Physicians Make Mistakes, Correct Them The Right Way

“If they will hand me the instruments when I need them, then they won’t get yelled at. This is my OR and my rules.”

“Well, I’ve always prescribed Cipro for strep throat. In my experience, it always works. No one can tell me how to practice medicine.”

We’ve all heard stuff like that before. Try to offer a correction or suggestion to a colleague and the walls go up immediately. It can be very uncomfortable, especially for non-physician staff, when a physician shuts down a conversation. Physicians often implicitly hold the most power in conversations or interactions that they have with staff and patients. If they refuse to discuss something further, then there is little recourse, but the long-lasting impact on relationships can be irreparable.

So how do we deal with this? As a supervisor, how do I hold staff accountable? As a colleague, how do you approach someone and speak up when you see a problem? It will always be uncomfortable to criticize someone, but if structured correctly, criticism can lead to growth.

If structured incorrectly, then these conversations can lead to worsening distrust within healthcare organizations. If administrators thought their job was hard now, try to lead a cadre of physicians that refuse any attempts you make at change or improvement. It can get ugly fast.

Peer To Peer Conversations

Physicians correct other physicians. That is the practice in my organization, and it is essential. Due to the extensive amount of training that the average physician undergoes, it is very difficult for non-physicians to grasp the knowledge base and unique experience that most physicians have.

This is similar to many other highly specialized fields. I wouldn’t dream of micromanaging the daily tasks of a nuclear physicist. I have no clue what he does on a daily basis. In the same way, physicians are much more apt to listen to a fellow colleague than a non-physician.

My first thought when an MBA tells me I’m not seeing enough patients? Who does this bean-counter think he is (no offense!)?

My first thought when a fellow internist tells me I’m not seeing enough patients? Holy crap, am I not pulling my weight?

Establish the Standards

If you’re going to hold someone accountable, then you need to define what the standards are. Decide the standards up front and include physicians in the decisions regarding this. As I always say, the mission is the answer, and you have to very clearly delineate what you expect your staff to accomplish when they show up at work.

These standards can get as specific or as broad as you like. I personally prefer to keep them broad so we hold each other to the spirit of the law rather than the letter of the law.

I may receive hate mail for this as well, but I think you should define what the standards are not only when it comes to behavior, but also clinical practice. Civility and respect should be a common expectation in all interactions, and most will not have a problem with this. ZdoggMD has an excellent video below demonstrating how to appropriately talk to patients:

OK, maybe not, but I think you get what I’m going for here.

There are numerous benefits to establishing clinical practice standards as well. If all physicians practice in a similar way, then it is much easier for staff to effectively do their jobs. We use published clinical practice guidelines as our starting point and have established methods for deviating from them if there is a compelling clinical reason that the physician staff can agree on.

If a situation is outside of established guidelines, then physicians need a formal venue for peer assistance. This can be through interdisciplinary rounds, tumor boards, etc. The purpose of clinical practice standards is not to cram every patient into the same box. The purpose is to practice in an evidence based manner where evidence is clear, and allow for reasonable judgement when the evidence is not clear.

Public Praise, Private Correction

Do you enjoy being called out in public? Didn’t think so. Then don’t do it to other people! Physicians are no different. Nobody responds well when called out in a meeting of their peers. A justified critique will easily be interpreted as a personal attack because of the venue.

Despite what some may think, adding the extra humiliation of public critique doesn’t “add emphasis” to what you say or “make them remember.” It just builds resentment. The average physician is a driven, hard working individual that will have no trouble remembering any criticism they receive.

In contrast, everyone wants their accolades to be publicly broadcasted. Even folks that shy away from the limelight enjoy being congratulated in front of their peers, whether they admit it or not.

Again, physicians, on average, amplify this even more. Physicians pride themselves on the quality of their work and enjoy seeing that work recognized. Remember you are talking to a group of people that earned a lot of A’s during their school years! Feed the ego a bit and let everyone know when someone performs well.

Professional Courtesy

I hear this phrase thrown around a lot in break rooms. Several physicians have told me before they should be “given the benefit of the doubt” or shown a little “professional courtesy.” Unfortunately, they don’t seem to know what that really means when they say it.

I think our professional athlete colleagues can assist us with an example. Here is Peyton Manning and Jeff Saturday, formerly of the Indianopolis Colts, giving a wonderful example of professional courtesy (note there is some language in the video courtesy of Youtube):

See, professional courtesy means you just sweep problems under the rug, right? Ha! Professional courtesy means I do you the courtesy of coming to you, peer to peer, to ask about what happened rather than simply acting on the information I receive (or calling a press conference in Peyton’s case), under the assumption that we are both on the same page regarding our common mission and goals.

There are many vocations where someone reporting your misdeeds leads directly to termination or other bad consequences. Try working at McDonald’s and have one of your co-workers report that you stole something. Your manager will have a conversation with you, but it will be very brief and will likely end with you handing in your name tag.

Professional courtesy means if someone reports a potential problem to me about a physician, then I do not pass judgement during that initial conversation. I will promise to investigate, but I will not promise to punish or even agree. This can be frustrating for other staff at times, but to me, innocent until proven guilty is an essential part of professional courtesy.

Second, I will review the facts surrounding the case myself and come to you, physician to physician, to discuss the matter (hopefully with fewer bleeps than Peyton). I will not pass judgement before talking to you, and I am open to hearing your reasoning for your actions. This may or may not change my mind, but I will speak directly to you and not to anyone else.

As I said before, professional courtesy never means that I will ignore problems. Our standards are our standards and everyone must be accountable to them. However, I will absolutely promise to come to you, and no one else, to discuss the issue. That is professional courtesy.

Address Problems Now

If there is any final piece of advice I can give, it is to address problems immediately. Don’t ignore them. Don’t say you’ll “address it next time.” Address it now. Show your colleagues that you really think accountability and performance standards matter. Demonstrate urgency with your actions.

The single greatest problem I see amongst physicians and physician supervisors is lack of urgency when it comes to accountability. We get caught in this every man is an island mode of thinking where we simply throw up our hands and say “he’s responsible for his own actions.”

We have to acknowledge that our fates as physicians are tied together and act accordingly. It is always better for physicians to collectively improve. Always. No improvement happens without accountability.

Remember that, at the end of the day, we are going to be accountable to someone. We can either be accountable to ourselves or to someone else. We’ve tried the someone else route in medicine. Time to do something different, wouldn’t you say?

Have you ever tried to correct a colleague or bring up a problem? Did it blow up in your face and turn out well? Tell me about your experience in the comments!

The Position Paper 9/8/17

Welcome to The Position Paper! The Position Paper is my series featuring my quick take on a particular topic to help you manage your position. I will often feature one outside article as well that will allow you to dig in deeper if you desire. Read this while you drink your coffee in the morning and start your day off right!

Today’s Position: Professional Position

Featured Article: None

My Take

No featured article today, as I thought I’d give my brief thoughts about physician accountability. As many of you know, I am a physician that supervises other physicians. As such, I am the guardian of our organization’s mission and values within our clinic.

I take this job very seriously, as I view this as just another way to ensure that our patients receive first class medical care. My role sometimes requires me to have tough, direct conversations with colleagues, and I don’t shy away from it.

I have marveled, however, that some others in similar positions refuse to speak up when noticing their employees delivering substandard work or behaving in an an unacceptable way. Often, they will tell me something along the lines of “I’m not going to tell another doctor how to practice medicine” or “They are responsible for their own actions.”

On the surface, I agree with these sentiments. I don’t go to work every day and tell my physicians how to practice medicine, and they most certainly are responsible for their actions on a daily basis, just like anyone else. However, professional courtesy requires that you act like a professional.

I am not going to sit by and watch one of my physicians treat a patient with disrespect. I’m also not going to watch any of them give out narcotics to every patient with back pain that walks in the door. There are standards of behavior and quality that we all must adhere to. Enforcing these standards does not diminish our profession; it enhances it.

As I tell my employees, we can either police ourselves or someone else will come and do it for us. As a physician, myself, I think I am the best positioned to fairly and accurately judge my staff’s performance and behavior. As long as I hold everyone accountable to a standard of excellence, then no one else will bother us.

If I fail to hold others accountable, then other people will likely start to bother us. I think we all can agree that medicine needs less outside people shaping our direction, not more. Accountability is the only way to ensure physicians remain the leaders of the healthcare system; we should embrace it.

Have a great day!

 

TheBossMD

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The Position Paper 9/1/17

Welcome to The Position Paper! The Position Paper is my series featuring my quick take on a particular topic to help you manage your position. I will often feature one outside article as well that will allow you to dig in deeper if you desire. Read this while you drink your coffee in the morning and start your day off right!

Today’s Position: Professional Position

Featured Article: Improving Physician Satisfaction By Eliminating Unnecessary Practice Burdens hosted by KevinMD

My Take

 

Dr. Yul Ejnes of the American College of Physicians (ACP) penned a home run with this guest post on KevinMD. Doctors everywhere have long lamented the mounting non-clinical activities that take up our day. We are finally starting to see some real movement to rein in all of this workload so doctors can focus more on patient care.

The ACP has a broader initiative, Patients Before Paperwork, which serves as its national campaign to support this topic. In this article, Dr. Ejnes discusses the growing burden of physician signature requirement and the absurdity associated with it. Any doctor that has checked their inbox can see the vast numbers of signatures required for items ranging from wheelchairs to diapers.

Dr. Ejnes eloquently discusses the intended role that insurance companies want doctors to play (medical fraud detectives) compared with the reality of completing all these forms while still providing high quality patient care. Physicians do not want or need to spend their time policing the contract between patients and insurance companies.

Up to this point, physicians have tolerated this exercise in the name of patient care. No doctor wants to see their incontinent patient go without diapers or their patient with history of stroke go without their wheelchair. We are here to help our patients, so that is what we have done.

The sheer volume of incoming fire, though, has triggered a tipping point where the time required to complete these tasks threatens our day to day ability to actually care for patients. We are willing to bend to provide our patients what they need. We are not willing to compromise the patient care we provide.

I am very hopeful that these type of national initiatives will spark real change in the insurance industry and, in turn, physicians’ day to day lives. Physician organizations will likely have to lead the way, as they are the only groups with the size necessary to interface directly with insurance companies.

Throughout our dialogue, we need to keep the patient at the forefront of our discussion. A signature may seem like a simple thing, but continued erosion of physicians’ time to focus on patient care will never have my endorsement.

TheBossMD

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The Position Paper 8/25/17

Welcome to The Position Paper! The Position Paper is my series featuring my quick take on a particular topic to help you manage your position. I will often feature one outside article as well that will allow you to dig in deeper if you desire. Read this while you drink your coffee in the morning and start your day off right!

Today’s Position: Professional Position

Featured Article: How Does Clutter Affect Employee Productivity shared by Productive Physician

My Take

In today’s Position Paper, Productive Physician shares an article outlining the many influences clutter has in our workspace. I think we have all walked into a physician work room or office with papers scattered everywhere. If you’re like me, it gives you a mini panic attack!

The article mentions some interesting statistics that are especially relevant for physicians. One cited study states the average employee spends up to 4.3 hours per week looking for papers. Physicians, I shouldn’t need to remind you of the administrative drain already placed on your day. If you’re like me, then you routinely traipse around the office looking for those home health orders or lab results.



There are several common sense tips mentioned including keeping an organized filing system and keeping workplaces clean. Personally, I speak with my physicians a lot about keeping our workspaces organized. Though this article may talk about the real economic cost, there is also the clinical cost to our patients we have to consider. Losing lab results or patient messages has real consequences for our patients.

An area the article does not delve into, which I think is especially relevant for doctors, is electronic clutter. Many electronic medical record (EMR) companies would have you believe that you can fire up your computer and only open your EMR each day. That is simply not true.

How many times a day do you realize that you have numerous things open on your computer including your EMR, email, reference materials, internet, and the list goes on? All of these extra “things” that stay open distract you from your primary job, patient care.

You don’t need to see what the next email is the second it comes in. You need to take care of the patient in front of you and check the email later. Decluttering your electronic workspace is key to accomplishing this.

Now go and clutter no more!

TheBossMD

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How To Disagree With A Patient

There has been a lot of talk about physician safety after the recent tragic news of a physician getting killed for refusing to prescribe opioids. The sad reality is that these types of situations are not new. Though many don’t end as tragically, physicians are bullied and pressured every day to provide care that is medically unnecessary.

How should we respond in these tense situations? What should we do when we anticipate that a confrontation might occur? These are questions every clinic and physician should be asking. Though the temptation may be to give in at times to avoid potentially catastrophic consequences, we must not do this. As the professionals tasked with caring for the public, our duty is to provide safe, high quality healthcare.

All of these situations, however, start out as a basic disagreement. It is there that I would like to focus our attention today. How can physicians best manage situations when patients ask for something we are not going to give? Do we yell and scream? Do we immediately assert our authority and shut down the conversation? Do we go silent and simply let the patient talk?

While no “strategy” is going to change a patient’s mind or prevent all situations from escalating, we owe it to ourselves, our families, and even our patients to manage these situations as best we can. I would like to propose seven strategies below to help us safely and effectively disagree with our patients. To be clear as well, many physicians have used all of these strategies I list below and still had bad outcomes. We are not going to prevent every bad situation, but we have to take action to reduce them.

Communicate Expectations Up Front

Every new patient that comes through my clinic spends the majority of their first appointment discussing office procedures and expectations. My nursing staff does the majority of this work, and it is essential. In essence, we tell each patient that we promise to communicate professionally with them, and in turn, they need to communicate professionally with us.

Professional communication entails communicating in a timely and civil way, and it goes both ways. We promise to communicate with you in a clear, calm, and courteous way and you must do the same. During moments of disagreement, I can call on this deal we made and remind them that I have held up my end of that bargain. It has been very helpful at times.


Tell Them You Care

As soon as I feel a disagreement is happening, I am going to work how much I care about the patient and their health within the next two sentences that I say. The reasoning for this is simple. First, I really do care about my patients. It’s not an act or a line I’m feeding them. My treatment of them prior to that moment can speak to that.

Second, discussing how I care for them reframes the conversation. The patient is approaching the situation as confrontational. I am approaching it in a cooperative manner. This is not the patient vs the physician. This is the patient and the physician against your chronic pain, or the patient and the physician against your viral URI that is making you miserable.

No matter what the patient says, I will always reiterate that we are on the same team and I am there to help them. It is much harder to escalate the situation when framed this way, and I can often steer us back towards something productive.

Let The Patient Talk

As someone who personally fields many patient complaints and reviews patient/physician disagreements, I can tell you that the vast majority of patients will tell you that they escalated the situation because they didn’t feel heard.

Yes, they disagreed with the doctor’s decision, but the part that really ticked them off was when the physician shut down the conversation. No one likes to be told they’re wrong and then be told to shut up, even if you know the other person is much more knowledgeable. There is a basic human response to lash out in that situation.

So, I tell my providers all the time to let the patients talk. Give them the courtesy of being heard. Sure, it may put you behind schedule. It may produce no change whatsoever in the decision you make. But, if it can save your relationship with your patient and help prevent something disastrous, then we must do it.

Tell Them Everything

Once you let your patient say everything they want to say, then tell them everything you possibly can. Explain in detail why you’re making the decision that you’re making, and explain it in a way that they understand. Define what certain terms mean if you have to, but you need to show your patient that this is not just a “cookie-cutter” decision. You have looked at their specific situation and applied your medical knowledge to them.

This way, patients know that you are not just lightly or blinding making decisions about aspects of their lives that affect them so much. You have taken your extensive medical knowledge and applied it specifically to their situation to formulate the best treatment plan. I will often say this exact phrase to make sure they understand this. I’m making the best choice for them, not just the best choice in general.

Lower Your Voice

Ok, this move is straight out of parenthood but there are multiple psychology studies to back this up. When someone is confronting you, the natural reaction is to raise your voice. Don’t do it. Consciously lower your voice. It is very difficult to yell at someone speaking softly back to you. Most people will naturally lower their voice if their verbal fire is not returned.

Interestingly, speaking softly can also be a very effective method of communicating confidence. Any of you that had a parent or boss use this style with you can attest to this. A person that quietly outlines their position and does not yell often appears much more authoritative and sure of themselves. A person that yells appears to be covering up their insecurity with volume.

Don’t Fire The Patient

Some of you are going to disagree with me on this point, but that’s OK. I very rarely “fire” patients. I’m not saying it never happens, but it’s rare. Part of this does have to do with my sense of duty towards the patient. The other part though is that you would be shocked how effective it is when you tell the patient that you want to see them again.

We all have cared for patients that have been fired from a previous practice. I have forged some pretty good relationships with some of these folks when I refuse to prescribe something and then immediately ask to follow up with them closely so we can see how things are going.

This reinforces the fact that I really do care about them; it’s not just an act. I’m also reinforcing that I really believe the treatment plan that I have proposed, and I’m willing to see them through it.

Many physicians will make a one time recommendation and ask the patient to never come back if they disagree. Right or wrong, this looks like you simply said something for the sake of saying it and then got rid of them. Consciously telling the patient that you want to keep seeing them communicates confidence and a desire to have an ongoing relationship with them.

Have A Safety Plan

At the end of the day, you’re still going to run into situations where patients inappropriately escalate a situation. Be ready. Have a written policy of how to handle these situations. Make sure everyone on your staff knows the policy and better yet, practice it regularly!

What do you do when a patient yells and won’t stop? What do you do when a patient threatens you or even becomes physically violent? Have everything planned down to how you communicate with your staff that you need help to who is responsible for calling 911.

As with all emergency situations, you will always revert to what is most ingrained. If you and your staff know your policy cold and have practiced it, then you will be much more likely to safely handle the situation. Heaven forbid that something were to happen and a patient would accuse you of wrongdoing, a written policy with documented staff education and routine practice will also help you prove that you had a well thought out plan that you followed.

Remember Your Value

At the end of the day, if no one else says its to you, let me tell you that you do hard work and you are valued. Healthcare is a tough environment right now, and doctors’ well-being is often lost in the shuffle. I hope the seven tips above can help prevent a at least a few situations from getting out of hand. We need more doctors engaging with their patients and honestly caring for them, not fearing for their safety.

I’m curious to hear from all of you about your experiences and what you think might help doctor safety. Leave a comment below so we can discuss more. This conversation needs to continue as we aim to make the exam room a caring environment for everyone, even the doctor.

We Need More Customer Service In Medicine

Customer service in medicine is important. I know many people don’t want to hear that, but it’s not going away. Patients are talking to each other more than ever. They’re leaving comments on Facebook, Twitter, and numerous physician review websites. Get a few bad reviews, and watch your patient volume drop. Your revenue won’t be far behind.

However, I believe the current focus on customer service is actually too narrow. Yep, that’s right. I think medicine needs more customer service, not less.

While much of the physician lounge discussion and staff meeting arguments stem from external customer service, medicine actually needs a larger focus on internal customer service.

The business world is already well versed in both internal and external customer service. Talk with any businessperson and you will hear them talk about their internal and external customers. It’s considered standard practice to extend the same level of customer service to your internal customers as your external customers.

The reason for this is simple. To best achieve your organization’s mission, everyone in your organization has to work together. Team work makes the dream work as we like to say.

Unfortunately, I have witnessed a lot of colleague interactions that were downright scary. Many times, they look something like this:

(video courtesy of Youtube and ZdoggMD.com)

While that video might be hilarious (this one is even better), these types of negative interactions not only throw a wet blanket on a everyone’s day, but they hamper patient care.

In my mind, there are three reasons that medicine, and physicians in particular, should focus on improving our collective internal customer service skills. Allow me to explain.

The Patient Is Still Sick

 

I use this phrase all the time when embroiled in some type of specialty turf war or argument. While we’re sitting here arguing about “whose problem” this should be, the patient is still sick. Think about the poor patient in the middle of this confrontation:

(video courtesy of Youtube)

I don’t know what the mission of each of your organizations is, but I’m willing to bet that taking care of patients is an integral part of it. As a profession that generally prides itself on caring for others, arguing and negative interactions takes the focus off the patient and onto ourselves. We should view this as countercultural and unacceptable.

I fully recognize that legitimate conflicts arise that need to be solved. However, my rule in my personal practice and those whom I supervise is to take care of the patient first, period. We will deal with the system issue, but step one is always to care for the patient in front of you.

By flexing our internal customer service skills, we can make these occurrences few and far between. I was involved in a great conversation on Twitter discussing the role of radiology and pathology in patient care, and specifically how both specialties desire to be more directly involved in the care of the patient. Here is one quote I think is poignant:

“Cannot tell you how many times I’ve gotten “I’m just covering” when calling back to ask more questions about a study.”

Good internal customer service recognizes that these types of conversations cannot happen and our relationships with our colleagues are essential to achieving our overall mission of caring for the patient. “I’m just covering” turns into “how can I help our patient today,” and the patients benefit at the end of the day.

Conflict Increases Your Workload

 

Can you afford to add more tasks to your day? Do you really want that routine case to take double the amount of time it should? No, right? Your day is already slammed.

Negative interactions with your colleagues not only hamper patient care, but they waste your time. First, there is the obvious. If you’re like me and you have an argument with a colleague, then its going to take you a few minutes to cool down. Are you going to do much productive during that time? Nope. Time wasted.

Second, are you going to work with that colleague in the near future if you need to? You might hesitate if you have a poor interaction with a radiologist and then need a quick chest x-ray interpretation. Might just wait for the report, right?

My previously mentioned Twitter conversation had someone that probably has lived out this reality. Check out this quote:

“Surgeons at my old institution referred to radiologists as “possums”. They lived in the dark and would bite if approached/provoked.”

Pretty sure you’re just going to wait for the report if you think the radiologists you work with are “possums.” Waiting for that report is probably going to cost you some time in the care of that patient. Instead of having the information you need and moving on, you’re going waste time because no one is practicing good internal customer service.

 


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Frustration Leads To Mistakes

 

Now its time for the rubber to meet the road. It’s one thing to have your schedule inconvenienced or to feel upset. It’s quite another to put patient safety at risk. Unfortunately, practicing poor internal customer service does just that.

Remember that example I just gave, where a physician and radiologist don’t want to talk because of a poor interaction? That lack of communication endangers patient safety. The patient safety literature already supports the idea that lack of communication amongst teams leads to medical errors.

As a community, are we OK with that? As a patient yourself, do you want your medical team to avoid communicating with each other? No! You want your medical team working together to provide care for you because you know that anything less is going to result in substandard care. If your medical team doesn’t communicate, then your care might look like this:

(video courtesy of Youtube)

So the next time you are frustrated at that specialist who is giving you a hard time about a consult or you’re nervous that the pathologist is going to bite your head off on the phone, remember we need more customer service in medicine, not less. Even Mr. Bean can figure it out.

Hopefully, I have convinced you that customer service inside of healthcare is actually the most important form of customer service. At the very least, I hope you got a few laughs watching the videos.

Just like we have resolved to provide excellent service to our external customers, patients, in our efforts to provide the best care possible, we must equally resolve to provide excellent service to our internal customers, our colleagues, so we can all provide excellent care to our patients. As professionals, we should demand no less from ourselves.

What do you think? Is customer service a bad word or do you agree we need more? Have you ever been assaulted by a colleague dressed as Darth Vader? Leave a comment and let’s talk about it.

Four Ways to Improve Physician Meetings

I often see physicians on my Twitter account bemoaning sitting through staff meetings. Some of the tales they tell are pretty harrowing. I silently grieved for one group as I read about how their meeting was three hours over time. I don’t like sitting through unnecessary meetings any more than the next guy, even when I’m running the meetings.

Based on my experience with colleagues in the business world and the medicine world, medical meetings typically lack in structure and organization. This meeting dysfunction makes many physicians staff meetings either ineffective or worse, unnecessary.

Physicians already have schedules that are highly compressed throughout the day. Calling meetings that accomplish nothing not only waste everyone’s time, but they erode trust between administration and doctors. Given our current climate of distrust in healthcare, I do not think this is something we can continue to do.

With this in mind, here are four tips that can help you run a better meeting with your colleagues. Feel free to use them at the next meeting you run, or print this out and anonymously leave it on the desk of your boss!

Negotiate the agenda before the meeting

 Staff meetings should not be mystery events where you show up to find out what the next bomb is going to be that will drop. No one trusts a leader that holds back all the information until they absolutely have to give it to you. Meetings are an excellent way to be transparent in this regard.

Meeting agendas should be posted prior to the meeting. Ideally, the meeting leader will request all attendees to send any items they wish to add to the agenda. The meeting leader will individually negotiate any items proposed that are outside the scope of the meeting.

Physicians can then actively participate in the structure of the meeting and not just have the meeting “happen to them.” Hopefully, physician participation leads to greater enthusiasm and a more productive meeting for everyone.

An added bonus of this process is that you will often find that some agenda items can be removed. This has happened for me many times. There may be an item that I think requires group discussion, but the barrage of emails that I get after sending out the agenda indicate that everyone already agrees on the solution. If everyone already agrees about an item, then don’t discuss it further and waste everyone’s time.


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Apply time limits

 

Meeting agendas should not only delineate what items to discuss, but they should state exactly how long to discuss each item. This practice will allow your staff to know what to expect during the meeting and get a general sense of the depth of each agenda item.

Using time limits will also shape how much discussion occurs about a topic. How many times have you been a part of a meeting where a minor point on the agenda railroaded the entire meeting because you talked about it for too long? This is much easier to avoid if the agenda already has the time listed next to each item. If something is only slated to be talked about for two minutes, then cut off the conversation at two minutes and move on.

Agenda time limits can take some adjustment for some groups. I recommend giving warnings at one minute or two minutes so everyone knows where you stand. You may have to even cut off a few conversations without making decisions at first. However, once your staff gets the hang of it, then they will be able to tell when it is time to make quick decisions and when it is time to discuss at length.

small meetingLimit meeting size

 

As meeting sizes increases, the productivity of the meeting goes down. This is true across all industries. Medicine is no exception.

I don’t like strong arm tactics, but this is an area where you should be militant. Do not invite people to meetings that don’t need to be there. If people are at a meeting unnecessarily, then ask them to leave.

There is no need to be rude about this. When I have to explain this to people that I am kicking out of a meeting, I explain it in terms of their personal productivity. What is the best way for them to use their time today? Sitting in a meeting where they are not going to participate or providing clinical care?

Most physicians will appreciate this gesture. I have never met a doctor that does not have some type of work to do. If it is a better use of their time to see patients or attend to clinical duties rather than being in the meeting, then that is what they should be doing.

Steve Jobs was famous for using this practice at Apple. There are some pretty entertaining stories of people being removed from meetings who had no idea it was coming.
His explanation, however, was directly in line with my thinking. I hired you to do a certain type of work. It is best if I do not distract you from doing it as much as possible.



Build in flex time

 

As good as you are as a leader and as well as you apply the above principles, unplanned things always happen in meetings. So…plan for that. I never run a meeting where the time limits on the agenda add up to the entire length of the meeting. For example, a 60 minute meeting always has 50 minutes worth of agenda items and 10 minutes of flex time.

You can use this flex time for any number of things. I typically use it for questions at the end of the meeting. This is a great way to give staff access to administration for any pressing matters. This will also give you time to discuss something that may have come up in the meeting, but it was not already on the agenda. If the questions that come up more of a personal nature, and don’t forget to cut the other staff members loose so they don’t have to listen to someone else’s personal questions.

The most popular use of flex time is to end the meeting early. Remember that ending a meeting early is never a bad thing. You will likely increase your popularity as a leader if you do this often.

Sometimes, it is even necessary to end a meeting early before all the agenda items are discussed, especially if you determine that you do not have the people or resources needed to make decisions about the agenda items. Never be scared to do this. As a leader, you need to respect both your time and the time of your colleagues. They will appreciate you for it.

I’m hopeful that following these tips will lead to fewer horror stories from my colleagues and honestly, less meetings doctors have to attend. Doctors really do tend to be happier when they focus on clinical care. That’s what they signed up to do. Let’s make staff meetings help them in this mission, not hurt them!

Let me know some of your best meeting stories below. Have you been a part of a particularly painful meeting? Do you have any funny stories about your staff meetings? Share in the comments!


Physicians Guide to Conquering Clinical Quality Metrics

I can think of no more well received topic amongst physicians than clinical quality metrics. Whenever I walk into a cafeteria or social event, quality metrics is one of my go to topics to lighten the mood and get everyone smiling.

OK, that’s a complete lie and all of you know it. However, that doesn’t diminish the importance of this topic. The number of metrics in healthcare has exploded over the past few years. They range from the essential to the absurd, and I’ve had a little fun on my Twitter account recently commenting on this.

The reality remains that metrics are not only increasing in our daily lives as clinicians, but they are starting to affect our wallets as well. I would venture to guess that a majority of you reading this now have some type of clinical quality metric that figures into your paycheck.

Once something starts affecting my paycheck, then you better believe it has my attention. As I’ve stated before, my goal is FIRN, so I cannot afford to have someone shaving pennies off my hard earned dollars.

My goal with this article is to give you some basic principles to apply whenever confronted with a clinical metric, not go through the ins and outs of all the different Medicare measures out there. I will readily admit that I am one of these weird physicians that enjoys this kind of stuff. Many of you are probably normal human beings that would be perfectly happy if this isn’t a part of your day. So, if you simply want to leave a snarky comment at the bottom as a means of taking out aggression, then please be my guest.

With that, let’s get started. I focus heavily on the mission whenever answering a question, so let’s start there.



Clinical Metrics

The Purpose of Quality Metrics

So, why are we doing this stuff? No, it is not as a means to pay doctors less money, despite what many may think. The reason we follow metrics is to improve the quality of care we provide. No improvement happens without first measuring what you want to improve. Clinical quality metrics are the first collective step in that process.

Most clinicians want to improve healthcare quality. On average, physicians are honorable professionals that want to do their best for their patients. They would gladly put in the work to improve their patients’ blood pressures or lower their patients’ collective risk of surgical site infections.

The disconnect occurs, however, in how the measurement process works and whether measuring things really leads directly to improving them. Many physicians feel that the steps required to collect and report clinical quality data are too onerous and take up inordinate amounts of their time (they’re right by the way and we’ll discuss how to spread the work around later).

Healthcare is still in the process of determining whether all of this measurement is beneficial to patients on a broad scale. From my vantage point, this depends heavily on what metric you pick and what resources are available to improve it. I think we are often guilty of trying to hit home runs in this arena when singles and doubles can score runs.

You can get tangible results by improving the colon cancer screening rate. A solid single. Cutting the thirty day readmission rate by fifty percent may be a home run but is a much tougher goal. This leads me to my next tip…

Picking the Right Metric

If you want to meet a metric, then pick one you can meet. It doesn’t get more obvious than that, but many fail to understand this. If you are already a physician administrator, then this is where you come in. You need to be able to explain to your non-clinical team that setting the goal of 100% of patients having a systolic blood pressure less than 130 is flat out impossible. Just like goal setting in any other realm of life, picking the right metrics to focus on should involve shooting for something that stretches you but won’t break you in half.

In addition, try to pick metrics that are actually meaningful. Picking some meaningless goal like “we will check blood pressures on ninety percent of our patients” is easy. Professionals want to be challenged, however, and will revolt against pointless work.

For those of you not directly involved in picking the quality metrics that your organization focuses on, you have two options to provide input. One is find the physician that does have direct input in the process so your voice can be heard. The other is to become the physician that gives input into the process. As I said before, your paycheck probably depends at least in part on this process. I prefer to be sitting at the table when the meal is served, and I suggest you do the same. I have done both of the above tactics in my career, depending on what my position in the organization was at the time.

Clinical MetricsKnow The Inputs

Once you have a metric picked, then you need to know exactly what the metric entails. Things seem very simple when sitting at a conference table, but they quickly become more complicated when you are back in the clinic seeing patients and trying to meet your goal.

Your electronic medical record (EMR) is intimately involved in this process, so plan to collaborate with your IT people or EMR vendor.

It’s probably easiest to use an example here so let’s suppose your clinic has decided to focus on your diabetic patients, and you want to get 80% of your diabetic patients to an A1c<9. Right off the bat, here are a few questions I would ask:

  1. Will ICD-10 codes identify diabetic patients or something else (i.e the EMR problem list)?
  2. If using ICD-10, which codes are we including (i.e what about the steroid induced diabetes folks etc)?
  3. Can patients be “cured” of diabetes? How will we figure that out?
  4. How do we track patients that have A1c’s done outside our healthcare system? Is someone going to manually enter these in the EMR or manually add them into the final calculations?
  5. Will both point of care A1c’s and serum A1c’s be included? Will the EMR capture both?
  6. Does the final A1c number of the year count or the average A1c?
  7. Will you be penalized if you go too long without measuring an A1c?
  8. Who are “your” patients? Is it the person that orders the A1c, the person that saw the patient last, or the person listed as the primary care?
  9. Do patients that move, change providers or get lost to follow up during the year still count?
  10. Do patients on hospice count?

A “simple metric” gets very complicated very fast, doesn’t it? Someone with a clinical background needs to be asking these questions, however, if you want to be successful. Knowing all of these details will allow you to take your next step in conquering a quality metric, building a systematic approach to success.


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Using Systems to Meet Metrics

Physicians cannot meet quality metrics by themselves. This concept is so important that I’ll say it again. Physicians cannot meet quality metrics by themselves. Systems of care meet quality metrics. Quality metrics are a means to improving systems of care at the end of the day. Physicians are essential to this system but are not the entire system.

This systematized approach happens at both an organizational level and an individual practice level. Let’s return to our A1c example from earlier. If trying to tackle this from an institutional level, I would address several items:

  1. Easy availability of A1c testing (lab availability or point of care testing)
  2. Technology transfer between health systems to obtain A1c data
  3. Working with EMR vendor to run periodic reports and ensure appropriate data capture
  4. Ensure appropriate diabetic referral resources available

As a provider in my daily practice, I would focus on different aspects of my individual system of care:

  1. Establish nursing staff protocol for nursing to test patient’s A1c’s automatically when due
  2. Establish or improve relationship with Endocrinology or clinical pharmacy to ensure quick patient access when needed
  3. Ask administration to give periodic updates on our numbers. Request real time data access if possible. Send the data to your staff so they can schedule appointments or deploy more resources for individual patients.
  4. Have front desk staff ask all diabetic patients if they have had labs drawn at other facilities. Get release of information on the spot for anyone that says yes.

As you can see, the scope of each approach is different but the concept is the same. You have to modify the system of care, not rely on one person (i.e the physician) to collect, analyze, and act on the data. The organization that can best implement systems at multiple levels instead of simply relying on doctors to do all the work will always win, and these doctors will not feel the onerous burden of meeting metrics by themselves.

healthcare administratorThe Evil Administrator Myth

Lastly, I want to tackle one common misconception that I constantly hear from physicians in regards to clinical metrics. I enjoy hearing physicians say things like,”This metric is just a way to cut into my paycheck,” or “I guess we’re not meeting the budget so they put in a few more metrics.” While I can’t speak for Uncle Sam’s motivation when it comes to implementing clinical quality metrics, I can tell you that the administration in your organization wants you to meet your metrics.

It is worth a lot more money to provide measurable, high quality care than to use metrics to deny doctors part of their salary. Number one, it makes for excellent marketing. If every primary care doctor you had controlled 100% of their diabetics, would you put that on a billboard if you were the CEO? You bet you would. More patients then come to your clinic, and everyone makes more money.

Second, meeting quality metrics produces improvements in staff morale.. There is a palpable improvement in the esprit de corps of a group when they meet a goal. Recognition for achievement will compound this effect even more in a group passionate about the cause. Healthcare professionals fit very well into this mold. Do these motivated groups then produce more? They do indeed. Every administrator on earth wants to improve the productivity of their people, so I promise, any administrator with sense is pulling for you (I hear you laughing back there!).

So, what do you think? Are you ready to conquer the clinical metric world? Do you still not care about this stuff at all? Does your boss need to read this article? Let me know what you think in the comments below. Remember that, at the end of the day, its still a great job to be able to take care of patients. Don’t let numbers on a page change that. But, if some numbers on a page can help you do a better job, then let’s do it!

Three Keys to Physician Negotiation

One of the most important career skills in any industry is the art of negotiation. There have been many books and articles written on this topic, and it is not my intention to cover negotiation in its entirety. 

Based on my experience negotiating things from service line agreements to compensation packages, there are three aspects of physician negotiation that I’d like to cover today. These apply to physician negotiations in any setting from private practice to military medicine (or negotiating with any other professional for that matter). Use them and you too can write a best selling negotiating book and become President (the reference was too good to pass up). Ignore them, and, as our esteemed President says, you’re fired!


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Good Faith

The fine folks over at Harvard Law School define good faith negotiation as “to deal honestly and fairly with one another so that each party will receive the benefits of your negotiated contract.” In short, negotiating in good faith means that both parties negotiate honestly with one another with the intention of reaching a mutually acceptable agreement.

You will find many instances of career blogs or journals suggesting that job candidates of all stripes, including physicians, should negotiate a job offer with an employer solely for the purpose of learning about the job market or using the offer as leverage in another negotiation. As the guy often sitting on the other side of the table during that negotiation, I can tell you that is bad idea. 

I’m not suggesting that you have to talk to one potential employer at a time or that you can’t use another offer you’ve received when sincerely negotiating with someone else. I can absolutely tell you, though, that it is not that difficult to spot someone who is going through the motions with no real intent of considering the position.

Not only is it flat out rude to waste everyone’s time and energy negotiating an agreement that you have no intention of considering, it is also detrimental to your professional reputation. Physicians managers absolutely talk to each other, especially in our local community. I have seen it happen where a physician has been found out trying to do this. Even if you are not found out during the negotiations, your reputation will follow you in the future.

This becomes even more true if you are negotiating with private practices about joining their group. As someone who hires for a larger organization, I may be annoyed with you but I will usually move on to the next candidate that my HR department has found for me. A private practice, however, who has spent considerable time, money, and effort recruiting you and getting you to the negotiating table, will likely be much more vindictive if you go all the way through the process to the end just to sign with the rival group in town.

Negotiation

Know What You Want

There is nothing more frustrating then trying to pick a restaurant for dinner with someone who has no clue what they want. Well, I take that back. The only thing more frustrating is someone who constantly changes their mind after supposedly making a decision.

Negotiation is no different. A good negotiation is contingent on both sides coming to the table knowing what you want. Not only does this make the process faster, but it also helps both sides get what they want out of the deal.

I’ve been a part of negotiations with physicians that have left me wondering if they had thought about what we were discussing at all before the conversation began. While negotiating with a new hire, I have had a physician literally try to figure out if they wanted to work part time or full time while negotiating salary. After providing two separate packages for part time for full time work, the physician began to negotiate each one separately, bouncing back and forth depending on which was the flavor of the minute.

Needless to say, I have no intention of negotiating two compensation packages for the price of one, and I halted the process until they could definitively tell me what they were after. I never hired that person, and have not heard from them again.

Even if I had remember them, however, it is very unlikely that they would have gotten the best deal out of me. I had already spent so much of my time and energy, that I was not inclined to haggle with them much more. There is only so much capital you have to spend in each negotiation. Know what you want and you can spend wisely to get what you want. Walk in clueless, and prepare to hear that a lot of things have suddenly become non-negotiable.



negotiation

Show Your Ethos

While my first two keys can be used by anyone when negotiating, this last one is specific to physicians and handful of other professions. As a physician myself, there is a certain ethos or characteristic spirit I expect to see in other physicians. A negotiation with a physician should be palpably different from a negotiation with a CEO, accountant or any other person.

I see physicians all the time that try to mimic some of the negotiation tactics they see other professionals use. I always tell anyone that will listen that your best tactic as a physician is to insist from the beginning that you are different from all of these other people. No one else has signed up to do the job you do. No one else will gladly be stopped in the grocery store for medical advice for free. No one else will sit at a patient’s bedside for as long as needed until they are cared for.

The way you conduct yourself at the negotiation table should reflect this inherently honorable aspect of being a physician. This should not only manifest itself in how you treat your negotiating partner, but it should also affect the subject matter that you discuss.

Everyone wants to discuss compensation when negotiating a new job, and physicians should absolutely strive to be paid what they are worth. No one expects less. The best hires I have ever made, however, never started with compensation. The best physician negotiators always started with something that displayed their ethos first.

I have seen one physician start out by negotiating how much free care he could provide if he had patients in need. He suggested a reasonable amount and then asked for a percentage of his own salary that he could throw in to help patients if needed. I hired him.

I had a physician ask if he could take a certain amount of his salary and pay it out to his staff as bonuses for excellent patient care. I hired him.

I had another physician negotiate a set amount of time where he could provide free lectures at events to benefit the local community. I hired him.

In many of those cases, these physicians asked me for more money above my initial offer. In each case, I gave it to them with minimal discussion. They were so impressive in how they conducted themselves and displayed their professional ethos that I had no doubt the extra money would be worth it to retain them. And so far, that has held true.

I’m interested to hear your stories about your negotiation experiences. What are your best negotiation tactics? What are your most awkward or strange experiences? Leave a comment below so we can talk further. Many become unnerved when the time to negotiate comes but if you keep a keep a clear head and represent what you stand for, then you will be just fine. Now, go out and get what you want!

I Love To Tell the Story

For those aspiring to be leaders in medicine or even have some influence over the operations of your clinic, you will have to know more than when to increase someone’s insulin. You will need to tell the story.

A hallmark of a good leader is the ability to express a narrative. A leader will not just tell his people what to do, he will tell them why they are doing it and the broader context behind why they are doing it. And if he’s really good, then he will do it in the context of a narrative that inspires and points to a noble mission.

Preventing the Turtle Response

This skill is especially important for a leader looking to introduce change. Physicians, in particular, can be a very tough audience to change. Given the current dynamic environment in healthcare, many physicians have taken to turtle mentalities where they retreat into their shell and resist any change that comes their way, no matter what the potential benefit to them is.

A competent physician leader will be able to coax their staff out of their shells and explain how change benefits them and the organization as a whole. Connecting change to the greater purpose and direction of the organization will give you the best chance of eliciting buy-in for the change you are trying to implement.

I have too often seen leaders elicit directives to physicians with minimal effort to tell the relevant story around why a decision was made. These “edicts” are always met with resentment, and in the absence of any narrative, physicians will fill in their own narrative that often assumes the worst intentions.


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The Angry Colleague

I can recall a particular example where it was necessary to change several physicians’ clinic grids. The clinic’s wait time for new patients had grown too long, and these particular physicians had not been seeing new patients recently. The situation was especially challenging because these were senior physicians in the group that had effectively pushed the responsibility to see new patients disproportionately onto the younger physicians in the group.

I made the mistake of sending an email with my decision first and then following up in person a day later (rookie move). By the time I was face to face with them 24 hours later, they had officially declared World War III. In their mind, I had switched from their colleague to a worthless bean counter with no regard for the many years of hard work they had put in. 

As I sat down, the most senior physician opened the conversation by angrily demanding why they were seeing new patients when the younger physicians needed to fill up their panels. He then started to rapid fire questions at me. Are the younger physicians lazy? Do we need to find better junior colleagues? It was not going well.

After he finished speaking, I paused for a moment to collect my thoughts and then asked a single question of him.

“Why have you worked so hard for so many years at this clinic?”

He was taken aback at this, but after a moment he answered.

“I became a physician to help my patients and community almost thirty years ago, and I expect others here to do the same.”

“Perfect, I said. I agree. Now, how are we going to achieve our common goal of helping the patients in our community if we can’t even get them in to be seen?”

There was much conversation that followed, but ultimately, the senior colleagues agreed to the schedule change. It could not have been done by forcing it on them and walking away. Tapping into our common mission and common narrative around that mission was the only way they would agree to get on board. If you are looking to lead in any realm at your clinic or hospital, then you can’t afford to do any less.

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