Are You a Bad Apple? 5 Steps out of The Crab Apple Funk

Much has been made of disruptive physicians, giving birth to “code of conduct” booklets that are required reading for physicians, as well as special coaches that help deal with physician behavior.  In my career, I have met only one disruptive physician, a neurosurgeon who was so dismissive and rude to the staff that I felt embarassed for my profession.  However, I think you may recognize some of the other ‘bad apples’ that can make the work day miserable.  You may even recognize yourself.  We all lapse in to ‘funks’, but if you are see yourself here consistently, time to work out a strategy to change from crab apple to golden delicious!

Types of crab apples:

The jerk: this physician delights in being critical, with out offering concrete suggestions on improvement.  Frequently condescending and short  (rude?).  Favorite comment, “Those ED docs are just sieves, man.  Why don’t they take two minutes and actually think?!”  (Heard last night, during my shift.)

The slacker: looks for as many ways as possible not to do the work.  Finds excuses on why tests and procedures can’t possibly be done.  At one institution where I work, if a particular cardiologist is on call, we all wait until the next day (if possible) to request a consult so we will get a different physician.  This particular cardiologist is famous for writing, “anti-arrythmics per hospitalist team.”

The depressive contrarian:  finds as many ways as possible to tell you that something won’t work.  Is so focused on what is wrong, doesn’t see what is right.  Guaranteed to make you feel as grey as a thunder cloud.  Chief sport is complaining. 

So what is to be done?

Here are steps to golden applehood:

  1. Practice optimism.  Before bringing out the sixshooter to gun down any thing remotely positive, try and think in terms of positive outcomes and solutions.
  2. Be civil.  We have lost much in the way we talk to each.  As your mom said, “If you can’t say anything nice, don’t say anything at all.”  Say please and thank you, don’t interrupt, and pretend to be Emily Post, even just briefly.
  3. Be honest, but not brutal.  Stick with the facts, and don’t embellish with emotions.
  4. Listen actively.  Listen much, talk little.
  5. Focus on  doing the right thing, rather than being right.
  6. Don’t be afraid to seek professional counseling.  Why go through life miserable?

Resources: Bad apples and Anger Blog.


Goodbye Grandpa

My husband is flying to Michigan today to attend the funeral of his grandfather.  He died over the holidays, but specified that his funeral was not to interrupt Christmas.  It’s been a rough several years for my husband, as his dad died of cancer, and now his grandfather died of the same.  My husband was extremely close to both of them, and as he puts it, “it’s the end of an era.”

Grandpa’s death has hit me hard.  We had flown out and spent Easter with him, and he was as vibrant as ever.  We knew he didn’t have long, but we took him out for some meals, reminisced and played some wicked games of cards.  He was so sharp that he sent emails to us until the end. 

Grandpa died the way he lived.  He had a clear sense of how his last days should go.  He didn’t want to be in the hospital, didn’t want any intervention for the kidney cancer, and wanted to play golf until the last.  He died surrounded by his family at home  hospice.  Nothing was done with out his consent, and tomorrow his family will celebrate a life well lived.

Grandpa died like patients SHOULD die, in full control, comfortable, with his wishes fully known and followed.  I would advocate  that we physicians treat our patients like Grandpa’s physicians treated him; they listened thoroughly, were completely honest, and allowed him to set his course til the last.  It takes a special type of physician to let go when it’s time, and fortunately that’s what Grandpa had.   Goodbye Grandpa, and thank you to all of the physicians that saw him through.

Enter to win a Amazon gift card–list a goal for your practice this year and a plan to achieve it!

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

Link Fest: Updates on group visits, RVUs, Medicare and the ‘Physician Shortage’

I’ve been storing up some links and today seemed to be a good time to have at ’em!  They range from the scary (Health Policy and Market) to the fun (the Efficient MD’s slide show.)

Read The Country Doc Report for another take on the group visit.  Country Doc relates how his practice does a group diabetic visit.  He uses smaller group sizes, and describes the three phases of the visit. 

For  an RVU Review, and exactly WHAT the RUC is, and how it effects you, visit Health Care Renewal blog. Boy, did I learn a lot about how we as physicians get paid (or not, as the case may be!)

To increase your understanding of the complexities of Medicare, Medicare Advantage, and Medicare Gap, see Insure Blog.  You may want to have this posted at  your front desk as patients come in with their “red white and blue” cards.

Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.

I love ways to improve my efficiency, and enjoyed the  fun, short  The Efficient MD’s  slide show.  I love his blog, and wish he would post more often!

For a chilly take on the role of physicians in the future, visit The Health Policy and Market blog.  According to the blog, we have plenty of doctors, and a “federal physician workforce policy” should be in place.  Just what I want, the federal government interfering even more into the business of health care! 

Establish a federal physician workforce policythat achieves the goals of organized care. TDI research has shown that the U.S. does not need more physicians; we have enough to care for America’s needs well into the future.

Let me know YOUR favority business of health care posts and I’ll put ’em up!

What Will You Be Thankful for NEXT Year?

I work with a business coach, aka the EntrepreneurialMD, who is a physician that helps other physicians who want to think outside the box of medicine.  She sent me a list of questions to ponder.  I have edited them somewhat to tailor them strictly to physicians in medical practice.  Following are items to contemplate as you enjoy that last piece of pie, the sip of wine and the companionship that is Thanksgiving.  If you are really motivated, you might even consider writing down the answers.  (You could do that between commercials during football games.)

– What’s your biggest business/professional objective in 2009?

– What are your biggest opportunities right now?

– Where do you see a gap in your “market” –what’s not being offered?

– What do your “people” (patients/practice partners/employees) complain most about?

– Where are you leaving money on the table?

– What are your top 3 time eaters and energy drainers?

– What is your “Biggest Opportunity Project” for 2009?

– What are the top 5 business/career development strategies you’ll focus on?

– How will you know you’ve had a great year?


And to all of our brethren working on Thanksgiving, I give a whole hearted thanks and God Bless.  We have all walked in your shoes, and are grateful for all you do.  Happy Thanksgiving!

See for more.

The Medicare No Pay, Never Ever List

The Centers for Medicare and Medicaid Services announced 10 hospital acquired conditions for which it will not reimburse.  The no pay rule has been in effect since October 1.  So, with out further ado: (drum roll):

  • “Stage III, IV pressure ulcers
  • Fall or trauma resulting in serious injury
  • Vascular catheter-associated infection
  • Catheter-associated urinary tract infection
  • Foreign object retained after surgery
  • Certain surgical site infections
  • Air embolism
  • Blood incompatibility
  • Certain manifestations of poor blood sugar control
  • Certain deep vein thromboses or pulmonary embolisms.”  (List from Aug 25, 2008).
  • CMS began to implement the no pay rule October 1, 2008.  Physicians will still be reimbursed for their services, but hospitals will not be reimbursed for their portion of the care.   Now, I don’t know about you, but I agree  some of the events are absolutely “never-ever” events  (retained surgical object, blood incompatibility), but some of the other conditions are out right ridiculous.

    My colleagues and I have come up with some ideas on how to respond to this latest demonstration of government “efficiency.”  We have proposed “buttocks rounds”, where the wound RN examines every patient’s behind and charts presence/absence of pressure ulcers.  We thought it especially important to do this on those 35 year old youngsters we are obligated to admit for chest pain.  We also thought that perhaps we could have a “fanny cam” to take pictures, so our documentation would be impeccable.  We advocated noting that all patients had decubs at admission, but the hospital administration shot this one down.

    Our next suggestion was that every patient, no matter what, should have an admission urine analysis, to document presence/absence of infection.  There could be a little check-in kiosk where the patient signs in, hands in a credit card for the hefty co-pay, and pees in a cup.  The patients could even dip their own urine, and record it on their check in information to speed the process up and decrease labor costs.  Additionally, we thought surveillance ua’s would be helpful in all patients with urinary catheters, probably daily.  Got to nip that e. coli in the bud!  We also considered putting a mandatory quinolone on every order set for patients with catheters, but became concerned when we realized c. diff may soon be added to the no pay list.  It may be worth a try for now, though!  Too bad about the cost of all those extra ua’s.

    As to falls, I have little to offer on prevention of the noscomial hip fracture.  Our hospital uses bed alarms (frequently it requres a doctor’s order, though), and of course we can always get a sitter.  (However, all the hospitals where I work discourage sitters secondary to cost.)  Occasionally we try to get family members to stay with the sun downing patient,  but they rarely do.  Now that Granny is in someone else’s care, they will give some sage advice, like “Don’t use ativan, or haldol, or ambien or seroquel, because Granny gets really nuts with those.  And don’t restrain her either.  Bye.”  They then hurry to the car for their first meal out in months.  Who could blame them? 

    CMS is planning on expanding the no pay list to ambulatory settings, nursing homes and home health agencies in 2009. 

    I am always in favor of intelligent uses of government regulation, but someone missed the boat.  What do you say we make some fanny cam rounds at CMS?

    21 Primary Care Time Wasters

    In my travels as the ExtraMD, I have seen many different practices, different styles and hundreds of ways practices waste time and annoy patients.  In my quest to help primary care physicians stay afloat, I will list my observations of time wasters that suck the joy out of medicine.  I will also include my incredibly astute suggestions for positive change.  Beware, you may even see your practice here.

    1) The doctor checking the patient in while the medical assistant stands there.  (Really.)

    2) The doctor calling every patient to tell them their labs were okay, while the MA stands there. (Is there a pattern here?)

    3) Not having the patient undressed and ready for the gyn exam.  There I am, setting out the speculum, diving around for the gown, searching for the pen to write their name on the specimen cup, while trying to keep up the patter.

    4) Not having the diabetic patient’s shoes and socks off. C’mon, it’s standard of care.

    5) Spending a lot of time arguing with the patient.  Give your viewpoint, listen to theirs, and then agree to disagree.  You will not convert everyone into exercise zealots in a day!

    6) Not having preprinted check off forms if you don’t have an EMR.

    7) If you do have an EMR, not learning how to type.  Get a typing a program and stop with the hunt and peck!

    8) Not telling patients when to come back–be specific!

    9) Waiting for late patients.  Have a policy that you if the patient is more than 10 minutes late, you will reschedule them, or try to work them in.  Caveat: YOU MUST BE ON TIME!  (Guess what patients complain about the most?  Waiting for you!)

    10)  Not having charts pulled when you return phone calls.  Document the phone call, or have your malpractice lawyer’s phone number handy if you don’t!

    11) Not having notepads in every room, so you can write instructions down (legibily) for your patients.  How much do you remember sitting in a paper gown in your tighty whities?

    12) Not having a stock phrase down, as in, “Mrs. Malady, which two problems would you like to focus on today?”

    13) Complaining.  Oh puhleez, nobody wants to hear you whine.  If you want to whine, start a blog.  Better yet, be the change you want to see.  (Thank you, Ghandi.)

    14) Not giving out educational material.  You look like the hero if you have some handouts, and it’s good medicine to boot.  Have info stocked in each room in a standardized fashion.

    15) Not relying on your staff.  You’re paying ’em, and they WANT to be useful! Use them to make calls, double check medications and allergies, hand out educational info, and answer questions.

    16) Losing stuff in your office.  Have a systemized approach to patient care, from check in to check out and follow up.  Your best approach is to go through a day with your staff, and see where stuff goes.  You will also gain a lot of insight into what everyone is doing.  You probably need to do this every quarter.  It is helpful to try to systematize every aspect of care delivery, so it is repeatable and reliable.  E.g.: all labs must have a physician signature before filing, all patients are asked to disrobe according to the exam, each room is stocked with the same supplies in the SAME places.

    17) Sloppy hand writing.  ‘Nuff said.

    18) Thinking you are superman/woman.  You need to allow other people to do their job, so you can do yours.  Even Batman had Robin.

    19) Charts that aren’t.  I have seen (not fibbing here!) a simple file folder with everything stuffed in it, in random order.  As a locums MD, how easy do you think it was to find important info?  Most charts have tabs–use them.  And train your staff to file properly.

    20) Not having your staff notify you immediately when the patient says the magic words, “Chest Pain.”  They should immediately mobilize the EKG and get you in the room.  So what if it’s NOT the big one–better to err on the conservative side then have some poor slob infarcting while waiting for you for 30 minutes to finish up with the fibromyalgia patient next door.

    21) Chatting about yourself.  Patients just don’t care, and find it annoying.  There are actually studies demonstrating this.  (Who funded those studies?…)

    Hope this helps.  Don’t be afraid to look at your practice as an experiment, change stuff, and then see what works out.  Most of all, enlist your staff.  You will be hugely surprised at how innovative and involved they will be!