Doug Brunk

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers reported in a poster session at the annual conference of the Medical Group Management Association.

However, the authors emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

The investigators, led by Christopher D. Stokes, program manager at MGMA's center for research, electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months, and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) of respondents said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS through the Idaho Bioterrorism Awareness and Preparedness Program.

The government needs to fund medical practice emergency preparation activities. MR. STOKES

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers reported in a poster session at the annual conference of the Medical Group Management Association.

However, the authors emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

The investigators, led by Christopher D. Stokes, program manager at MGMA's center for research, electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months, and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) of respondents said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS through the Idaho Bioterrorism Awareness and Preparedness Program.

The government needs to fund medical practice emergency preparation activities. MR. STOKES

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers reported in a poster session at the annual conference of the Medical Group Management Association.

However, the authors emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

The investigators, led by Christopher D. Stokes, program manager at MGMA's center for research, electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months, and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) of respondents said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS through the Idaho Bioterrorism Awareness and Preparedness Program.

The government needs to fund medical practice emergency preparation activities. MR. STOKES

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, a medical marketing specialist advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Andrea T. Eliscu, R.N., who is a medical marketing consultant based in Orlando.

“They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged.

“The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis.

Ms. Eliscu recommends contacting the referring physicians directly to introduce yourself and ask if you're meeting their needs.

“Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals, she urges. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note to the physician.

“In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact,” she said. “Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved. The more personal and thoughtful the gift, the greater the value it will have to the recipient.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral.

The majority of respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions. They want and demand the best for themselves and their loved ones.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers.

“Get into story telling as a way to communicate,” Ms. Eliscu recommended. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?”

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said.

“Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

▸ Accountability. Prosumers “want to know [whom they're] dealing with and what their name is,” she said.

“Every member of your staff should have a name badge that says where they're from. That way, if I think you've done something great in terms of service, I can call the practice and say 'Susie from Cleveland did a great job. She was so sensitive when I was feeling so distraught.' “

▸ Accommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” she said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

'Find out what they want, not necessarily what you want to give them,' and say 'thank you' for referrals. MS. ELISCU

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, a medical marketing specialist advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Andrea T. Eliscu, R.N., who is a medical marketing consultant based in Orlando.

“They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged.

“The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis.

Ms. Eliscu recommends contacting the referring physicians directly to introduce yourself and ask if you're meeting their needs.

“Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals, she urges. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note to the physician.

“In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact,” she said. “Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved. The more personal and thoughtful the gift, the greater the value it will have to the recipient.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral.

The majority of respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions. They want and demand the best for themselves and their loved ones.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers.

“Get into story telling as a way to communicate,” Ms. Eliscu recommended. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?”

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said.

“Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

▸ Accountability. Prosumers “want to know [whom they're] dealing with and what their name is,” she said.

“Every member of your staff should have a name badge that says where they're from. That way, if I think you've done something great in terms of service, I can call the practice and say 'Susie from Cleveland did a great job. She was so sensitive when I was feeling so distraught.' “

▸ Accommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” she said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

'Find out what they want, not necessarily what you want to give them,' and say 'thank you' for referrals. MS. ELISCU

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, a medical marketing specialist advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Andrea T. Eliscu, R.N., who is a medical marketing consultant based in Orlando.

“They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged.

“The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis.

Ms. Eliscu recommends contacting the referring physicians directly to introduce yourself and ask if you're meeting their needs.

“Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals, she urges. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note to the physician.

“In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact,” she said. “Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved. The more personal and thoughtful the gift, the greater the value it will have to the recipient.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral.

The majority of respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions. They want and demand the best for themselves and their loved ones.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers.

“Get into story telling as a way to communicate,” Ms. Eliscu recommended. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?”

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said.

“Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

▸ Accountability. Prosumers “want to know [whom they're] dealing with and what their name is,” she said.

“Every member of your staff should have a name badge that says where they're from. That way, if I think you've done something great in terms of service, I can call the practice and say 'Susie from Cleveland did a great job. She was so sensitive when I was feeling so distraught.' “

▸ Accommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” she said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

'Find out what they want, not necessarily what you want to give them,' and say 'thank you' for referrals. MS. ELISCU

SAN DIEGO — The good news about low back pain is that it's often self-resolving. The bad news is it tends to reoccur.

“One in five people at any time will have low back pain,” said Dr. Francis O'Connor, medical director of the Consortium for Health and Military Performance at the Uniformed Services University of the Health Sciences, Bethesda, Md.

About 40%–50% of patients improve within 1 week, regardless of the type of intervention. In injured workers, 85%–90% “are going to improve within 6–12 weeks. So the natural history of acute low back pain is fairly favorable.”

But overall, 40% of patients report a recurrence of low back pain within 6 months of follow-up and 44% are in a chronic phase within 2 years.

“In over 85% of cases of low back pain, no definitive diagnosis can be made. There are so many structures that cause back pain or referred pain that it's difficult to pin it on one particular structure,” said Dr. O'Connor at the annual meeting of the American Academy of Family Physicians.

Clinical assessment of patients with low back pain should begin with an observation of posture. “We're looking for asymmetry, atrophy, and function,” he said. “You [also] want to look for skin lesions like café-au-lait spots, which may be a clue to underlying neurofibromatosis, or a hairy patch, which might be related to an underlying neurodegenerative process.”

Lipomas may indicate spina bifida occulta; and asymmetry between the shoulders and pelvis might be a clue for an underlying muscular spasm or fixed deformity.

Making note of the patient's lordosis is also advised. “If it's exaggerated, that could be a characteristic of a weak abdominal wall or spondylolisthesis.”

Other components of a clinical work-up should include palpation of the back, range-of-motion testing, gait assessment, and a neurologic exam to evaluate motor and sensory function.

One should also evaluate for Waddell's signs—nonorganic signs indicating the presence of a functional component of back pain. The signs are superficial, nonanatomic tenderness; pain with simulated testing; inconsistent responses with distraction; nonorganic regional disturbances; and overreaction verbally or with exaggerated body language. Being positive for three of the five suggests a nonorganic etiology and a poor potential outcome with operative intervention, Dr. O'Connor said.

Within 6 months of follow-up, 40% of patients report a recurrence of low back pain; 44% are in a chronic phase in 2 years. DR. O'CONNOR

SAN DIEGO — The good news about low back pain is that it's often self-resolving. The bad news is it tends to reoccur.

“One in five people at any time will have low back pain,” said Dr. Francis O'Connor, medical director of the Consortium for Health and Military Performance at the Uniformed Services University of the Health Sciences, Bethesda, Md.

About 40%–50% of patients improve within 1 week, regardless of the type of intervention. In injured workers, 85%–90% “are going to improve within 6–12 weeks. So the natural history of acute low back pain is fairly favorable.”

But overall, 40% of patients report a recurrence of low back pain within 6 months of follow-up and 44% are in a chronic phase within 2 years.

“In over 85% of cases of low back pain, no definitive diagnosis can be made. There are so many structures that cause back pain or referred pain that it's difficult to pin it on one particular structure,” said Dr. O'Connor at the annual meeting of the American Academy of Family Physicians.

Clinical assessment of patients with low back pain should begin with an observation of posture. “We're looking for asymmetry, atrophy, and function,” he said. “You [also] want to look for skin lesions like café-au-lait spots, which may be a clue to underlying neurofibromatosis, or a hairy patch, which might be related to an underlying neurodegenerative process.”

Lipomas may indicate spina bifida occulta; and asymmetry between the shoulders and pelvis might be a clue for an underlying muscular spasm or fixed deformity.

Making note of the patient's lordosis is also advised. “If it's exaggerated, that could be a characteristic of a weak abdominal wall or spondylolisthesis.”

Other components of a clinical work-up should include palpation of the back, range-of-motion testing, gait assessment, and a neurologic exam to evaluate motor and sensory function.

One should also evaluate for Waddell's signs—nonorganic signs indicating the presence of a functional component of back pain. The signs are superficial, nonanatomic tenderness; pain with simulated testing; inconsistent responses with distraction; nonorganic regional disturbances; and overreaction verbally or with exaggerated body language. Being positive for three of the five suggests a nonorganic etiology and a poor potential outcome with operative intervention, Dr. O'Connor said.

Within 6 months of follow-up, 40% of patients report a recurrence of low back pain; 44% are in a chronic phase in 2 years. DR. O'CONNOR

SAN DIEGO — The good news about low back pain is that it's often self-resolving. The bad news is it tends to reoccur.

“One in five people at any time will have low back pain,” said Dr. Francis O'Connor, medical director of the Consortium for Health and Military Performance at the Uniformed Services University of the Health Sciences, Bethesda, Md.

About 40%–50% of patients improve within 1 week, regardless of the type of intervention. In injured workers, 85%–90% “are going to improve within 6–12 weeks. So the natural history of acute low back pain is fairly favorable.”

But overall, 40% of patients report a recurrence of low back pain within 6 months of follow-up and 44% are in a chronic phase within 2 years.

“In over 85% of cases of low back pain, no definitive diagnosis can be made. There are so many structures that cause back pain or referred pain that it's difficult to pin it on one particular structure,” said Dr. O'Connor at the annual meeting of the American Academy of Family Physicians.

Clinical assessment of patients with low back pain should begin with an observation of posture. “We're looking for asymmetry, atrophy, and function,” he said. “You [also] want to look for skin lesions like café-au-lait spots, which may be a clue to underlying neurofibromatosis, or a hairy patch, which might be related to an underlying neurodegenerative process.”

Lipomas may indicate spina bifida occulta; and asymmetry between the shoulders and pelvis might be a clue for an underlying muscular spasm or fixed deformity.

Making note of the patient's lordosis is also advised. “If it's exaggerated, that could be a characteristic of a weak abdominal wall or spondylolisthesis.”

Other components of a clinical work-up should include palpation of the back, range-of-motion testing, gait assessment, and a neurologic exam to evaluate motor and sensory function.

One should also evaluate for Waddell's signs—nonorganic signs indicating the presence of a functional component of back pain. The signs are superficial, nonanatomic tenderness; pain with simulated testing; inconsistent responses with distraction; nonorganic regional disturbances; and overreaction verbally or with exaggerated body language. Being positive for three of the five suggests a nonorganic etiology and a poor potential outcome with operative intervention, Dr. O'Connor said.

Within 6 months of follow-up, 40% of patients report a recurrence of low back pain; 44% are in a chronic phase in 2 years. DR. O'CONNOR

SAN DIEGO — Barrier products may play a role as adjuvant therapy for patients with atopic dermatitis, but better studies are needed to show how they fit into the armamentarium.

That's the conclusion Dr. Andrew C. Krakowski came to about three barrier products— ceramide-based emulsion (EpiCeram), palmitamide monoethanolamine (PEA) nonsteroidal cream (MimyX), and hydrolipidic cream MAS063DP (Atopiclair)—he discussed at a meeting on skin disorders sponsored by Rady Children's Hospital.

The products are 510(k) medical devices that have been cleared for marketing by the Food and Drug Administration. The manufacturers claim they contain ingredients that might help replace normal epidermal lipids, improve skin hydration, decrease skin barrier dysfunction, and relieve the atopic dermatitis symptoms of stinging, burning, and pruritus.

Such features are important, because “barrier dysfunction correlates with atopic dermatitis severity and we think there is a possible increased allergy absorption that happens through the skin of our atopic dermatitic patients,” said Dr. Krakowski. “Atopic dermatitis skin is a great setup for microbial colonization, and that puts you at increased risk of secondary infection.”

There are several barrier products on the market, but Dr. Krakowski focused on the three that have been studied recently:

▸ EpiCeram. A combination of ceramides, cholesterols, and fatty acids, Epiceram has been licensed by the University of California and manufactured by Ceragenix Pharmaceuticals Inc.

In a multicenter, randomized study sponsored by Ceragenix and presented during a poster session at the 2008 annual meeting of the Society of Pediatric Dermatology, investigators compared 4 weeks of twice-daily ceramide-based emulsion with fluticasone propionate in 121 pediatric subjects with moderate to severe atopic dermatitis.

On day 14, subjects in the fluticasone group had significantly better Scoring Atopic Dermatitis scores, compared with those in the ceramide-based emulsion group. By day 28, there were no significant differences in the scores between the two groups.

In a second multicenter, randomized study that included patients from Rady Children's Hospital, investigators compared 4 weeks of twice-daily ceramide-based emulsion to pimecrolimus in 38 pediatric subjects with mild to moderate atopic dermatitis. No intention-to-treat analysis was performed.

Subjects in both groups demonstrated significant improvement in Investigator Global Assessment scores at day 14 and day 28. “There was also no significant difference in pruritus between the two groups, but it wasn't clear if there was any improvement from baseline,” said Dr. Krakowski, a pediatrician and first-year dermatology resident at the University of California, San Diego.

Subjects in the ceramide-based emulsion group had no significant improvement from baseline in Eczema Area and Severity Index (EASI) scores. By day 14, subjects in the pimecrolimus group had significantly better EASI scores, compared with their counterparts in the ceramide emulsion group. By day 28, there were no differences in median score reductions between the groups.

▸ MimyX. Manufactured by Stiefel Laboratories Inc., this water-based product is described as a fragrance-, dye-, and preservative-free emulsion to be used three times a day or as needed. According to the company's Web site, it comes as a 140-g tube, with a cost of $101, or about $22 per ounce.

The main ingredient is PEA, which is found naturally in the stratum granulosum and is thought to downregulate inflammatory response. “It's a cannabinoid agonist that is believed to modulate mast cells and immune cells, theoretically reducing histamines, cytokines, and IL-4, −6, and −8,” Dr. Krakowski added. “It's also thought to bind CB2 receptors on cutaneous nerves and decrease the transmission of pruritus.”

In an international open-label study, investigators assessed the effects of the PEA nonsteroidal cream applied at least twice daily for 38 days in 2,456 patients with mild to moderate atopic dermatitis (J. Eur. Acad. Dermatol. Venereol. 2008;22:73–82). Of the 2,456 patients, 923 were 12 years of age or younger.

Physician assessment scores demonstrated that pruritus improved by 56%, erythema by 54%, dryness by 57%, lichenification by 55%, and excoriations by 63%.

The investigators also found that by the end of the treatment period, 63% of children reduced their use of topical corticosteroids, compared with 53% of adults. In addition, 34% of subjects were able to stop using their topical corticosteroid altogether, 12% were able to switch to a lower-potency steroid, and 3% switched to a high-potency steroid.

▸ Atopiclair. Manufactured by Graceway Pharmaceuticals LLC, this product contains hyaluronic acid, Vitis vinifera (grape leaf extract), telmesteine, glycyrrhetinic acid (licorice extract), and shea butter, a derivative of shea nut oil. The product is described as dye- and fragrance-free and is used 2–3 times per day or as needed. It comes in a 100-g tube and costs about $34 per ounce.

In a multicenter, randomized, double-blind, vehicle-controlled trial, 106 infants and children with mild to moderate atopic dermatitis applied hydrolipidic cream MAS063DP or vehicle three times a day to past, current, or “reasonable future” sites as monotherapy for 43 days (J. Pediatr. 2008;152:854–9). The mean age of subjects was 5 years.

One target lesion was chosen by investigators for evaluation and photography (mostly identified on extremities). Success was defined as reaching an IGA score of 0 (clear) or 1 (almost clear).

In an intention-to-treat analysis, 53 of 69 subjects (77%) in the hydrolipidic cream group achieved a score of 0 or 1 at day 22, compared with none in the vehicle group.

Dr. Krakowski disclosed having had no relevant conflicts of interest.

Several FDA-approved products relieve the atopic dermatitis symptoms of stinging, burning, and pruritus. Courtesy Dr. Andrew C. Krakowski

SAN DIEGO — Barrier products may play a role as adjuvant therapy for patients with atopic dermatitis, but better studies are needed to show how they fit into the armamentarium.

That's the conclusion Dr. Andrew C. Krakowski came to about three barrier products— ceramide-based emulsion (EpiCeram), palmitamide monoethanolamine (PEA) nonsteroidal cream (MimyX), and hydrolipidic cream MAS063DP (Atopiclair)—he discussed at a meeting on skin disorders sponsored by Rady Children's Hospital.

The products are 510(k) medical devices that have been cleared for marketing by the Food and Drug Administration. The manufacturers claim they contain ingredients that might help replace normal epidermal lipids, improve skin hydration, decrease skin barrier dysfunction, and relieve the atopic dermatitis symptoms of stinging, burning, and pruritus.

Such features are important, because “barrier dysfunction correlates with atopic dermatitis severity and we think there is a possible increased allergy absorption that happens through the skin of our atopic dermatitic patients,” said Dr. Krakowski. “Atopic dermatitis skin is a great setup for microbial colonization, and that puts you at increased risk of secondary infection.”

There are several barrier products on the market, but Dr. Krakowski focused on the three that have been studied recently:

▸ EpiCeram. A combination of ceramides, cholesterols, and fatty acids, Epiceram has been licensed by the University of California and manufactured by Ceragenix Pharmaceuticals Inc.

In a multicenter, randomized study sponsored by Ceragenix and presented during a poster session at the 2008 annual meeting of the Society of Pediatric Dermatology, investigators compared 4 weeks of twice-daily ceramide-based emulsion with fluticasone propionate in 121 pediatric subjects with moderate to severe atopic dermatitis.

On day 14, subjects in the fluticasone group had significantly better Scoring Atopic Dermatitis scores, compared with those in the ceramide-based emulsion group. By day 28, there were no significant differences in the scores between the two groups.

In a second multicenter, randomized study that included patients from Rady Children's Hospital, investigators compared 4 weeks of twice-daily ceramide-based emulsion to pimecrolimus in 38 pediatric subjects with mild to moderate atopic dermatitis. No intention-to-treat analysis was performed.

Subjects in both groups demonstrated significant improvement in Investigator Global Assessment scores at day 14 and day 28. “There was also no significant difference in pruritus between the two groups, but it wasn't clear if there was any improvement from baseline,” said Dr. Krakowski, a pediatrician and first-year dermatology resident at the University of California, San Diego.

Subjects in the ceramide-based emulsion group had no significant improvement from baseline in Eczema Area and Severity Index (EASI) scores. By day 14, subjects in the pimecrolimus group had significantly better EASI scores, compared with their counterparts in the ceramide emulsion group. By day 28, there were no differences in median score reductions between the groups.

▸ MimyX. Manufactured by Stiefel Laboratories Inc., this water-based product is described as a fragrance-, dye-, and preservative-free emulsion to be used three times a day or as needed. According to the company's Web site, it comes as a 140-g tube, with a cost of $101, or about $22 per ounce.

The main ingredient is PEA, which is found naturally in the stratum granulosum and is thought to downregulate inflammatory response. “It's a cannabinoid agonist that is believed to modulate mast cells and immune cells, theoretically reducing histamines, cytokines, and IL-4, −6, and −8,” Dr. Krakowski added. “It's also thought to bind CB2 receptors on cutaneous nerves and decrease the transmission of pruritus.”

In an international open-label study, investigators assessed the effects of the PEA nonsteroidal cream applied at least twice daily for 38 days in 2,456 patients with mild to moderate atopic dermatitis (J. Eur. Acad. Dermatol. Venereol. 2008;22:73–82). Of the 2,456 patients, 923 were 12 years of age or younger.

Physician assessment scores demonstrated that pruritus improved by 56%, erythema by 54%, dryness by 57%, lichenification by 55%, and excoriations by 63%.

The investigators also found that by the end of the treatment period, 63% of children reduced their use of topical corticosteroids, compared with 53% of adults. In addition, 34% of subjects were able to stop using their topical corticosteroid altogether, 12% were able to switch to a lower-potency steroid, and 3% switched to a high-potency steroid.

▸ Atopiclair. Manufactured by Graceway Pharmaceuticals LLC, this product contains hyaluronic acid, Vitis vinifera (grape leaf extract), telmesteine, glycyrrhetinic acid (licorice extract), and shea butter, a derivative of shea nut oil. The product is described as dye- and fragrance-free and is used 2–3 times per day or as needed. It comes in a 100-g tube and costs about $34 per ounce.

In a multicenter, randomized, double-blind, vehicle-controlled trial, 106 infants and children with mild to moderate atopic dermatitis applied hydrolipidic cream MAS063DP or vehicle three times a day to past, current, or “reasonable future” sites as monotherapy for 43 days (J. Pediatr. 2008;152:854–9). The mean age of subjects was 5 years.

One target lesion was chosen by investigators for evaluation and photography (mostly identified on extremities). Success was defined as reaching an IGA score of 0 (clear) or 1 (almost clear).

In an intention-to-treat analysis, 53 of 69 subjects (77%) in the hydrolipidic cream group achieved a score of 0 or 1 at day 22, compared with none in the vehicle group.

Dr. Krakowski disclosed having had no relevant conflicts of interest.

Several FDA-approved products relieve the atopic dermatitis symptoms of stinging, burning, and pruritus. Courtesy Dr. Andrew C. Krakowski

SAN DIEGO — Barrier products may play a role as adjuvant therapy for patients with atopic dermatitis, but better studies are needed to show how they fit into the armamentarium.

That's the conclusion Dr. Andrew C. Krakowski came to about three barrier products— ceramide-based emulsion (EpiCeram), palmitamide monoethanolamine (PEA) nonsteroidal cream (MimyX), and hydrolipidic cream MAS063DP (Atopiclair)—he discussed at a meeting on skin disorders sponsored by Rady Children's Hospital.

The products are 510(k) medical devices that have been cleared for marketing by the Food and Drug Administration. The manufacturers claim they contain ingredients that might help replace normal epidermal lipids, improve skin hydration, decrease skin barrier dysfunction, and relieve the atopic dermatitis symptoms of stinging, burning, and pruritus.

Such features are important, because “barrier dysfunction correlates with atopic dermatitis severity and we think there is a possible increased allergy absorption that happens through the skin of our atopic dermatitic patients,” said Dr. Krakowski. “Atopic dermatitis skin is a great setup for microbial colonization, and that puts you at increased risk of secondary infection.”

There are several barrier products on the market, but Dr. Krakowski focused on the three that have been studied recently:

▸ EpiCeram. A combination of ceramides, cholesterols, and fatty acids, Epiceram has been licensed by the University of California and manufactured by Ceragenix Pharmaceuticals Inc.

In a multicenter, randomized study sponsored by Ceragenix and presented during a poster session at the 2008 annual meeting of the Society of Pediatric Dermatology, investigators compared 4 weeks of twice-daily ceramide-based emulsion with fluticasone propionate in 121 pediatric subjects with moderate to severe atopic dermatitis.

On day 14, subjects in the fluticasone group had significantly better Scoring Atopic Dermatitis scores, compared with those in the ceramide-based emulsion group. By day 28, there were no significant differences in the scores between the two groups.

In a second multicenter, randomized study that included patients from Rady Children's Hospital, investigators compared 4 weeks of twice-daily ceramide-based emulsion to pimecrolimus in 38 pediatric subjects with mild to moderate atopic dermatitis. No intention-to-treat analysis was performed.

Subjects in both groups demonstrated significant improvement in Investigator Global Assessment scores at day 14 and day 28. “There was also no significant difference in pruritus between the two groups, but it wasn't clear if there was any improvement from baseline,” said Dr. Krakowski, a pediatrician and first-year dermatology resident at the University of California, San Diego.

Subjects in the ceramide-based emulsion group had no significant improvement from baseline in Eczema Area and Severity Index (EASI) scores. By day 14, subjects in the pimecrolimus group had significantly better EASI scores, compared with their counterparts in the ceramide emulsion group. By day 28, there were no differences in median score reductions between the groups.

▸ MimyX. Manufactured by Stiefel Laboratories Inc., this water-based product is described as a fragrance-, dye-, and preservative-free emulsion to be used three times a day or as needed. According to the company's Web site, it comes as a 140-g tube, with a cost of $101, or about $22 per ounce.

The main ingredient is PEA, which is found naturally in the stratum granulosum and is thought to downregulate inflammatory response. “It's a cannabinoid agonist that is believed to modulate mast cells and immune cells, theoretically reducing histamines, cytokines, and IL-4, −6, and −8,” Dr. Krakowski added. “It's also thought to bind CB2 receptors on cutaneous nerves and decrease the transmission of pruritus.”

In an international open-label study, investigators assessed the effects of the PEA nonsteroidal cream applied at least twice daily for 38 days in 2,456 patients with mild to moderate atopic dermatitis (J. Eur. Acad. Dermatol. Venereol. 2008;22:73–82). Of the 2,456 patients, 923 were 12 years of age or younger.

Physician assessment scores demonstrated that pruritus improved by 56%, erythema by 54%, dryness by 57%, lichenification by 55%, and excoriations by 63%.

The investigators also found that by the end of the treatment period, 63% of children reduced their use of topical corticosteroids, compared with 53% of adults. In addition, 34% of subjects were able to stop using their topical corticosteroid altogether, 12% were able to switch to a lower-potency steroid, and 3% switched to a high-potency steroid.

▸ Atopiclair. Manufactured by Graceway Pharmaceuticals LLC, this product contains hyaluronic acid, Vitis vinifera (grape leaf extract), telmesteine, glycyrrhetinic acid (licorice extract), and shea butter, a derivative of shea nut oil. The product is described as dye- and fragrance-free and is used 2–3 times per day or as needed. It comes in a 100-g tube and costs about $34 per ounce.

In a multicenter, randomized, double-blind, vehicle-controlled trial, 106 infants and children with mild to moderate atopic dermatitis applied hydrolipidic cream MAS063DP or vehicle three times a day to past, current, or “reasonable future” sites as monotherapy for 43 days (J. Pediatr. 2008;152:854–9). The mean age of subjects was 5 years.

One target lesion was chosen by investigators for evaluation and photography (mostly identified on extremities). Success was defined as reaching an IGA score of 0 (clear) or 1 (almost clear).

In an intention-to-treat analysis, 53 of 69 subjects (77%) in the hydrolipidic cream group achieved a score of 0 or 1 at day 22, compared with none in the vehicle group.

Dr. Krakowski disclosed having had no relevant conflicts of interest.

Several FDA-approved products relieve the atopic dermatitis symptoms of stinging, burning, and pruritus. Courtesy Dr. Andrew C. Krakowski

SAN DIEGO – Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Ms. Eliscu, a medical marketing consultant based in Orlando. “They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged. “The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. “Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or a personal, handwritten thank-you note to the physician.

“Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. Most of the respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question,” she asked

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said. “Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

▸ Accountability. Prosumers “want to know [whom they're] dealing with and what their name is. “Every member of your staff should have a name badge,” she said.

▸ Accommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” Ms. Eliscu said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

SAN DIEGO – Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Ms. Eliscu, a medical marketing consultant based in Orlando. “They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged. “The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. “Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or a personal, handwritten thank-you note to the physician.

“Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. Most of the respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question,” she asked

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said. “Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

▸ Accountability. Prosumers “want to know [whom they're] dealing with and what their name is. “Every member of your staff should have a name badge,” she said.

▸ Accommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” Ms. Eliscu said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

SAN DIEGO – Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Ms. Eliscu, a medical marketing consultant based in Orlando. “They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged. “The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. “Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or a personal, handwritten thank-you note to the physician.

“Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. Most of the respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question,” she asked

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said. “Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

▸ Accountability. Prosumers “want to know [whom they're] dealing with and what their name is. “Every member of your staff should have a name badge,” she said.

▸ Accommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” Ms. Eliscu said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

SAN DIEGO – About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

For the study, the researchers electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months; and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

More than 60% of the practices surveyed had not had disaster drills within the last 12 months. MR. STOKES

SAN DIEGO – About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

For the study, the researchers electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months; and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

More than 60% of the practices surveyed had not had disaster drills within the last 12 months. MR. STOKES

SAN DIEGO – About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

For the study, the researchers electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months; and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

More than 60% of the practices surveyed had not had disaster drills within the last 12 months. MR. STOKES

Dr. Chris Frost and Dr. Marc Frost acquired their love for off-road motorcycle riding as youngsters growing up in St. Donatus, Iowa, a small town with rolling hills near Dubuque.

Their father was a motor sports enthusiast who thought off-road riding would be a good hobby for his boys, so he bought them motorcycles to tool around with. But he was a stickler for riding safety.

"When we were in grade school our dad told us that if he ever caught us riding a motorcycle either in a crazy way or not wearing a helmet, the motorcycle would be sold and gone," recalled Chris, a dermatologist who practices in Somerset, Ky. "We believed him, and we never rode without one."

Chris and Marc put riding on hold during college and medical school but, since 2002, they have been taking occasional weekend outings on off-road designated trails in the 770,000-acre Daniel Boone National Forest in Kentucky, which consists of mostly rugged terrain with steep ridges and sandstone cliffs.

Once every 3 months, Marc and his two teenage children drive 4 hours from their home in Indianapolis to Chris's home in Somerset.

The next day, the crew drives to the forest for a 20- to 30-mile ride on mountainous trails that can last up to 6 hours—but not before a careful inspection of each bike. "If something goes wrong, you're a long way from being able to easily remedy it," said Marc, the more mechanically inclined of the two brothers, who has a private dermatology practice in Indianapolis.

The rides "are no piece of cake," he added, describing each day's ride as the physical equivalent of running a half-marathon. "For years, I was the sort who was not physically active, and did not really eat well. Now I exercise on a regular basis. I carefully watch what I eat and my weight. My general condition is far better than it was when I was 40."

There have been mishaps on the trips, like the time a 1996 motorcycle Chris was riding "got away from him" and careened off a cliff. Since he's an experienced rider he knew not to stay on the bike, "but my brother said they watched as the motorcycle went flying off the side of the cliff and I wasn't on it," Chris said. "They were wondering where I was. When it went off the cliff, it got stuck on a tree and we were able to haul it back."

They had just finished up a day of riding before they were interviewed. "Today, there were six of us riding together, but each of us had a partner we'd stick with." This is important because if something were to happen, you're not out there by yourself. "We never ride alone," said Marc.

Both brothers remarked about the positive impact of the quarterly motorcycle rides on family life. For Marc, one of the best parts "is getting to spend 4 hours with both of my kids driving down here and 4 hours driving back,"he said. Adding, "You'd be amazed at how much family stuff we get to talk about. Anytime teenagers can't wait to do something with their dad or uncle, that's a pretty good gig."

Chris described the camaraderie that evolves from the rides as "one of the most valuable things in the world: to get to know your relatives better and to enjoy the limited time you have with them. We're all getting older and need to spend more time with each other."

The brothers always wear full safety gear, noting an occasion when Chris (left) careened off a cliff. Courtesy Dr. Andrew Frost

Dr. Chris Frost and Dr. Marc Frost acquired their love for off-road motorcycle riding as youngsters growing up in St. Donatus, Iowa, a small town with rolling hills near Dubuque.

Their father was a motor sports enthusiast who thought off-road riding would be a good hobby for his boys, so he bought them motorcycles to tool around with. But he was a stickler for riding safety.

"When we were in grade school our dad told us that if he ever caught us riding a motorcycle either in a crazy way or not wearing a helmet, the motorcycle would be sold and gone," recalled Chris, a dermatologist who practices in Somerset, Ky. "We believed him, and we never rode without one."

Chris and Marc put riding on hold during college and medical school but, since 2002, they have been taking occasional weekend outings on off-road designated trails in the 770,000-acre Daniel Boone National Forest in Kentucky, which consists of mostly rugged terrain with steep ridges and sandstone cliffs.

Once every 3 months, Marc and his two teenage children drive 4 hours from their home in Indianapolis to Chris's home in Somerset.

The next day, the crew drives to the forest for a 20- to 30-mile ride on mountainous trails that can last up to 6 hours—but not before a careful inspection of each bike. "If something goes wrong, you're a long way from being able to easily remedy it," said Marc, the more mechanically inclined of the two brothers, who has a private dermatology practice in Indianapolis.

The rides "are no piece of cake," he added, describing each day's ride as the physical equivalent of running a half-marathon. "For years, I was the sort who was not physically active, and did not really eat well. Now I exercise on a regular basis. I carefully watch what I eat and my weight. My general condition is far better than it was when I was 40."

There have been mishaps on the trips, like the time a 1996 motorcycle Chris was riding "got away from him" and careened off a cliff. Since he's an experienced rider he knew not to stay on the bike, "but my brother said they watched as the motorcycle went flying off the side of the cliff and I wasn't on it," Chris said. "They were wondering where I was. When it went off the cliff, it got stuck on a tree and we were able to haul it back."

They had just finished up a day of riding before they were interviewed. "Today, there were six of us riding together, but each of us had a partner we'd stick with." This is important because if something were to happen, you're not out there by yourself. "We never ride alone," said Marc.

Both brothers remarked about the positive impact of the quarterly motorcycle rides on family life. For Marc, one of the best parts "is getting to spend 4 hours with both of my kids driving down here and 4 hours driving back,"he said. Adding, "You'd be amazed at how much family stuff we get to talk about. Anytime teenagers can't wait to do something with their dad or uncle, that's a pretty good gig."

Chris described the camaraderie that evolves from the rides as "one of the most valuable things in the world: to get to know your relatives better and to enjoy the limited time you have with them. We're all getting older and need to spend more time with each other."

The brothers always wear full safety gear, noting an occasion when Chris (left) careened off a cliff. Courtesy Dr. Andrew Frost

Dr. Chris Frost and Dr. Marc Frost acquired their love for off-road motorcycle riding as youngsters growing up in St. Donatus, Iowa, a small town with rolling hills near Dubuque.

Their father was a motor sports enthusiast who thought off-road riding would be a good hobby for his boys, so he bought them motorcycles to tool around with. But he was a stickler for riding safety.

"When we were in grade school our dad told us that if he ever caught us riding a motorcycle either in a crazy way or not wearing a helmet, the motorcycle would be sold and gone," recalled Chris, a dermatologist who practices in Somerset, Ky. "We believed him, and we never rode without one."

Chris and Marc put riding on hold during college and medical school but, since 2002, they have been taking occasional weekend outings on off-road designated trails in the 770,000-acre Daniel Boone National Forest in Kentucky, which consists of mostly rugged terrain with steep ridges and sandstone cliffs.

Once every 3 months, Marc and his two teenage children drive 4 hours from their home in Indianapolis to Chris's home in Somerset.

The next day, the crew drives to the forest for a 20- to 30-mile ride on mountainous trails that can last up to 6 hours—but not before a careful inspection of each bike. "If something goes wrong, you're a long way from being able to easily remedy it," said Marc, the more mechanically inclined of the two brothers, who has a private dermatology practice in Indianapolis.

The rides "are no piece of cake," he added, describing each day's ride as the physical equivalent of running a half-marathon. "For years, I was the sort who was not physically active, and did not really eat well. Now I exercise on a regular basis. I carefully watch what I eat and my weight. My general condition is far better than it was when I was 40."

There have been mishaps on the trips, like the time a 1996 motorcycle Chris was riding "got away from him" and careened off a cliff. Since he's an experienced rider he knew not to stay on the bike, "but my brother said they watched as the motorcycle went flying off the side of the cliff and I wasn't on it," Chris said. "They were wondering where I was. When it went off the cliff, it got stuck on a tree and we were able to haul it back."

They had just finished up a day of riding before they were interviewed. "Today, there were six of us riding together, but each of us had a partner we'd stick with." This is important because if something were to happen, you're not out there by yourself. "We never ride alone," said Marc.

Both brothers remarked about the positive impact of the quarterly motorcycle rides on family life. For Marc, one of the best parts "is getting to spend 4 hours with both of my kids driving down here and 4 hours driving back,"he said. Adding, "You'd be amazed at how much family stuff we get to talk about. Anytime teenagers can't wait to do something with their dad or uncle, that's a pretty good gig."

Chris described the camaraderie that evolves from the rides as "one of the most valuable things in the world: to get to know your relatives better and to enjoy the limited time you have with them. We're all getting older and need to spend more time with each other."

The brothers always wear full safety gear, noting an occasion when Chris (left) careened off a cliff. Courtesy Dr. Andrew Frost

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department "has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster," they wrote in their poster.

The researchers electronically surveyed 188 medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months, and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices "should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities." They went on to note that medical practices "have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources."

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

'The federal government needs to fund medical practice emergency preparation activities.' MR. STOKES

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department "has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster," they wrote in their poster.

The researchers electronically surveyed 188 medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months, and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices "should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities." They went on to note that medical practices "have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources."

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

'The federal government needs to fund medical practice emergency preparation activities.' MR. STOKES

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department "has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster," they wrote in their poster.

The researchers electronically surveyed 188 medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months, and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make human-powered telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mail messages (24%).

Mr. Stokes and his colleagues concluded that all medical practices "should have an emergency preparedness plan and the federal government needs to fund medical practice emergency preparation activities." They went on to note that medical practices "have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources."

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

'The federal government needs to fund medical practice emergency preparation activities.' MR. STOKES

SAN DIEGO — The demand for medical spa services is holding steady despite the current economic downturn, Michael R. Lowe, P.A., said at the annual conference of the Medical Group Management Association.

"I represent about 25 medical spas, and I haven't seen any of them slow down in the last 6–8 months," said Mr. Lowe, a health law attorney based in Longwood, Fla. "Most of them are diverse in what they do, from laser hair removal to hormone replacement therapy, but the baby boomer generation is driving this. They're smart consumers, health conscious, and they want to see a doctor on their terms."

Add declining physician reimbursement from third-party payers and increasing costs of running a medical practice and you have a lot of physicians considering adding medical spa services to their practice. Such services may include Botox injections, dermal fillers, mesotherapy, intense pulsed light treatments, massage therapy, hormone replacement therapy, laser hair removal, weight management, or diet and nutritional counseling.

Mr. Lowe outlined the following points to consider before adding a medical spa service to your practice:

▸ Know what licenses are required. Laws vary by state, so check with your state medical board or an experienced health law attorney. In Florida, for example, a medical assistant can assist a physician with a Botox injection, but only under the personal supervision and involvement of the physician.

"Doctors get that confused," he said.

He also noted that Florida mandates that only licensed nutritionists can give nutritional advice. Mr. Lowe noted that he has represented personal fitness trainers who have been investigated for imparting nutritional advice to their clients. "I've had to defend them against the state medical board and the department of health for the unlicensed practice of medicine, which in our state is a third-degree felony," he said. "So be very careful."

▸ Find out your supervision requirements. Laws on this vary from state to state, and can be murky. For example, in their meeting minutes the Florida Board of Medicine states that to provide laser hair removal you must be a medical doctor, a doctor of osteopathy, a nurse practitioner, or a physician assistant.

At the same time, a state statute mandates that laser hair removal be directly supervised if it's performed by a nurse practitioner or a physician assistant. So if a complaint involving laser hair removal comes before the Florida Board of Medicine, Mr. Lowe said, it is more likely to apply its policy from the meeting minutes than from the state statute. "The best thing you can do is call your licensing board or hire a lawyer who has experience in medical spas and these types of issues," he said.

As a starting point, "make a list of everyone working for you and what service they provide."

▸ Determine if the service is covered by your liability insurance. Check with your carrier to make sure you're covered. "In Florida, a lot of medical spa services aren't covered and the carriers are very resistant to cover them," he pointed out. "The last thing you want is to have an untoward outcome and have a patient come after you and not be covered. The most expensive thing about malpractice is paying the lawyers to defend you."

▸ Be careful with medical director agreements. What duties will the physician perform as medical director? These should be specified in the agreement. Mr. Lowe recommends having the physicians track their hours and the performance of their specific duties.

In order to be compliant with federal law, the medical director agreement must be in writing and signed by all parties involved. It must cover all of the services to be provided by the physician. Understanding the Stark federal antikickback law and regulatory safe harbors legislation is also essential.

▸ Obtain informed consent for all procedures. Mr. Lowe advises having Medicare patients fill out an Advance Beneficiary Notice. "That way they can't come back to you and say, 'You didn't tell me this procedure wasn't covered. … You didn't tell me what I was getting. You didn't tell me how much it would cost.'"

▸ Communicate off-label medication uses. Be sure to inform the patient and discuss all potential risks while having the patient sign an informed consent. Note the discussion in the medical record as well.

▸ Be mindful of patient privacy rights. If you breach the Health Insurance Portability and Accountability Act and cause the patient to suffer, "you may be liable," Mr. Lowe said. "Be careful with this, especially if you work with nonlicensed health care professionals [who don't understand the law]. People are looking to sue for privacy issues."

'The best thing you can do is call your licensing board or hire a lawyer who has experience in medical spas.' MR. LOWE

SAN DIEGO — The demand for medical spa services is holding steady despite the current economic downturn, Michael R. Lowe, P.A., said at the annual conference of the Medical Group Management Association.

"I represent about 25 medical spas, and I haven't seen any of them slow down in the last 6–8 months," said Mr. Lowe, a health law attorney based in Longwood, Fla. "Most of them are diverse in what they do, from laser hair removal to hormone replacement therapy, but the baby boomer generation is driving this. They're smart consumers, health conscious, and they want to see a doctor on their terms."

Add declining physician reimbursement from third-party payers and increasing costs of running a medical practice and you have a lot of physicians considering adding medical spa services to their practice. Such services may include Botox injections, dermal fillers, mesotherapy, intense pulsed light treatments, massage therapy, hormone replacement therapy, laser hair removal, weight management, or diet and nutritional counseling.

Mr. Lowe outlined the following points to consider before adding a medical spa service to your practice:

▸ Know what licenses are required. Laws vary by state, so check with your state medical board or an experienced health law attorney. In Florida, for example, a medical assistant can assist a physician with a Botox injection, but only under the personal supervision and involvement of the physician.

"Doctors get that confused," he said.

He also noted that Florida mandates that only licensed nutritionists can give nutritional advice. Mr. Lowe noted that he has represented personal fitness trainers who have been investigated for imparting nutritional advice to their clients. "I've had to defend them against the state medical board and the department of health for the unlicensed practice of medicine, which in our state is a third-degree felony," he said. "So be very careful."

▸ Find out your supervision requirements. Laws on this vary from state to state, and can be murky. For example, in their meeting minutes the Florida Board of Medicine states that to provide laser hair removal you must be a medical doctor, a doctor of osteopathy, a nurse practitioner, or a physician assistant.

At the same time, a state statute mandates that laser hair removal be directly supervised if it's performed by a nurse practitioner or a physician assistant. So if a complaint involving laser hair removal comes before the Florida Board of Medicine, Mr. Lowe said, it is more likely to apply its policy from the meeting minutes than from the state statute. "The best thing you can do is call your licensing board or hire a lawyer who has experience in medical spas and these types of issues," he said.

As a starting point, "make a list of everyone working for you and what service they provide."

▸ Determine if the service is covered by your liability insurance. Check with your carrier to make sure you're covered. "In Florida, a lot of medical spa services aren't covered and the carriers are very resistant to cover them," he pointed out. "The last thing you want is to have an untoward outcome and have a patient come after you and not be covered. The most expensive thing about malpractice is paying the lawyers to defend you."

▸ Be careful with medical director agreements. What duties will the physician perform as medical director? These should be specified in the agreement. Mr. Lowe recommends having the physicians track their hours and the performance of their specific duties.

In order to be compliant with federal law, the medical director agreement must be in writing and signed by all parties involved. It must cover all of the services to be provided by the physician. Understanding the Stark federal antikickback law and regulatory safe harbors legislation is also essential.

▸ Obtain informed consent for all procedures. Mr. Lowe advises having Medicare patients fill out an Advance Beneficiary Notice. "That way they can't come back to you and say, 'You didn't tell me this procedure wasn't covered. … You didn't tell me what I was getting. You didn't tell me how much it would cost.'"

▸ Communicate off-label medication uses. Be sure to inform the patient and discuss all potential risks while having the patient sign an informed consent. Note the discussion in the medical record as well.

▸ Be mindful of patient privacy rights. If you breach the Health Insurance Portability and Accountability Act and cause the patient to suffer, "you may be liable," Mr. Lowe said. "Be careful with this, especially if you work with nonlicensed health care professionals [who don't understand the law]. People are looking to sue for privacy issues."

'The best thing you can do is call your licensing board or hire a lawyer who has experience in medical spas.' MR. LOWE

SAN DIEGO — The demand for medical spa services is holding steady despite the current economic downturn, Michael R. Lowe, P.A., said at the annual conference of the Medical Group Management Association.

"I represent about 25 medical spas, and I haven't seen any of them slow down in the last 6–8 months," said Mr. Lowe, a health law attorney based in Longwood, Fla. "Most of them are diverse in what they do, from laser hair removal to hormone replacement therapy, but the baby boomer generation is driving this. They're smart consumers, health conscious, and they want to see a doctor on their terms."

Add declining physician reimbursement from third-party payers and increasing costs of running a medical practice and you have a lot of physicians considering adding medical spa services to their practice. Such services may include Botox injections, dermal fillers, mesotherapy, intense pulsed light treatments, massage therapy, hormone replacement therapy, laser hair removal, weight management, or diet and nutritional counseling.

Mr. Lowe outlined the following points to consider before adding a medical spa service to your practice:

▸ Know what licenses are required. Laws vary by state, so check with your state medical board or an experienced health law attorney. In Florida, for example, a medical assistant can assist a physician with a Botox injection, but only under the personal supervision and involvement of the physician.

"Doctors get that confused," he said.

He also noted that Florida mandates that only licensed nutritionists can give nutritional advice. Mr. Lowe noted that he has represented personal fitness trainers who have been investigated for imparting nutritional advice to their clients. "I've had to defend them against the state medical board and the department of health for the unlicensed practice of medicine, which in our state is a third-degree felony," he said. "So be very careful."

▸ Find out your supervision requirements. Laws on this vary from state to state, and can be murky. For example, in their meeting minutes the Florida Board of Medicine states that to provide laser hair removal you must be a medical doctor, a doctor of osteopathy, a nurse practitioner, or a physician assistant.

At the same time, a state statute mandates that laser hair removal be directly supervised if it's performed by a nurse practitioner or a physician assistant. So if a complaint involving laser hair removal comes before the Florida Board of Medicine, Mr. Lowe said, it is more likely to apply its policy from the meeting minutes than from the state statute. "The best thing you can do is call your licensing board or hire a lawyer who has experience in medical spas and these types of issues," he said.

As a starting point, "make a list of everyone working for you and what service they provide."

▸ Determine if the service is covered by your liability insurance. Check with your carrier to make sure you're covered. "In Florida, a lot of medical spa services aren't covered and the carriers are very resistant to cover them," he pointed out. "The last thing you want is to have an untoward outcome and have a patient come after you and not be covered. The most expensive thing about malpractice is paying the lawyers to defend you."

▸ Be careful with medical director agreements. What duties will the physician perform as medical director? These should be specified in the agreement. Mr. Lowe recommends having the physicians track their hours and the performance of their specific duties.

In order to be compliant with federal law, the medical director agreement must be in writing and signed by all parties involved. It must cover all of the services to be provided by the physician. Understanding the Stark federal antikickback law and regulatory safe harbors legislation is also essential.

▸ Obtain informed consent for all procedures. Mr. Lowe advises having Medicare patients fill out an Advance Beneficiary Notice. "That way they can't come back to you and say, 'You didn't tell me this procedure wasn't covered. … You didn't tell me what I was getting. You didn't tell me how much it would cost.'"

▸ Communicate off-label medication uses. Be sure to inform the patient and discuss all potential risks while having the patient sign an informed consent. Note the discussion in the medical record as well.

▸ Be mindful of patient privacy rights. If you breach the Health Insurance Portability and Accountability Act and cause the patient to suffer, "you may be liable," Mr. Lowe said. "Be careful with this, especially if you work with nonlicensed health care professionals [who don't understand the law]. People are looking to sue for privacy issues."

'The best thing you can do is call your licensing board or hire a lawyer who has experience in medical spas.' MR. LOWE

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

"Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices," said Ms. Eliscu, a medical marketing consultant based in Orlando. "They spend very little time nurturing those relationships."

Getting a handle on who's referring patients to you is easier said than done, with "so much outpatient medicine and lost camaraderie between physicians these days," she acknowledged. "The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing."

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. "Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same," she said.

Devise a way to say "thank you" for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note.

"In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact," she said. "Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity."

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. The majority of respondents expected their physicians to "know on a firsthand basis about the experience and expertise of the doctor they're being sent to," said Ms. Eliscu, author of the book "A+ Marketing: Proven Tactics for Success" (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is "prosumers" (people who are proactive about educating themselves before they consume health care services).

"Today's health care consumers shop around before making decisions," she explained. "They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions."

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves. "Get into story telling as a way to communicate," Ms. Eliscu recommended. "How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?"

Her "4As" for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers "want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms," Ms. Eliscu said.

▸ Accountability. Prosumers "want to know [whom they're] dealing with and what their name is," she said.

▸ Accommodation. Prosumers want your help to "work through the things they have to do, the appointments that they have to make," she said. "It's not about what's convenient for the practice; it's about what's convenient for the prosumer."

'Most of the medical groups I work with … don't know who's referring to their practice.' MS. ELISCU

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

"Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices," said Ms. Eliscu, a medical marketing consultant based in Orlando. "They spend very little time nurturing those relationships."

Getting a handle on who's referring patients to you is easier said than done, with "so much outpatient medicine and lost camaraderie between physicians these days," she acknowledged. "The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing."

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. "Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same," she said.

Devise a way to say "thank you" for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note.

"In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact," she said. "Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity."

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. The majority of respondents expected their physicians to "know on a firsthand basis about the experience and expertise of the doctor they're being sent to," said Ms. Eliscu, author of the book "A+ Marketing: Proven Tactics for Success" (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is "prosumers" (people who are proactive about educating themselves before they consume health care services).

"Today's health care consumers shop around before making decisions," she explained. "They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions."

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves. "Get into story telling as a way to communicate," Ms. Eliscu recommended. "How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?"

Her "4As" for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers "want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms," Ms. Eliscu said.

▸ Accountability. Prosumers "want to know [whom they're] dealing with and what their name is," she said.

▸ Accommodation. Prosumers want your help to "work through the things they have to do, the appointments that they have to make," she said. "It's not about what's convenient for the practice; it's about what's convenient for the prosumer."

'Most of the medical groups I work with … don't know who's referring to their practice.' MS. ELISCU

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

"Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices," said Ms. Eliscu, a medical marketing consultant based in Orlando. "They spend very little time nurturing those relationships."

Getting a handle on who's referring patients to you is easier said than done, with "so much outpatient medicine and lost camaraderie between physicians these days," she acknowledged. "The days of the doctor's lounge are gone. That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing."

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. "Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same," she said.

Devise a way to say "thank you" for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note.

"In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact," she said. "Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity."

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. The majority of respondents expected their physicians to "know on a firsthand basis about the experience and expertise of the doctor they're being sent to," said Ms. Eliscu, author of the book "A+ Marketing: Proven Tactics for Success" (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is "prosumers" (people who are proactive about educating themselves before they consume health care services).

"Today's health care consumers shop around before making decisions," she explained. "They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions."

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves. "Get into story telling as a way to communicate," Ms. Eliscu recommended. "How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?"

Her "4As" for effective marketing include the following:

▸ Access. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

▸ Availability. Prosumers "want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms," Ms. Eliscu said.

▸ Accountability. Prosumers "want to know [whom they're] dealing with and what their name is," she said.

▸ Accommodation. Prosumers want your help to "work through the things they have to do, the appointments that they have to make," she said. "It's not about what's convenient for the practice; it's about what's convenient for the prosumer."

'Most of the medical groups I work with … don't know who's referring to their practice.' MS. ELISCU