Walk the Talk: the Patient Encounter

I am fascinated by how we physicians communicate (or not) with each other and with our patients.  As a medical student and resident NO ONE ever thought about how physicians communicated with patients.  We were always so focused on nailing the disease process and treatment that the patient was nearly ignored.  I don’t think I had a single attending that excelled in talking and listening to patients.  I have tried to self educate (isn’t that what most of medicine is?) and found a thoughtful curriculum for residents on line, from the University of Washington.  I will reproduce the salient points here:

  1. Have an opening introduction: “Hi, Mrs. Marlboro, I’m Dr. Pookie.”  (Hand shake, sit down, look at patient.)
  2. Allow the patient to complete their opening statement.
  3. Attempt to get the patients full agenda: “Mrs. Marlboro, what is the most important thing we need to work on today?” At this point, prioritizing the patients concerns is key.
  4. Set the ground rules: “Mrs. Marlboro, it sounds like stopping smoking is what we should focus on today.  Is that right?”
  5. Gather information, with a  mixture of open and closed ended questions.  Summarize and clarify with out interrupting.
  6. Actively listen, using non verbal cues as well as verbal cues.  (“Uh huh, ah…”)
  7. Explore their beliefs about the illness.  (Yes it’s hard to keep your mouth shut when a patient insists that smoking isn’t bad “because, Doc, I know you’ve heard it before, but I don’t inhale.”  Just heard this from a diabetic as he went on his way to the cardiac cath lab…  But try!)
  8. Acknowledge the patients feelings/values.  (“Yes, quitting smoking is really hard, even our President Elect thinks so.”)
  9. Share information in terms that patients understand.  (Save the free radical talk, two gene promotor theory of cancer for some one who cares.)
  10. Encourage questions: “what questions or concerns do you have?”
  11. Reach agreement on the treatment plan, actively encouraging patients to participate in the plan. 
  12.  IMPORTANT: TRY TO GAUGE THE PATIENTS WILLINGNESS  AND ABILITY ENGAGE IN THE TREATMENT PLAN!  The best plan in the world is worthless if the patient can’t/won’t follow it!
  13. Provide resources (hand outs, referrals etc.)
  14. Realize you can NOT cover every item at every visit. 
  15. Close the encounter by summarizing the treatment plan and setting up the follow up plan.

The patient encounter needs to be a balance between “patient centered skills” and “agenda setting skills.”  Interestingly, when a patient is dissatisfied, they underestimate by 8% how much time the physician spent with them, while if they are satisfied, they overestimate the time the physician spent with them by 20%!

Please see link from Society of General Internal Medicine below.   First author is Matthew F. Hollon, M.D., M.P.H., from the University of Washington. 

http://sgim.org/userfiles/file/AMHandouts/AM08/WC01%20Matthew%20Hollon.pdf

TightMD Gazette II: 11 More Tips to Tighten the Belt

All right, Dr. Practice Owner, here are more tips to keep you practice’s head above water in these turbulent times:

  • Share staff.  If you have an excess of staff, could they be shared with another office rather than laid off?  You  get to retain a valued staff member, the staff member keeps their job, and everyone wins.
  • Enlist your staff for help.  Everyone is anxious about keeping their jobs.  Set up a brain storming session for ways to save money, and ask your staff for input.  Once they realize they can directly impact how the practice runs, they will be diligent in finding ways to keep the doors open!
  • Pay bills on line.  You can pay bills closer to the due date, and keep the money in your account longer.  (See “sweep account” in previous post.)
  • Get a free energy audit.  Your local power company will do this for free, and can give you information on where the energy is going, and how to improve the leaks.
  • Turn off your computer at night and on weekends.  Ditto the lights.  (Duh, but did I turn off my computer last night?!)
  • Evaluate your payroll company.  Payroll companies must guarantee accuracy in withholding and tax filing.   (Penalties are huge for mess ups!)  However, make sure you are not paying for services you are not using–if there is just three of you, do you really need the Human Relations functions?  Also, examine direct deposit.  See if you can get your payroll service to do it for free.  Direct deposit saves the payroll company money–which should you be paying for it?
  • Make sure you take all the tax deductions you are entitled to.  Keep receipts as if they were gold.  If you haven’t done this during 2008, make it a top priority for 2009.
  • Tax tips continued: ( http://smallbusinessonlinecommunity.bankofamerica.com/blogs/Taxes/2008/03/20/five-tax-filing-mistakes-to-avoid)     

–If you started a qualified retirement plan, you can claim a credit of $500 per year for the first three years to offset the administrative start up costs (e.g., educating your employees about their participation in the plan).
–If you conducted scientific research, you may qualify for a 20% tax credit for these research activities.
–If you hired someone from certain targeted groups, such as a disabled veteran or long-time family assistance recipient, you can claim a credit for a portion of their wages.

  • Choose the best business entity.  Partnerships, LLCs, and Corporations all have various tax benefits.  Talk to your accountant and then business attorney about what is right for your practice.  General rule: “Any business with the potential for claims against it, which includes most businesses with employees as well as those with customers who visit the business premises, should probably opt for an entity type that protects owners’ personal assets.”  (Barbara Weltman, contributing writer for Inc. magazine.)
  • Cross train your employees.  Rather than laying off, see if they can do other functions.  Beware of the training costs, but it may just save you money.
  • Don’t be Scrooge McDuck.  Get creative with perks.  Consider dress down Fridays, if appropriate, or Pizza Fridays.  Ask you staff if they want that Holiday Gala, or if they would prefer some decent lunches, or maybe just a bonus check.

My company, ExtraMD, does the following: we use a virtual assistant, we pay bills on line, we keep payroll in  house, and are looking at giving bonuses this year.  I look at our profit/loss and budget variances monthly.  We have an ace controller, and an amazing tax attorney.  Our accountant is appropriately pessimisic  (that’s what I am paying him for!)  And, yes, I print on both sides of the paper.  I promise to turn off my computer at night.

Good luck!   Keep the doors open, the employees EMPLOYED and your practice business in the black.  Remember, if you aren’t open, you can’t see patients!

Resuscitating Primary Care, Part I

 
As promised, I will turn my laser like focus to the task of “fixing” primary care.  I will examine both micro and macro ways of doing this, coming up with to do lists that physicians can implement in their practices as well as global suggestions that will take shifts in health care policy.  (Which only we as a group of physicians can enact!)

1.  The pay stinks. Yes it does.  Physicians do not get pay raises because they are more experienced or incredibly good.  The only way to increase the pay is to do one of three things: see more patients, add more services and globally lobby for getting paid for thinking (which is what primary care physicians do best).  At the practice level, you need to examine patient flow, appropriate billing for services rendered (example: are you billing/coding appropriately for immunizations?) and decide on an appropriate number of patients to see.  Calm down, I am NOT telling you to become a patient care mill, rather to be realistic and set a REASONABLE number of patients you could see.  Also realize that the pay is limited, and it will take a major change in reimbursement to get paid appropriately for what you do.  (Sorry, it is what it is.  Get out there and lobby for change!)

2.  You got an MD instead of an MBA.  I am addressing this early in the game because it is probably the most important.  In my neck of the woods, massage therapists, as part of their curriculum, learn marketing and accounting.  They are better equipped to set up a practice then a physician who has spent 4 years in medical school then 3 more in residency! (Academic medicine, are you listening?) Here is the big message of this post:

You must learn the business of medicine.

But how?  There are books on practice management, seminars on practice management, journals on practice management, and a good accountant and bookkeeper are essential.  But YOU must understand the financial underpinnings of your practice, even if you have God’s gift to office managers.  (For more on seminars, visit my website: www.extramd.com.)  Later this week, after I do my nights shifts, I will put up a page with a list of resources I found helpful.  C’mon, as a physician, you are used to soaking up knowledge like a sponge, you can do it!

 3.  Coding is really fun.  Sorry, but this is another one you MUST learn.  I don’t care that it is boring, picky and strong medicine even for the most confirmed of insomniacs.  Once again, avail yourself of every resource you can to learn it.  Think seminars, books, consultants.  No whining, just do it.  (And remember, ICD-10 is coming.  Sheesh.)

 4.  You are a hamster on a wheel.  You will have to weigh revenues vs. practice style here.  Of course, you will need to maximize revenues, billing and collections no matter what you do.  However, if you choose to see fewer patients per day, then you need to reconcile yourself to less revenues, and ultimately less income.  Your practice partners may have some input on this (!), but if you are solo, consider the micro practice model that is getting a fair amount of hype.  Whatever you do, be very clear in your mind what your expectations are.

All right, enough for today.  We will continue PookieMD’s crash course on primary care resuscitation in my next post.  Until then, keep the doors open, and get out and learn a little about the business of medicine!

PookieMD Airlines: How aviation check lists apply to medicine

I am married to an electrical engineer that loves to fly around in a small airplane.  Because I hang out with him, I’ve been forced to observe the intricacies of not crashing into other planes and landing safely.  I’ve learned a lot.

Pilots have a check list for everything.  Plane manufacturers include an entire book of checklists for every contingency, from take off, to landing, to what to do if there is an emergency.  ( It is a BOOK, mind you!)  My husband straps the needed check list to his leg and goes through it every time we land or take off or preflight.  He actually LOOKS at the list, touches each instrument and taps on the applicable gauges.  It is not a passive process.  Hence my hubbie and I have logged over 1000 hours safely in the cockpit of our tiny plane.  (Don’t look at me.  I don’t know a dang thing about flying.  I just kiss the ground when we land.)

Why do we physicians not utilize more check lists as we go through our day?  The medical profession has been (reasonably) stubborn on adapting algorithms and treatment pathways, arguing that each patient is different and no one algorithm can apply to every patient.  But from a patient safety stand point, I will side with the check list every time.  When a patient goes to the OR a check list is utilized, and when a patient is transported in one of the hospitals where I work, there is a “ticket to ride.”  Why don’t we have some simple checklists for ourselves, listing important but (sadly) forgettable to do items for each patient?  Now, some hospitals have an EMR that will generate order sets, but they are usually not as robust as they could be, and frequently only cover one disease state.  These order sets are good, but incomplete, and  lead to “drop offs” on treatment plans.  Hence the need for the check list.

When one of the hospitals I work at transitioned to order entry, I had to develop a check list that I carried around with me, because going back and forth between multiple screens is onerous.  It included the following:

  • Order labs for next day (first screen)
  • Review current meds (screen #2)
  • order new meds (screen #3)
  • order radiology studies (screen #3)
  • make sure note is entered in the EMR (screen #4)
  • review labs (screen #5)
  • read other doctor’s notes (screens 6 and more, each note a different screen)
  • review radiology studies (screens 7 and 8, depending on if you actually looked at the image.)

It’s quite easy to drop the details we internists live for.  Seems silly, but given it was a new EMR for me, I had to develop a system to make sure my work flow was preserved and important information and procedures were addressed.  Most of us used check lists as medical students, and then gave up the habit as we grew more comfortable with medicine.   You don’t have to have a check list for everything, but it’s helpful when you are encountering a different situation then usual, like the new EMR I described. 

I encourage you to add to your history and physical check list the following things:

  • Prophylaxis: e.g. have you written for GI prophylaxis (if warranted) and DVT prophylaxis  (don’t forget that DVT is now one of the  medicare “no pays”)
  • “Treatment plan discussed with patient and family, and they are in agreement.”
  • Note the time spent with patient and coordinating care.  (A must, for billing.  Heck, have this tattooed on your hand if you can’t remember it!)
  • Pressure ulcer present/absent at _____________(location).  (I have a skin category in my physical exam and include the pressure eval here.  Pressure ulcers that develop during a hospital stay are another Medicare no-pay.  More on that in a later post.)

One of my hospitalist colleagues uses the following check list at discharge, necessitated because the EMR we use makes us go between several screens and logins:

  • write discharge summary
  • write discharge orders
  • send note to PCP
  • set up follow up
  • write scripts

Useful primary care check lists would be:

  • State of undress for each exam:  (female pap: the full Monty, male: off with the tighty whities for the prostate check, diabetics: off with their shoes and socks!)
  • Check list clipped to chart as to what screenings are done at what age, or in each room.
  • Check list on cabinet door detailing what items go in each cabinet.
  • Check list at discharge for assistant to review: does patient have scripts, referrals, test info, and know when to come back.
  • List of items your front desk staff needs to check at each check in (check address, insurance card, HIPPA).
  • List of items your assistant needs to check as they room the patient (chief complaint, allergies, meds etc.)

When I wrote this post,  I considered making a “write post” check list, which would include looking for typos.  It seemed like a good idea, but I wuz too bzy so I didn’t have tim to go threw my list witch wud have reminded me to make sur I didn’t have no tipos.   

We can learn a lot from the world of aviation.    Should we have a check list for Code Blue/COR-0?  Nah, we’re physicians, we know it all.  Besides, the guidelines will change in two years anyway.

Flaps up!