concentrating, he felt down, and he was having difficulty sleeping at night, all contributing to trouble both at work and in his personal life. Suicide was not a concern of his. He shook his head. He said he understood that we, as doctors, had to put information into the computer, but he also felt that the doctor’s main goal during that visit appeared to be to get through the forms on the computer rather than taking care of him. He admonished that physicians also need to remember that there is a patient in the room and that we should pay attention to the patient first. The computer should be second. I couldn’t have said it better myself. I told him that I would look into what happened, and then we continued with his visit.
You can already see where this discussion is going. The odd thing about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare’s quality payment program, is that, unless we are careful, the result of the program may be the opposite of what it’s intended to accomplish. By leading to an over-focus on documentation of the quality of care, we are at risk of diminishing the quality of care itself. In essence, many of the requirements appear to simply be more advanced versions of the meaningful (meaningless?) use provisions with which we have previously grappled. It is clear that we should assess the quality of care that is given and that physician payment should be influenced by that care. It is also clear that the only reasonable way to measure the care provided is by collecting data from the EHR. The problem is that the sophistication of the EHR has not caught up to the sophistication of our goals.
Our challenge as physicians who care for patients therefore occurs at an individual level for each of us. How do we provide the necessary documentation scattered throughout our digital charts to satisfy reporting requirements, yet still meet the very real needs of patients to have their voices heard and their emotions acknowledged? The Physician Charter by the American Board of Internal Medicine discusses “the primacy of patient welfare” as a core tenant of medical practice. It goes on to state that “administrative exigencies must not compromise this principle.”2 Given competing demands, how do we continue to accomplish these goals which are often in conflict with one another?
We cannot provide an answer to this question because unfortunately – or perhaps fortunately – the answer does not come in the form of a clear algorithm of behaviors or a form that we can click on. However that does not mean that it cannot be done. Simply being mindful of how important personal interaction is to our patients will help us stay focused on patient needs. In fact, one of the most exciting aspects of our digital age (and our use of EHRs) is that the need to actually connect with people is more important than ever, and prioritizing this stands to reward those individuals who continue to pay attention to patients. In a future column, we will discuss suggestions and strategies for integrating the EHR into truly patient-centered care. In the early 1920s, Dr. Francis W. Peabody said, “The treatment of a disease may be entirely impersonal: the care of the patient must be completely personal.”1 Medical competency is essential and documentation is required, but neither alone is sufficient for the care of patients.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. Peabody FW. The care of the patient. JAMA. 1927;88:877-82.
2. The Physician Charter. American Board of Internal Medicine Foundation at http://abimfoundation.org/what-we-do/physician-charter.
The secret to the care of the patient ... is in caring for the patient.
-Francis W. Peabody, MD1
Last month I received a call from a man who was upset about the way he was treated in our office. He had presented with depression and felt insulted by one of our resident physicians in the way he had interacted with him during his visit. I offered to see him the next day.
When I walked into the exam room, I noticed that his eyes were bloodshot and he was fidgeting in his chair. He explained that it was difficult for him to address this issue, but he had been taken aback at his previous visit to our office when the doctor who saw him, after introducing himself, proceeded to sit down, open his computer, and start typing. The patient went on to describe that the physician – while staring at his computer screen – first acknowledged that he was being seen for depression and then immediately asked him if he had any plans to commit suicide. He did not have any suicidal plans, but he felt strongly that being asked about suicide as the first question in the doctor’s interview missed the point of his visit. He was having trouble concentrating, he felt down, and he was having difficulty sleeping at night, all contributing to trouble both at work and in his personal life. Suicide was not a concern of his. He shook his head. He said he understood that we, as doctors, had to put information into the computer, but he also felt that the doctor’s main goal during that visit appeared to be to get through the forms on the computer rather than taking care of him. He admonished that physicians also need to remember that there is a patient in the room and that we should pay attention to the patient first. The computer should be second. I couldn’t have said it better myself. I told him that I would look into what happened, and then we continued with his visit.
You can already see where this discussion is going. The odd thing about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare’s quality payment program, is that, unless we are careful, the result of the program may be the opposite of what it’s intended to accomplish. By leading to an over-focus on documentation of the quality of care, we are at risk of diminishing the quality of care itself. In essence, many of the requirements appear to simply be more advanced versions of the meaningful (meaningless?) use provisions with which we have previously grappled. It is clear that we should assess the quality of care that is given and that physician payment should be influenced by that care. It is also clear that the only reasonable way to measure the care provided is by collecting data from the EHR. The problem is that the sophistication of the EHR has not caught up to the sophistication of our goals.
Our challenge as physicians who care for patients therefore occurs at an individual level for each of us. How do we provide the necessary documentation scattered throughout our digital charts to satisfy reporting requirements, yet still meet the very real needs of patients to have their voices heard and their emotions acknowledged? The Physician Charter by the American Board of Internal Medicine discusses “the primacy of patient welfare” as a core tenant of medical practice. It goes on to state that “administrative exigencies must not compromise this principle.”2 Given competing demands, how do we continue to accomplish these goals which are often in conflict with one another?
We cannot provide an answer to this question because unfortunately – or perhaps fortunately – the answer does not come in the form of a clear algorithm of behaviors or a form that we can click on. However that does not mean that it cannot be done. Simply being mindful of how important personal interaction is to our patients will help us stay focused on patient needs. In fact, one of the most exciting aspects of our digital age (and our use of EHRs) is that the need to actually connect with people is more important than ever, and prioritizing this stands to reward those individuals who continue to pay attention to patients. In a future column, we will discuss suggestions and strategies for integrating the EHR into truly patient-centered care. In the early 1920s, Dr. Francis W. Peabody said, “The treatment of a disease may be entirely impersonal: the care of the patient must be completely personal.”1 Medical competency is essential and documentation is required, but neither alone is sufficient for the care of patients.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. Peabody FW. The care of the patient. JAMA. 1927;88:877-82.
2. The Physician Charter. American Board of Internal Medicine Foundation at http://abimfoundation.org/what-we-do/physician-charter.
Hiring the right employees
Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing but also hasn’t done anything special to merit continued employment. I always advise getting rid of such people and then changing the hiring criteria that all too often result in poor hires.
Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.
Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate just to get the process over with.
It is also sometimes tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.
Be alert for red flags in resumes: significant time gaps between jobs, positions at companies that are no longer in business or are otherwise impossible to verify, job titles that don’t make sense given the applicant’s qualifications.
Background checks are a dicey subject, but publicly available information can be found, cheap or free, on multiple web sites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes. It’s usually wise to get their written consent to do so.
Many employers skip the essential step of calling references, and many applicants know that. Some old bosses will be reluctant to tell you anything substantive, so I always ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.
Interviews often get short shrift as well. Many doctors tend to do all the talking. As I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.
By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workman’s compensation.
However, there are acceptable alternatives to some of those questions. You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.
Once you have hired people whose skills and personalities best fit your needs, train them well. Then, give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is one who has sense enough to pick good people to do what he [or she] wants done and self-restraint enough to keep from meddling with them while they do it.” ”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.
Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing but also hasn’t done anything special to merit continued employment. I always advise getting rid of such people and then changing the hiring criteria that all too often result in poor hires.
Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.
Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate just to get the process over with.
It is also sometimes tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.
Be alert for red flags in resumes: significant time gaps between jobs, positions at companies that are no longer in business or are otherwise impossible to verify, job titles that don’t make sense given the applicant’s qualifications.
Background checks are a dicey subject, but publicly available information can be found, cheap or free, on multiple web sites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes. It’s usually wise to get their written consent to do so.
Many employers skip the essential step of calling references, and many applicants know that. Some old bosses will be reluctant to tell you anything substantive, so I always ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.
Interviews often get short shrift as well. Many doctors tend to do all the talking. As I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.
By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workman’s compensation.
However, there are acceptable alternatives to some of those questions. You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.
Once you have hired people whose skills and personalities best fit your needs, train them well. Then, give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is one who has sense enough to pick good people to do what he [or she] wants done and self-restraint enough to keep from meddling with them while they do it.” ”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.
Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing but also hasn’t done anything special to merit continued employment. I always advise getting rid of such people and then changing the hiring criteria that all too often result in poor hires.
Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.
Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate just to get the process over with.
It is also sometimes tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.
Be alert for red flags in resumes: significant time gaps between jobs, positions at companies that are no longer in business or are otherwise impossible to verify, job titles that don’t make sense given the applicant’s qualifications.
Background checks are a dicey subject, but publicly available information can be found, cheap or free, on multiple web sites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes. It’s usually wise to get their written consent to do so.
Many employers skip the essential step of calling references, and many applicants know that. Some old bosses will be reluctant to tell you anything substantive, so I always ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.
Interviews often get short shrift as well. Many doctors tend to do all the talking. As I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.
By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workman’s compensation.
However, there are acceptable alternatives to some of those questions. You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.
Once you have hired people whose skills and personalities best fit your needs, train them well. Then, give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is one who has sense enough to pick good people to do what he [or she] wants done and self-restraint enough to keep from meddling with them while they do it.” ”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.
Acute cholecystitis: Not always routine
The more we think we know, the less we actually may know. As new techniques develop and their use is closely examined and reported, details about the patient’s disease and the surgeon’s skill and judgment turn out to matter more and more in the decision-making process. So it is with acute cholecystitis.
I have recently been puzzled and intrigued by changing trends in the management of acute cholecystitis that are apparent in the medical literature, discussions in the ACS Communities, and practice in my local community.
When I was a resident, the debate about early cholecystectomy vs antibiotics with interval operation 6 weeks later was just being settled in the literature in favor of early cholecystectomy. The weight of evidence in the surgical literature found that delay made the eventual operation more difficult and costly.
In the following 2 decades, early cholecystectomy became the indicated treatment for acute cholecystitis. In that era, of course, these operations were open, as that was our only option and one which we all learned to perform with confidence during residency. Tube cholecystostomy was a rarity reserved only for the most severely ill and feeble, and done by surgeons, since interventional radiologists had not yet appeared on the scene.
In the rare instance of acute cholecystitis so severe, and anatomic landmarks so obscured, that the gallbladder could not be safely dissected away from the common bile duct, a remnant of the gallbladder might be left behind, the mucosa cauterized, and the right upper quadrant drained.
Fast forward 40 years, and we find a distinctly different landscape. As the Boomer generation reaches geriatric age in expanding numbers, surgeons encounter an increasingly older patient population, often with numerous comorbidities and high surgical risk. Our increased critical care capability to rescue patients from sepsis and organ failure also introduces new challenges in decision-making about whether immediate cholecystectomy or a temporizing option is better for the elderly septic ICU patient before us.
At the same time, our overwhelmingly most common elective biliary procedure has become a laparoscopic cholecystectomy (LC), with which our younger surgeons have become comfortable and facile. Multiple randomized studies also confirm the superiority of early LC for acute cholecystitis, although LC is associated with a higher rate of conversion to open cholecystectomy in acute cholecystitis than in the elective setting. Since it is acknowledged that the mortality and morbidity of an open cholecystectomy is greater than that of its laparoscopic counterpart, especially in the setting of severe inflammation, and the younger surgeons are less confident in performing open cholecystectomy, it is not surprising that they embrace a strategy that allows them to avoid surgical management of acute cholecystitis in the high-risk patient with severe disease.
The ready availability of interventional radiologists in the past 30 years also offers a less invasive option than surgery – the percutaneous tube cholecystostomy (PC). It is no wonder that PC has increasingly become the “go-to” early option when the patient is old and sick or the surgeon lacks confidence in his/her open surgical skills in a potentially hostile, inflamed right upper quadrant. If the increasing number of articles on PC appearing in the literature is any indication, its use has proliferated in the recent past. As yet, no randomized clinical trials or other high-quality evidence have emerged to support its increased use, but a consensus panel of experts has issued the Tokyo Guidelines, recommending PC as primary therapy for stage III acute cholecystitis, the form of disease associated with organ failure, but not citing evidence to support this recommendation (J Hepatobiliary Pancreat Surg. 2007;14[1]:91-7). Although the rate of PC use in Medicare patients with stage III acute cholecystitis has more than doubled in the past 20 years, Tokyo Guidelines have clearly not been uniformly adopted in the U.S., since PC use in patients with stage III acute cholecystitis is only 10% (J Am Coll Surg. 2017;224[4]: 502-14).
Whether the increase in PC use is appropriate or not remains undetermined. Other uncertainties about PC need clarification. When patients have a PC placed for acute cholecystitis, do they always need their gallbladders removed later? The rate of recurrent acute cholecystitis after PC is variable in the literature, although it appears to be more likely in patients with acute calculous than acalculous cholecystitis. The likelihood that the patient will later undergo a cholecystectomy varies from a low of 3% to a high of 57% in various studies.(Surgery. 2014;155[4]:615-22; J Am Coll Surg. 2012; 214[2]:196-201).
The exact rate may not even accurately be known, since some patients may be lost to follow-up or get subsequent care in another facility. The decision to perform cholecystectomy after PC involves assessment of patient risk for surgery and, ultimately, surgeon judgment. Other questions also remain unanswered: What is the role of surgeon experience in the decision to defer surgical therapy for acute cholecystitis? Is the surgeon even the one who is in charge of the decision in all cases, or is that decision being made by an internist, intensivist, or hospitalist, who may judge the patient’s risk differently than a surgeon would? Are we witnessing an evolution in management of severe cholecystitis in the high-risk, septic and elderly patient towards antibiotics and PC unless the patient fails that treatment? This strategy appears to be gaining in popularity, since several studies have shown that the minority of patients who have PC end up having their gallbladders removed. If symptoms recur and nonoperative treatment has clearly failed, should the decision be made to refer to a highly experienced surgeon (by virtue of laparoscopic skills or reputation as a hepatic-pancreatic biliary specialist)? Recent studies show that 46%-86% of elective interval cholecystectomies after successful PC can be performed laparoscopically with low complication rates, although those studies came from institutions with notable laparoscopic expertise (J Am Coll Surg. 2012;214[2]:196-201; J Gastrointest Surg. 2017; 21[5]:761-69).
One of my most revered senior surgical mentors recently opined that the safest strategy for the high-risk patient with severe acute cholecystitis was indeed PC and antibiotics followed by watchful waiting, and reserving cholecystectomy only for those who fail nonoperative therapy. I initially bristled at that concept as being antithetic to the surgical bias in favor of cholecystectomy as the answer to all gallbladder evils. But after reflecting further on the changing landscape of our therapeutic options and our changing surgical training, I’m thinking that his strategy may be reasonable.
After all, it’s about choosing the safest path for the patient. All cholecystectomies are not routine.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
The more we think we know, the less we actually may know. As new techniques develop and their use is closely examined and reported, details about the patient’s disease and the surgeon’s skill and judgment turn out to matter more and more in the decision-making process. So it is with acute cholecystitis.
I have recently been puzzled and intrigued by changing trends in the management of acute cholecystitis that are apparent in the medical literature, discussions in the ACS Communities, and practice in my local community.
When I was a resident, the debate about early cholecystectomy vs antibiotics with interval operation 6 weeks later was just being settled in the literature in favor of early cholecystectomy. The weight of evidence in the surgical literature found that delay made the eventual operation more difficult and costly.
In the following 2 decades, early cholecystectomy became the indicated treatment for acute cholecystitis. In that era, of course, these operations were open, as that was our only option and one which we all learned to perform with confidence during residency. Tube cholecystostomy was a rarity reserved only for the most severely ill and feeble, and done by surgeons, since interventional radiologists had not yet appeared on the scene.
In the rare instance of acute cholecystitis so severe, and anatomic landmarks so obscured, that the gallbladder could not be safely dissected away from the common bile duct, a remnant of the gallbladder might be left behind, the mucosa cauterized, and the right upper quadrant drained.
Fast forward 40 years, and we find a distinctly different landscape. As the Boomer generation reaches geriatric age in expanding numbers, surgeons encounter an increasingly older patient population, often with numerous comorbidities and high surgical risk. Our increased critical care capability to rescue patients from sepsis and organ failure also introduces new challenges in decision-making about whether immediate cholecystectomy or a temporizing option is better for the elderly septic ICU patient before us.
At the same time, our overwhelmingly most common elective biliary procedure has become a laparoscopic cholecystectomy (LC), with which our younger surgeons have become comfortable and facile. Multiple randomized studies also confirm the superiority of early LC for acute cholecystitis, although LC is associated with a higher rate of conversion to open cholecystectomy in acute cholecystitis than in the elective setting. Since it is acknowledged that the mortality and morbidity of an open cholecystectomy is greater than that of its laparoscopic counterpart, especially in the setting of severe inflammation, and the younger surgeons are less confident in performing open cholecystectomy, it is not surprising that they embrace a strategy that allows them to avoid surgical management of acute cholecystitis in the high-risk patient with severe disease.
The ready availability of interventional radiologists in the past 30 years also offers a less invasive option than surgery – the percutaneous tube cholecystostomy (PC). It is no wonder that PC has increasingly become the “go-to” early option when the patient is old and sick or the surgeon lacks confidence in his/her open surgical skills in a potentially hostile, inflamed right upper quadrant. If the increasing number of articles on PC appearing in the literature is any indication, its use has proliferated in the recent past. As yet, no randomized clinical trials or other high-quality evidence have emerged to support its increased use, but a consensus panel of experts has issued the Tokyo Guidelines, recommending PC as primary therapy for stage III acute cholecystitis, the form of disease associated with organ failure, but not citing evidence to support this recommendation (J Hepatobiliary Pancreat Surg. 2007;14[1]:91-7). Although the rate of PC use in Medicare patients with stage III acute cholecystitis has more than doubled in the past 20 years, Tokyo Guidelines have clearly not been uniformly adopted in the U.S., since PC use in patients with stage III acute cholecystitis is only 10% (J Am Coll Surg. 2017;224[4]: 502-14).
Whether the increase in PC use is appropriate or not remains undetermined. Other uncertainties about PC need clarification. When patients have a PC placed for acute cholecystitis, do they always need their gallbladders removed later? The rate of recurrent acute cholecystitis after PC is variable in the literature, although it appears to be more likely in patients with acute calculous than acalculous cholecystitis. The likelihood that the patient will later undergo a cholecystectomy varies from a low of 3% to a high of 57% in various studies.(Surgery. 2014;155[4]:615-22; J Am Coll Surg. 2012; 214[2]:196-201).
The exact rate may not even accurately be known, since some patients may be lost to follow-up or get subsequent care in another facility. The decision to perform cholecystectomy after PC involves assessment of patient risk for surgery and, ultimately, surgeon judgment. Other questions also remain unanswered: What is the role of surgeon experience in the decision to defer surgical therapy for acute cholecystitis? Is the surgeon even the one who is in charge of the decision in all cases, or is that decision being made by an internist, intensivist, or hospitalist, who may judge the patient’s risk differently than a surgeon would? Are we witnessing an evolution in management of severe cholecystitis in the high-risk, septic and elderly patient towards antibiotics and PC unless the patient fails that treatment? This strategy appears to be gaining in popularity, since several studies have shown that the minority of patients who have PC end up having their gallbladders removed. If symptoms recur and nonoperative treatment has clearly failed, should the decision be made to refer to a highly experienced surgeon (by virtue of laparoscopic skills or reputation as a hepatic-pancreatic biliary specialist)? Recent studies show that 46%-86% of elective interval cholecystectomies after successful PC can be performed laparoscopically with low complication rates, although those studies came from institutions with notable laparoscopic expertise (J Am Coll Surg. 2012;214[2]:196-201; J Gastrointest Surg. 2017; 21[5]:761-69).
One of my most revered senior surgical mentors recently opined that the safest strategy for the high-risk patient with severe acute cholecystitis was indeed PC and antibiotics followed by watchful waiting, and reserving cholecystectomy only for those who fail nonoperative therapy. I initially bristled at that concept as being antithetic to the surgical bias in favor of cholecystectomy as the answer to all gallbladder evils. But after reflecting further on the changing landscape of our therapeutic options and our changing surgical training, I’m thinking that his strategy may be reasonable.
After all, it’s about choosing the safest path for the patient. All cholecystectomies are not routine.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
The more we think we know, the less we actually may know. As new techniques develop and their use is closely examined and reported, details about the patient’s disease and the surgeon’s skill and judgment turn out to matter more and more in the decision-making process. So it is with acute cholecystitis.
I have recently been puzzled and intrigued by changing trends in the management of acute cholecystitis that are apparent in the medical literature, discussions in the ACS Communities, and practice in my local community.
When I was a resident, the debate about early cholecystectomy vs antibiotics with interval operation 6 weeks later was just being settled in the literature in favor of early cholecystectomy. The weight of evidence in the surgical literature found that delay made the eventual operation more difficult and costly.
In the following 2 decades, early cholecystectomy became the indicated treatment for acute cholecystitis. In that era, of course, these operations were open, as that was our only option and one which we all learned to perform with confidence during residency. Tube cholecystostomy was a rarity reserved only for the most severely ill and feeble, and done by surgeons, since interventional radiologists had not yet appeared on the scene.
In the rare instance of acute cholecystitis so severe, and anatomic landmarks so obscured, that the gallbladder could not be safely dissected away from the common bile duct, a remnant of the gallbladder might be left behind, the mucosa cauterized, and the right upper quadrant drained.
Fast forward 40 years, and we find a distinctly different landscape. As the Boomer generation reaches geriatric age in expanding numbers, surgeons encounter an increasingly older patient population, often with numerous comorbidities and high surgical risk. Our increased critical care capability to rescue patients from sepsis and organ failure also introduces new challenges in decision-making about whether immediate cholecystectomy or a temporizing option is better for the elderly septic ICU patient before us.
At the same time, our overwhelmingly most common elective biliary procedure has become a laparoscopic cholecystectomy (LC), with which our younger surgeons have become comfortable and facile. Multiple randomized studies also confirm the superiority of early LC for acute cholecystitis, although LC is associated with a higher rate of conversion to open cholecystectomy in acute cholecystitis than in the elective setting. Since it is acknowledged that the mortality and morbidity of an open cholecystectomy is greater than that of its laparoscopic counterpart, especially in the setting of severe inflammation, and the younger surgeons are less confident in performing open cholecystectomy, it is not surprising that they embrace a strategy that allows them to avoid surgical management of acute cholecystitis in the high-risk patient with severe disease.
The ready availability of interventional radiologists in the past 30 years also offers a less invasive option than surgery – the percutaneous tube cholecystostomy (PC). It is no wonder that PC has increasingly become the “go-to” early option when the patient is old and sick or the surgeon lacks confidence in his/her open surgical skills in a potentially hostile, inflamed right upper quadrant. If the increasing number of articles on PC appearing in the literature is any indication, its use has proliferated in the recent past. As yet, no randomized clinical trials or other high-quality evidence have emerged to support its increased use, but a consensus panel of experts has issued the Tokyo Guidelines, recommending PC as primary therapy for stage III acute cholecystitis, the form of disease associated with organ failure, but not citing evidence to support this recommendation (J Hepatobiliary Pancreat Surg. 2007;14[1]:91-7). Although the rate of PC use in Medicare patients with stage III acute cholecystitis has more than doubled in the past 20 years, Tokyo Guidelines have clearly not been uniformly adopted in the U.S., since PC use in patients with stage III acute cholecystitis is only 10% (J Am Coll Surg. 2017;224[4]: 502-14).
Whether the increase in PC use is appropriate or not remains undetermined. Other uncertainties about PC need clarification. When patients have a PC placed for acute cholecystitis, do they always need their gallbladders removed later? The rate of recurrent acute cholecystitis after PC is variable in the literature, although it appears to be more likely in patients with acute calculous than acalculous cholecystitis. The likelihood that the patient will later undergo a cholecystectomy varies from a low of 3% to a high of 57% in various studies.(Surgery. 2014;155[4]:615-22; J Am Coll Surg. 2012; 214[2]:196-201).
The exact rate may not even accurately be known, since some patients may be lost to follow-up or get subsequent care in another facility. The decision to perform cholecystectomy after PC involves assessment of patient risk for surgery and, ultimately, surgeon judgment. Other questions also remain unanswered: What is the role of surgeon experience in the decision to defer surgical therapy for acute cholecystitis? Is the surgeon even the one who is in charge of the decision in all cases, or is that decision being made by an internist, intensivist, or hospitalist, who may judge the patient’s risk differently than a surgeon would? Are we witnessing an evolution in management of severe cholecystitis in the high-risk, septic and elderly patient towards antibiotics and PC unless the patient fails that treatment? This strategy appears to be gaining in popularity, since several studies have shown that the minority of patients who have PC end up having their gallbladders removed. If symptoms recur and nonoperative treatment has clearly failed, should the decision be made to refer to a highly experienced surgeon (by virtue of laparoscopic skills or reputation as a hepatic-pancreatic biliary specialist)? Recent studies show that 46%-86% of elective interval cholecystectomies after successful PC can be performed laparoscopically with low complication rates, although those studies came from institutions with notable laparoscopic expertise (J Am Coll Surg. 2012;214[2]:196-201; J Gastrointest Surg. 2017; 21[5]:761-69).
One of my most revered senior surgical mentors recently opined that the safest strategy for the high-risk patient with severe acute cholecystitis was indeed PC and antibiotics followed by watchful waiting, and reserving cholecystectomy only for those who fail nonoperative therapy. I initially bristled at that concept as being antithetic to the surgical bias in favor of cholecystectomy as the answer to all gallbladder evils. But after reflecting further on the changing landscape of our therapeutic options and our changing surgical training, I’m thinking that his strategy may be reasonable.
After all, it’s about choosing the safest path for the patient. All cholecystectomies are not routine.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
An Act of Service, an Act of Love
Since its foundation in 1913 as the premier surgical professional organization in the United States, and one of the most influential in the world, the American College of Surgeons has shaped the policies and molded the education of numerous generations of surgeons. All young surgeons should aspire to be invested as Fellows some day as the highest honor in their career.
Service is an important factor in the decision to become a surgeon. As a Fellow of the ACS, the young surgeon will find many opportunities for service. Active participation as a Fellow is an act of service and can be an act of love for our patients, our colleagues, and our profession. And, with it, comes loyalty, a spirit of dedication, and a sense of unity. In addition, by joining the College we contribute to influencing our society in a positive way to protect our patients and our profession.
Becoming an active participant in the College means serving on committees, attending the Clinical Congress as frequently as feasible, and encouraging colleagues to aspire to become a Fellow.
In the end, being a part of our College and contributing to its growth and legacy is an act of service and, for many, an act of love.
Dr. Oviedo is with Capital Regional Surgical Associates, Tallahassee, Fla., and is Assistant Professor of Surgery, Florida State University College of Medicine. He serves as the ACS Young Fellow Association Liaison.
Since its foundation in 1913 as the premier surgical professional organization in the United States, and one of the most influential in the world, the American College of Surgeons has shaped the policies and molded the education of numerous generations of surgeons. All young surgeons should aspire to be invested as Fellows some day as the highest honor in their career.
Service is an important factor in the decision to become a surgeon. As a Fellow of the ACS, the young surgeon will find many opportunities for service. Active participation as a Fellow is an act of service and can be an act of love for our patients, our colleagues, and our profession. And, with it, comes loyalty, a spirit of dedication, and a sense of unity. In addition, by joining the College we contribute to influencing our society in a positive way to protect our patients and our profession.
Becoming an active participant in the College means serving on committees, attending the Clinical Congress as frequently as feasible, and encouraging colleagues to aspire to become a Fellow.
In the end, being a part of our College and contributing to its growth and legacy is an act of service and, for many, an act of love.
Dr. Oviedo is with Capital Regional Surgical Associates, Tallahassee, Fla., and is Assistant Professor of Surgery, Florida State University College of Medicine. He serves as the ACS Young Fellow Association Liaison.
Since its foundation in 1913 as the premier surgical professional organization in the United States, and one of the most influential in the world, the American College of Surgeons has shaped the policies and molded the education of numerous generations of surgeons. All young surgeons should aspire to be invested as Fellows some day as the highest honor in their career.
Service is an important factor in the decision to become a surgeon. As a Fellow of the ACS, the young surgeon will find many opportunities for service. Active participation as a Fellow is an act of service and can be an act of love for our patients, our colleagues, and our profession. And, with it, comes loyalty, a spirit of dedication, and a sense of unity. In addition, by joining the College we contribute to influencing our society in a positive way to protect our patients and our profession.
Becoming an active participant in the College means serving on committees, attending the Clinical Congress as frequently as feasible, and encouraging colleagues to aspire to become a Fellow.
In the end, being a part of our College and contributing to its growth and legacy is an act of service and, for many, an act of love.
Dr. Oviedo is with Capital Regional Surgical Associates, Tallahassee, Fla., and is Assistant Professor of Surgery, Florida State University College of Medicine. He serves as the ACS Young Fellow Association Liaison.
The perils of the National Practitioner Data Bank
Question: With reference to the National Practitioner Data Bank (NPDB), which of the following statements is incorrect?
A. Both court judgments and out-of-court settlements are reportable to the NPDB.
B. Adverse actions by a hospital against a physician are reportable within 15 days.
C. In states with “Disclosure, Apology, and Offer” laws, a prompt settlement through mediation need not be reported.
D. Hospitals, state licensing boards, medical organizations, and the physician himself/herself can access the NPDB.
E. A plaintiff’s attorney cannot access the NPDB for information regarding a defendant.
Answer: C. Congress implemented the NPDB to collect information about an individual doctor’s malpractice and disciplinary histories, with the objective of restricting errant doctors from moving from one state to another.1
Federal law requires medical liability payments stemming from either a court judgment or an out-of-court settlement be reported to the NPDB. An institution’s disciplinary actions against a medical staff member must also be reported. In turn, the NPDB is obligated to make its information available to hospitals, state licensure boards, and legitimate medical organizations charged with granting privileges or membership. A physician also can ask to see his or her own records, but a plaintiff’s attorney cannot access the NPDB unless there is evidence that a hospital failed to query the NPDB as part of its credentialing process.
Some observers have claimed that the NPDB’s existence has hindered settlement negotiations, because many doctors fear being listed in the NPDB, thus significantly diminishing the likelihood of payments to satisfy a claim. It has been stated that within 6 years of NPDB’s inception, the probability that an injured patient’s claim would receive payment had fallen to 59% of the pre-NPDB level.
Many states have enacted so-called “apology laws” that promote full disclosure of medical errors and prompt out-of-court settlements, if warranted. However, the federal Department of Health and Human Services has ruled that all written demands for payment must be reported, even if the cases are resolved under state programs designed for early out-of-court resolution.
For example, a provision in the Oregon law asserts that a payment under the measure’s mediation mechanism “is not a payment resulting from a written claim or demand for payment.” The HHS has rejected this as “explicitly designed to avoid medical malpractice reporting to the NPDB for any claims that are part of the new process that do not proceed to litigation.”
Massachusetts’ 2012 apology law had proposed reporting only those cases where it was determined that a practitioner failed to meet the standard of care. The HHS responded by indicating that all cases had to be reported, regardless of whether care was determined to be up to standards, and that the state’s prelitigation notice to initiate the meditation process qualified as a reportable “written claim.”
Physicians can be impacted greatly by the NPDB. How much of an impact depends in large part on the underlying events and the wording of the report.
An NPDB account of a medical malpractice payment doesn’t necessarily affect a physician’s ability to practice, while those – especially when “severely-worded” – involving denial or restriction of privileges are taken more seriously by state licensing boards and employers. Physicians should therefore play an active role whenever a report to the NPDB appears likely.
The dispute review process is highly technical and requires the knowledge and skill of an experienced health law attorney. To start out, consider making a request to the reporting entity to correct or vacate the report due to error. If the reporting entity declines, the physician may request a review by the HHS and file an accompanying statement seeking to explain the report.
Yet, out of more than 800,000 total reports for all practitioner types captured in the system, apparently only 44,273 included accompanying clarifying statements by the physician. Risk managers have urged vigilance.
For example, it may be that multiple reports involved a single incident, leading to a “piling on” effect. If an adverse decision at one hospital caused a physician’s clinical privileges to be terminated, this might lead the state medical board to restrict the physician’s license. It is necessary to explain that both of these NPDB-reportable events involved the same incident, and that the state board did not have any independent knowledge of anything that was wrong.
Others have advised that one should always clarify one’s involvement, e.g., “I was not the main doctor in the case.” And if dismissed in a malpractice lawsuit, be sure your name or identifying information isn’t included in the judgment or settlement agreement.
Hospital disciplinary actions being far more serious, physicians would do well to familiarize themselves with medical staff bylaws dealing with peer review and investigations. To avoid being reported to the NPDB, physicians must resist adverse actions that would be in effect for more than 30 days and fight attempts to place restrictions or sanctions on their licenses by the hospital or professional societies. Don’t withdraw applications for privileges during an investigation.
The 2015 NPDB Guidebook, the first update in more than 10 years, contains important changes pertaining to hospital adverse actions.2 The regulations now require any “surrender” of privileges while the physician is a subject of an investigation to be a reportable event. Previously, physicians sought to avoid being reported by simply giving up their privileges when an adverse decision appeared imminent.
Surrender includes not renewing one’s hospital privileges or the taking of a leave of absence, and “investigation” is widely defined to include any formal inquiry into a physician’s competence or conduct. And there need not be any “nexus,” i.e., connection, between what is being investigated and the privileges surrendered, in order to be reportable.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.
References
1. Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
2. 2015 NPDB e-Guidebook, available at www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
Question: With reference to the National Practitioner Data Bank (NPDB), which of the following statements is incorrect?
A. Both court judgments and out-of-court settlements are reportable to the NPDB.
B. Adverse actions by a hospital against a physician are reportable within 15 days.
C. In states with “Disclosure, Apology, and Offer” laws, a prompt settlement through mediation need not be reported.
D. Hospitals, state licensing boards, medical organizations, and the physician himself/herself can access the NPDB.
E. A plaintiff’s attorney cannot access the NPDB for information regarding a defendant.
Answer: C. Congress implemented the NPDB to collect information about an individual doctor’s malpractice and disciplinary histories, with the objective of restricting errant doctors from moving from one state to another.1
Federal law requires medical liability payments stemming from either a court judgment or an out-of-court settlement be reported to the NPDB. An institution’s disciplinary actions against a medical staff member must also be reported. In turn, the NPDB is obligated to make its information available to hospitals, state licensure boards, and legitimate medical organizations charged with granting privileges or membership. A physician also can ask to see his or her own records, but a plaintiff’s attorney cannot access the NPDB unless there is evidence that a hospital failed to query the NPDB as part of its credentialing process.
Some observers have claimed that the NPDB’s existence has hindered settlement negotiations, because many doctors fear being listed in the NPDB, thus significantly diminishing the likelihood of payments to satisfy a claim. It has been stated that within 6 years of NPDB’s inception, the probability that an injured patient’s claim would receive payment had fallen to 59% of the pre-NPDB level.
Many states have enacted so-called “apology laws” that promote full disclosure of medical errors and prompt out-of-court settlements, if warranted. However, the federal Department of Health and Human Services has ruled that all written demands for payment must be reported, even if the cases are resolved under state programs designed for early out-of-court resolution.
For example, a provision in the Oregon law asserts that a payment under the measure’s mediation mechanism “is not a payment resulting from a written claim or demand for payment.” The HHS has rejected this as “explicitly designed to avoid medical malpractice reporting to the NPDB for any claims that are part of the new process that do not proceed to litigation.”
Massachusetts’ 2012 apology law had proposed reporting only those cases where it was determined that a practitioner failed to meet the standard of care. The HHS responded by indicating that all cases had to be reported, regardless of whether care was determined to be up to standards, and that the state’s prelitigation notice to initiate the meditation process qualified as a reportable “written claim.”
Physicians can be impacted greatly by the NPDB. How much of an impact depends in large part on the underlying events and the wording of the report.
An NPDB account of a medical malpractice payment doesn’t necessarily affect a physician’s ability to practice, while those – especially when “severely-worded” – involving denial or restriction of privileges are taken more seriously by state licensing boards and employers. Physicians should therefore play an active role whenever a report to the NPDB appears likely.
The dispute review process is highly technical and requires the knowledge and skill of an experienced health law attorney. To start out, consider making a request to the reporting entity to correct or vacate the report due to error. If the reporting entity declines, the physician may request a review by the HHS and file an accompanying statement seeking to explain the report.
Yet, out of more than 800,000 total reports for all practitioner types captured in the system, apparently only 44,273 included accompanying clarifying statements by the physician. Risk managers have urged vigilance.
For example, it may be that multiple reports involved a single incident, leading to a “piling on” effect. If an adverse decision at one hospital caused a physician’s clinical privileges to be terminated, this might lead the state medical board to restrict the physician’s license. It is necessary to explain that both of these NPDB-reportable events involved the same incident, and that the state board did not have any independent knowledge of anything that was wrong.
Others have advised that one should always clarify one’s involvement, e.g., “I was not the main doctor in the case.” And if dismissed in a malpractice lawsuit, be sure your name or identifying information isn’t included in the judgment or settlement agreement.
Hospital disciplinary actions being far more serious, physicians would do well to familiarize themselves with medical staff bylaws dealing with peer review and investigations. To avoid being reported to the NPDB, physicians must resist adverse actions that would be in effect for more than 30 days and fight attempts to place restrictions or sanctions on their licenses by the hospital or professional societies. Don’t withdraw applications for privileges during an investigation.
The 2015 NPDB Guidebook, the first update in more than 10 years, contains important changes pertaining to hospital adverse actions.2 The regulations now require any “surrender” of privileges while the physician is a subject of an investigation to be a reportable event. Previously, physicians sought to avoid being reported by simply giving up their privileges when an adverse decision appeared imminent.
Surrender includes not renewing one’s hospital privileges or the taking of a leave of absence, and “investigation” is widely defined to include any formal inquiry into a physician’s competence or conduct. And there need not be any “nexus,” i.e., connection, between what is being investigated and the privileges surrendered, in order to be reportable.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.
References
1. Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
2. 2015 NPDB e-Guidebook, available at www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
Question: With reference to the National Practitioner Data Bank (NPDB), which of the following statements is incorrect?
A. Both court judgments and out-of-court settlements are reportable to the NPDB.
B. Adverse actions by a hospital against a physician are reportable within 15 days.
C. In states with “Disclosure, Apology, and Offer” laws, a prompt settlement through mediation need not be reported.
D. Hospitals, state licensing boards, medical organizations, and the physician himself/herself can access the NPDB.
E. A plaintiff’s attorney cannot access the NPDB for information regarding a defendant.
Answer: C. Congress implemented the NPDB to collect information about an individual doctor’s malpractice and disciplinary histories, with the objective of restricting errant doctors from moving from one state to another.1
Federal law requires medical liability payments stemming from either a court judgment or an out-of-court settlement be reported to the NPDB. An institution’s disciplinary actions against a medical staff member must also be reported. In turn, the NPDB is obligated to make its information available to hospitals, state licensure boards, and legitimate medical organizations charged with granting privileges or membership. A physician also can ask to see his or her own records, but a plaintiff’s attorney cannot access the NPDB unless there is evidence that a hospital failed to query the NPDB as part of its credentialing process.
Some observers have claimed that the NPDB’s existence has hindered settlement negotiations, because many doctors fear being listed in the NPDB, thus significantly diminishing the likelihood of payments to satisfy a claim. It has been stated that within 6 years of NPDB’s inception, the probability that an injured patient’s claim would receive payment had fallen to 59% of the pre-NPDB level.
Many states have enacted so-called “apology laws” that promote full disclosure of medical errors and prompt out-of-court settlements, if warranted. However, the federal Department of Health and Human Services has ruled that all written demands for payment must be reported, even if the cases are resolved under state programs designed for early out-of-court resolution.
For example, a provision in the Oregon law asserts that a payment under the measure’s mediation mechanism “is not a payment resulting from a written claim or demand for payment.” The HHS has rejected this as “explicitly designed to avoid medical malpractice reporting to the NPDB for any claims that are part of the new process that do not proceed to litigation.”
Massachusetts’ 2012 apology law had proposed reporting only those cases where it was determined that a practitioner failed to meet the standard of care. The HHS responded by indicating that all cases had to be reported, regardless of whether care was determined to be up to standards, and that the state’s prelitigation notice to initiate the meditation process qualified as a reportable “written claim.”
Physicians can be impacted greatly by the NPDB. How much of an impact depends in large part on the underlying events and the wording of the report.
An NPDB account of a medical malpractice payment doesn’t necessarily affect a physician’s ability to practice, while those – especially when “severely-worded” – involving denial or restriction of privileges are taken more seriously by state licensing boards and employers. Physicians should therefore play an active role whenever a report to the NPDB appears likely.
The dispute review process is highly technical and requires the knowledge and skill of an experienced health law attorney. To start out, consider making a request to the reporting entity to correct or vacate the report due to error. If the reporting entity declines, the physician may request a review by the HHS and file an accompanying statement seeking to explain the report.
Yet, out of more than 800,000 total reports for all practitioner types captured in the system, apparently only 44,273 included accompanying clarifying statements by the physician. Risk managers have urged vigilance.
For example, it may be that multiple reports involved a single incident, leading to a “piling on” effect. If an adverse decision at one hospital caused a physician’s clinical privileges to be terminated, this might lead the state medical board to restrict the physician’s license. It is necessary to explain that both of these NPDB-reportable events involved the same incident, and that the state board did not have any independent knowledge of anything that was wrong.
Others have advised that one should always clarify one’s involvement, e.g., “I was not the main doctor in the case.” And if dismissed in a malpractice lawsuit, be sure your name or identifying information isn’t included in the judgment or settlement agreement.
Hospital disciplinary actions being far more serious, physicians would do well to familiarize themselves with medical staff bylaws dealing with peer review and investigations. To avoid being reported to the NPDB, physicians must resist adverse actions that would be in effect for more than 30 days and fight attempts to place restrictions or sanctions on their licenses by the hospital or professional societies. Don’t withdraw applications for privileges during an investigation.
The 2015 NPDB Guidebook, the first update in more than 10 years, contains important changes pertaining to hospital adverse actions.2 The regulations now require any “surrender” of privileges while the physician is a subject of an investigation to be a reportable event. Previously, physicians sought to avoid being reported by simply giving up their privileges when an adverse decision appeared imminent.
Surrender includes not renewing one’s hospital privileges or the taking of a leave of absence, and “investigation” is widely defined to include any formal inquiry into a physician’s competence or conduct. And there need not be any “nexus,” i.e., connection, between what is being investigated and the privileges surrendered, in order to be reportable.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.
References
1. Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
2. 2015 NPDB e-Guidebook, available at www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
See one, do one ...
It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.
Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.
In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.
In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”
For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.
It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.
Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.
Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.
In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.
In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”
For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.
It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.
Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.
Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.
In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.
In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”
For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.
It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.
Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
Hospitalists and cost control in the U.S. health care system
The rising cost of care has been a major concern in the U.S. health care system. In 1990, about $714 million was spent on health care. In 2010, the cost had risen exponentially to about $2.6 trillion.1 An estimated $750 billion dollars is attributed to health care waste.2
Health care waste includes spending on laboratory testing, diagnostic imaging, procedures or other treatments. Below is a list of the various sources that contribute to health care spending waste:2
1. Unnecessary Services ($210 billion)
2. Excessive Administrative Costs (190 billion)
3. Inefficient Service Delivery ($130 billion)
4. Overpricing ($105 billion)
5. Fraud ($75 billion)
6. Treatment for services that could have been prevented ($55 billion)
Reducing the cost of care
The predominant fee-for-service method of reimbursement does not encourage hospitals or providers to try to control areas of waste. One strategy that puts pressure on the providers of health care to control these areas of waste is the bundled payment system. Bundled payment systems deter unnecessary testing and procedures and encourage care coordination between care providers to promote efficiency.
As hospitalists, we play a key role in the bundled payment arena. Hospitalists are strategically placed to ensure that each episode of care is provided in the most cost-efficient way possible without sacrificing quality.
Training about the evidence supporting bundled payments can be incorporated into medical school and the residency curriculum. Hospitalists can serve as educators for trainees regarding the benefits of bundled payments. This will help drive sustainability by making sure new doctors entering the health field are already equipped with knowledge about bundled payments and their advantages.
Hospitalists can also help spur innovation by engaging with hospital leadership to develop new bundled systems. Payment incentives to organizations that participate will help to drive hospitalist engagement. Hospitalists can also advocate for the development of a risk adjustment system to ensure that each patient’s severity is reflected in the payment. This will allow for more buy-in by hospitals and providers.
Improving the quality of care
The Institute of Medicine published a report that made recommendations for improving the quality of the U.S. health care system by identifying six dimensions that need to be addressed:
1. Safety
2. Effectiveness
3. Patient-centeredness
4. Timeliness
5. Efficiency
6. Equity
The Value Based Purchasing program aims to address these dimensions. The fee-for-service system does not provide an incentive to provide quality care, similar to the way it does not drive cost-conscious care. By linking reimbursement to quality care, hospitals and providers have a significant incentive to ensure that their patients receive high quality care. The passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is another step in the direction of rewarding providers for quality of care rendered, not just quantity.
Role of hospitalists
Again, hospitalists should serve as educators about the importance of value based purchasing on quality outcomes,\ and its potential for cost savings through rendering appropriate and effective care.
Hospitalists should advocate for expanding value based purchasing across all payers. This will encourage providers to treat all their patients the same, with the expectation of improving quality of care for all patients and not just a limited insurance pool.
Hospitalists can also advocate for the utilization of the same measure for determining quality across all payers. This will allow for more efficient administrative efforts by eliminating the time used to report different measures to different insurance companies.
Unfortunately, the digital era has not made the same advances in the field of medicine as it has in other areas of life. As hospitalists, our clinical perspective puts us in a position of leadership in the area of informatics. We are uniquely qualified to exploit the power of the hospital’s information technology service and push it to its full potential.
Dr. Arole is chief hospitalist, Griffin Faculty Physicians, at Griffin Hospital in Derby, Conn.
References
1. The Healthcare Imperative: Lowering Costs and Improving Outcomes – Workshop Series Summary. 2011 Feb 24. The Institute of Medicine.
2. Health Affairs Policy Brief; Reducing Waste in Health Care. http://www.healthaffairs.org/healthpolicybriefs/brief.
The rising cost of care has been a major concern in the U.S. health care system. In 1990, about $714 million was spent on health care. In 2010, the cost had risen exponentially to about $2.6 trillion.1 An estimated $750 billion dollars is attributed to health care waste.2
Health care waste includes spending on laboratory testing, diagnostic imaging, procedures or other treatments. Below is a list of the various sources that contribute to health care spending waste:2
1. Unnecessary Services ($210 billion)
2. Excessive Administrative Costs (190 billion)
3. Inefficient Service Delivery ($130 billion)
4. Overpricing ($105 billion)
5. Fraud ($75 billion)
6. Treatment for services that could have been prevented ($55 billion)
Reducing the cost of care
The predominant fee-for-service method of reimbursement does not encourage hospitals or providers to try to control areas of waste. One strategy that puts pressure on the providers of health care to control these areas of waste is the bundled payment system. Bundled payment systems deter unnecessary testing and procedures and encourage care coordination between care providers to promote efficiency.
As hospitalists, we play a key role in the bundled payment arena. Hospitalists are strategically placed to ensure that each episode of care is provided in the most cost-efficient way possible without sacrificing quality.
Training about the evidence supporting bundled payments can be incorporated into medical school and the residency curriculum. Hospitalists can serve as educators for trainees regarding the benefits of bundled payments. This will help drive sustainability by making sure new doctors entering the health field are already equipped with knowledge about bundled payments and their advantages.
Hospitalists can also help spur innovation by engaging with hospital leadership to develop new bundled systems. Payment incentives to organizations that participate will help to drive hospitalist engagement. Hospitalists can also advocate for the development of a risk adjustment system to ensure that each patient’s severity is reflected in the payment. This will allow for more buy-in by hospitals and providers.
Improving the quality of care
The Institute of Medicine published a report that made recommendations for improving the quality of the U.S. health care system by identifying six dimensions that need to be addressed:
1. Safety
2. Effectiveness
3. Patient-centeredness
4. Timeliness
5. Efficiency
6. Equity
The Value Based Purchasing program aims to address these dimensions. The fee-for-service system does not provide an incentive to provide quality care, similar to the way it does not drive cost-conscious care. By linking reimbursement to quality care, hospitals and providers have a significant incentive to ensure that their patients receive high quality care. The passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is another step in the direction of rewarding providers for quality of care rendered, not just quantity.
Role of hospitalists
Again, hospitalists should serve as educators about the importance of value based purchasing on quality outcomes,\ and its potential for cost savings through rendering appropriate and effective care.
Hospitalists should advocate for expanding value based purchasing across all payers. This will encourage providers to treat all their patients the same, with the expectation of improving quality of care for all patients and not just a limited insurance pool.
Hospitalists can also advocate for the utilization of the same measure for determining quality across all payers. This will allow for more efficient administrative efforts by eliminating the time used to report different measures to different insurance companies.
Unfortunately, the digital era has not made the same advances in the field of medicine as it has in other areas of life. As hospitalists, our clinical perspective puts us in a position of leadership in the area of informatics. We are uniquely qualified to exploit the power of the hospital’s information technology service and push it to its full potential.
Dr. Arole is chief hospitalist, Griffin Faculty Physicians, at Griffin Hospital in Derby, Conn.
References
1. The Healthcare Imperative: Lowering Costs and Improving Outcomes – Workshop Series Summary. 2011 Feb 24. The Institute of Medicine.
2. Health Affairs Policy Brief; Reducing Waste in Health Care. http://www.healthaffairs.org/healthpolicybriefs/brief.
The rising cost of care has been a major concern in the U.S. health care system. In 1990, about $714 million was spent on health care. In 2010, the cost had risen exponentially to about $2.6 trillion.1 An estimated $750 billion dollars is attributed to health care waste.2
Health care waste includes spending on laboratory testing, diagnostic imaging, procedures or other treatments. Below is a list of the various sources that contribute to health care spending waste:2
1. Unnecessary Services ($210 billion)
2. Excessive Administrative Costs (190 billion)
3. Inefficient Service Delivery ($130 billion)
4. Overpricing ($105 billion)
5. Fraud ($75 billion)
6. Treatment for services that could have been prevented ($55 billion)
Reducing the cost of care
The predominant fee-for-service method of reimbursement does not encourage hospitals or providers to try to control areas of waste. One strategy that puts pressure on the providers of health care to control these areas of waste is the bundled payment system. Bundled payment systems deter unnecessary testing and procedures and encourage care coordination between care providers to promote efficiency.
As hospitalists, we play a key role in the bundled payment arena. Hospitalists are strategically placed to ensure that each episode of care is provided in the most cost-efficient way possible without sacrificing quality.
Training about the evidence supporting bundled payments can be incorporated into medical school and the residency curriculum. Hospitalists can serve as educators for trainees regarding the benefits of bundled payments. This will help drive sustainability by making sure new doctors entering the health field are already equipped with knowledge about bundled payments and their advantages.
Hospitalists can also help spur innovation by engaging with hospital leadership to develop new bundled systems. Payment incentives to organizations that participate will help to drive hospitalist engagement. Hospitalists can also advocate for the development of a risk adjustment system to ensure that each patient’s severity is reflected in the payment. This will allow for more buy-in by hospitals and providers.
Improving the quality of care
The Institute of Medicine published a report that made recommendations for improving the quality of the U.S. health care system by identifying six dimensions that need to be addressed:
1. Safety
2. Effectiveness
3. Patient-centeredness
4. Timeliness
5. Efficiency
6. Equity
The Value Based Purchasing program aims to address these dimensions. The fee-for-service system does not provide an incentive to provide quality care, similar to the way it does not drive cost-conscious care. By linking reimbursement to quality care, hospitals and providers have a significant incentive to ensure that their patients receive high quality care. The passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is another step in the direction of rewarding providers for quality of care rendered, not just quantity.
Role of hospitalists
Again, hospitalists should serve as educators about the importance of value based purchasing on quality outcomes,\ and its potential for cost savings through rendering appropriate and effective care.
Hospitalists should advocate for expanding value based purchasing across all payers. This will encourage providers to treat all their patients the same, with the expectation of improving quality of care for all patients and not just a limited insurance pool.
Hospitalists can also advocate for the utilization of the same measure for determining quality across all payers. This will allow for more efficient administrative efforts by eliminating the time used to report different measures to different insurance companies.
Unfortunately, the digital era has not made the same advances in the field of medicine as it has in other areas of life. As hospitalists, our clinical perspective puts us in a position of leadership in the area of informatics. We are uniquely qualified to exploit the power of the hospital’s information technology service and push it to its full potential.
Dr. Arole is chief hospitalist, Griffin Faculty Physicians, at Griffin Hospital in Derby, Conn.
References
1. The Healthcare Imperative: Lowering Costs and Improving Outcomes – Workshop Series Summary. 2011 Feb 24. The Institute of Medicine.
2. Health Affairs Policy Brief; Reducing Waste in Health Care. http://www.healthaffairs.org/healthpolicybriefs/brief.
Risks of keeping controlled substances in office tilt away from benefits
I don’t stack narcotics in my office. Never have, never will.
Honestly, in this day and age, I don’t understand why anyone would.
I get the occasional patient with a bad migraine who wants to come in for “a shot.” Sorry, I don’t carry that. I suppose I could carry Ketorolac, but I try to run a simple, nonurgent practice. If you have an urgent situation, go to an emergency department or urgent care.
I couldn’t agree more. It’s better to avoid the problem altogether.
In 1998, on my very first day of work as an attending, the group I’d signed with put me in a satellite office normally used by their headache specialist. While familiarizing myself with what was where, I discovered a bottle of injectable meperidine. It wasn’t locked up, just sitting next to the zolmitriptan (Zomig) samples in an unsecured cabinet. I picked it up in shock to make sure I’d read the label correctly. I put it back down then (somewhat paranoid) picked it back up, wiped my fingerprints off, and put it down in the exact same spot it had been. Although it was obviously a serious infraction, I didn’t want to jeopardize my standing as a new hire. So, I just ignored it. But, I sure worried about what would happen if a DEA inspector showed up.
So, today, I just don’t deal with it. No controlled substances, less paperwork, fewer worries. Simplicity is bliss, and modern medicine has enough worries as it is.
This still gets me the occasional complaint of, “Well, my other neurologist did!” but, frankly, I don’t care. They can run their practice how they want, and I’ll run mine.
In a world of regulations, daily press stories on “pill mills” overusing narcotics, and my quarterly prescription tracking reports from the state board, I want to keep my involvement in them as minimal as possible. I may prescribe them, but I don’t want the potential nightmares of having them on site.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t stack narcotics in my office. Never have, never will.
Honestly, in this day and age, I don’t understand why anyone would.
I get the occasional patient with a bad migraine who wants to come in for “a shot.” Sorry, I don’t carry that. I suppose I could carry Ketorolac, but I try to run a simple, nonurgent practice. If you have an urgent situation, go to an emergency department or urgent care.
I couldn’t agree more. It’s better to avoid the problem altogether.
In 1998, on my very first day of work as an attending, the group I’d signed with put me in a satellite office normally used by their headache specialist. While familiarizing myself with what was where, I discovered a bottle of injectable meperidine. It wasn’t locked up, just sitting next to the zolmitriptan (Zomig) samples in an unsecured cabinet. I picked it up in shock to make sure I’d read the label correctly. I put it back down then (somewhat paranoid) picked it back up, wiped my fingerprints off, and put it down in the exact same spot it had been. Although it was obviously a serious infraction, I didn’t want to jeopardize my standing as a new hire. So, I just ignored it. But, I sure worried about what would happen if a DEA inspector showed up.
So, today, I just don’t deal with it. No controlled substances, less paperwork, fewer worries. Simplicity is bliss, and modern medicine has enough worries as it is.
This still gets me the occasional complaint of, “Well, my other neurologist did!” but, frankly, I don’t care. They can run their practice how they want, and I’ll run mine.
In a world of regulations, daily press stories on “pill mills” overusing narcotics, and my quarterly prescription tracking reports from the state board, I want to keep my involvement in them as minimal as possible. I may prescribe them, but I don’t want the potential nightmares of having them on site.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t stack narcotics in my office. Never have, never will.
Honestly, in this day and age, I don’t understand why anyone would.
I get the occasional patient with a bad migraine who wants to come in for “a shot.” Sorry, I don’t carry that. I suppose I could carry Ketorolac, but I try to run a simple, nonurgent practice. If you have an urgent situation, go to an emergency department or urgent care.
I couldn’t agree more. It’s better to avoid the problem altogether.
In 1998, on my very first day of work as an attending, the group I’d signed with put me in a satellite office normally used by their headache specialist. While familiarizing myself with what was where, I discovered a bottle of injectable meperidine. It wasn’t locked up, just sitting next to the zolmitriptan (Zomig) samples in an unsecured cabinet. I picked it up in shock to make sure I’d read the label correctly. I put it back down then (somewhat paranoid) picked it back up, wiped my fingerprints off, and put it down in the exact same spot it had been. Although it was obviously a serious infraction, I didn’t want to jeopardize my standing as a new hire. So, I just ignored it. But, I sure worried about what would happen if a DEA inspector showed up.
So, today, I just don’t deal with it. No controlled substances, less paperwork, fewer worries. Simplicity is bliss, and modern medicine has enough worries as it is.
This still gets me the occasional complaint of, “Well, my other neurologist did!” but, frankly, I don’t care. They can run their practice how they want, and I’ll run mine.
In a world of regulations, daily press stories on “pill mills” overusing narcotics, and my quarterly prescription tracking reports from the state board, I want to keep my involvement in them as minimal as possible. I may prescribe them, but I don’t want the potential nightmares of having them on site.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
‘How could he?’
The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?
However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.
I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.
This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.
We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?
However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.
I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.
This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.
We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?
However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.
I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.
This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.
We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.