Brain, Brawn And Building Strong Character

There is a strong relationship comparing sports to the military, business, and also to medicine.  Young athletes, in their late teens and early 20s, are mostly brawn and use their strength and speed to achieve success early in their professional careers.  As the athlete matures in their late 20s and early 30s, the physiologic processes slowly decrease and efficiency and maturity and other cerebral skills emerge.  There are 2 rainbow arcs that describe this brawn-brain interaction.  The arc of brawn rises earlier than the arc of brain-based skills which appear later only when brawn starts on its downslope and intersects with the rising arc of experience that peak performance occurs.

The same 2 arcs probably take place in every medical doctor’s career.  Young doctors are full of energy and knowledge.  It is only after years in practice that the doctors develop maturity of their clinical skills that makes them peak performers.

When I was a newly minted urologist in 1978 I was referred a Crohn’s patient who complained of foul smelling urine and passing “bubbles” in her urine.  I worked her up and diagnosed a colovesical fistula.  I called the referring doctor and told him that I could surgically correct this with the assistance of a general surgeon.  The gastroenterologist said, “Neil, I am going to do you a favor and not allow you to operate on her.  She has terrible nutrition and has a history of multiple fistulae and would not heal and she would likely be made worse by the surgery.”  What a valuable lesson that was helpful in my early maturation as a physician.  I was able to learn that I couldn’t cure everything and that were times when keeping the scalpel on the shelf was in the best interest of the patient. 

I think part of our medical education is to learn our limitations.  My best lesson I learned was to always think of our actions appearing on the front page of the paper or on 60 Minutes.  Always ask yourself, “Would I want my decision to appear in public?” or “Is this decision or action in the best interest of the patient?”  If the answer to both questions is yes, you will not be making an error where your brawn gets in the way of your brain. 

 

Color Of Pills May Make A Difference In Patient Compliance

One of my friends, Dr. Aaron Kesselheim, at Brigham and Women’s Hospital and Harvard Medical School recently reported that patients seem less likely to take their medications if the pill color changes between prescriptions, which can happen when switching from a brand name to generic drug, says a new study. Currently, the U.S. allows cheaper generic drugs to be sold to patients after a brand-name counterpart’s market exclusivity ends. The U.S. Food and Drug Administration (FDA) states that generic drugs must be essentially as effective as the brand-name drugs, but may be different colors, shapes and sizes. One reason for the same drug having different appearances is that brand-name manufacturers may claim legal ownership of their drugs’ physical appearances.

That confusion may lead to patients being unsure about their medications and end with them not taking the drugs.

The researchers used a national database of medical claims from the early 2000s to compare people who got their seizure drugs refilled on time to those who did not.

Overall, they had information on about 61,000 people who were taking one of eight drugs, which were offered in 37 colors and four shapes.

The researchers found that changes in pill color between prescriptions rarely occurred, but there was a difference between those who filled their orders and those who did not.

Of the approximately 11,500 people who did not fill their prescriptions, 1.2 percent had their drugs change color. That compared to 0.97 percent of people who got their prescriptions filled on time.  Not very impressive numbers but with the millions of elderly patients, the impact can be significant.

Dr. Kesselheim points out that if patients are taking nine medicines, they get at least 36 ‘opportunities’ a year to experience a color change. This seemingly small risk then starts to appear very substantial. A patient taking five medicines twice a day, each produced by five different generic manufacturers, theoretically the patient faces over 3,000 possible arrays of pill appearances a year for what are, chemically and clinically speaking, the same drugs.

Perhaps equivalent generic medicines should be required to look like their brand-name counterparts.  Dr. Kesselheim said that until there is a better solution, it’s important for patients to know that a pill’s clinical impact doesn’t change just because it looks different.

SOURCE: http://bit.ly/W1EWU3, and JAMA Internal Medicine, online December 31, 2012.

The Importance of a Timely Note

Lou Holtz Coached At Notre Dame

In my medical practice, I’ve used note writing extensively, to communicate with patients, with families of patients and with referring physicians.  And yet, when I received a note, which is not related to patient care, it is always a little surprising and uplifting, and emphasizes why note writing (and note receiving) is so appealing.

In this Internet age and the age of information, we are bombarded with electronically conveyed messages, television and radio broadcast, faxes and even computerized bulletin boards.  There’s a generation of young people that do nothing but text each other and seldom make use of the phone or face-to-face interactions with peers and friends.  A hand written note is now a rather novel, and therefore, powerful method of communication.  It tells the recipient that you thought about them following your face-to-face or telephone encounter.  A note tells the person you value them and allows you to reinforce the points discuss during your encounter.  Let me give you an example.

Several years ago I had the pleasure of a five-minute meeting with Lou Holtz, who at the time was the head football coach at Notre Dame.  One week after meeting the famous coach, I received a personal note from him, acknowledging our meeting and highlighting several points we had discussed, including our mutual interest in motivating others to reach their full potential.

I called Coach Holtz and asked him how he was able, with his busy schedule, to not only find time to write such a personal note, but to remember details from our brief conversation.  During our subsequent conversation, Coach Holtz revealed some of his note writing secrets, and illustrated how notes can have a similar empowering impact on people in your life.  We covered the following points:

To whom should you write?  Coach Holtz suggests writing to anyone to whom you want to express thanks, appreciation, congratulations or acknowledgment. Coach Holtz writes his barber or a waitress if he is receiving good service.  If someone goes the “extra mile” for Coach Holtz or his family, that person receives a personal note.  Coach Holtz is so committed to note writing that he encouraged his coaching staff and all his players to write at least one note a day.

How do you remember to whom you will write?  The best way to remember seems to be to write yourself a note!  I use a cell phone and a free app, Dragon Dictate, to record notes and reminders to whom I will write.  When you write or dictate the names of people to write, you can also record a key word(s) that will jog your memory later about your conversation.

How long showed your no be?  According to Coach Holtz the shorter, the better.  The person to whom you are writing may be overwhelmed with junk mail, faxes and letters that must be read and respond to.  If you’re note is short, you can be sure that your note will be read.  A long letter may be skimmed over, as the reader feels pressed to get on to other tasks.  A concise note delivered in a timely fashion is better than a longer note that takes days or weeks to arrive.

In addition, Coach Holtz recommends brevity and relevance.  Don’t ramble.  Be personal and sincere.  The best style is a simple, conversational manner.  Unless you are generally a formal person, avoid formalities such as “I’ve acknowledge the delivery of your parcel” or “It was indeed a pleasure to have made your acquaintance.”

What should the content of your note include?  You want to immediately grasp the attention of your reader.  Coach Holtz suggests that the first sentence give the reason for your note.  He usually begins his notes by simply stating, “The purpose of this note is…” or “I just wanted to say thank you for…” and then give the specific reason he’s writing.  You might not begin a note this way, but Coach Holtz is a direct and honest man, and his opening fits his personality.  When you write a note of appreciation or thanks, you’ll want to do it any style that’s yours and with which you are comfortable.

Why is timing important?  As with all forms of communication, promptness is important.  The sooner your note is on the desk or in the hands of the person to whom you written, the greater is its impact.  Think of the difference between and note arriving 1- 2 days after you communicated with someone, and a note arriving weeks or months later.  If you’re serious about incorporating note writing into your business or into your personal life, you will have to prioritize and organize your day’s activities to make time for it.

Why are timely note so important in building your network?  Social psychologists report that written communication is one of the best ways to enhance a relationship.  Everyone enjoys receiving mail, and the thoughts enclosed in a timely, appreciative note can be read and savored her for a long time.  My encounter with Coach Holtz underscored for me why so many business people and professionals should make use of timely notes.

Coach Holtz believes that the few minutes you take each day to write a note of thanks, congratulations or acknowledgment to a friend or colleague is in investment in your friendships and in your business or professional practice.  Networking is predicted to be the contact sport for the new Millennium.  My encounter with Coach Holtz emphasized that successful professionals, whether in coaching or medicine, have discovered the importance of a timely note.

The thank you note I use is a “Thanks a Million” check shown in Figure 1.

Figure 1.

Thanks a Million Check

Is Your Desk Creating a Good Impression of You and Your Practice?

What is your impression of an airlines when you sit down and open the tray on the back of the seat in front of you and find food and coffee stains on the tray?  You may just worry if the same attention that was given to tray tables carries over to the maintenance of the engines.  Or what is your opinion of a restaurant when you go to use the restroom and find paper towels and toilet paper on the floor and puddles of fluid around the urinal?  You may just question the hygiene that takes place in the kitchen.  Well those same impressions that you receive in other service industries, may also take place in your office.

For the most part, patients do not go into a physician’s private office.  However, they, on occasion, will be invited into that office or often they will walk by the office and look inside.  What impression are you creating if you have papers strewn over the desk, journals stacked high on the desk or on the floor, and post-it notes attached to the computer, the phone or desk lamp?  Your office desk says a great deal about your level of organization, your habits, and your attention to detail.  Also, what does a cluttered desk say to your employees who will almost always see the interior of your private office?

I suggest that we give the same attention to our desk as we do to detail of our performing a careful history and physical exam.  First of all, you can rid your desk of a great deal of paper if you go through your mail and take action steps on each piece of mail, i.e, that which immediately goes into the wastepaper basket, that which must be addressed immediately, and that mail which can be reviewed at a later date.  You can also have three baskets on the desk or the credenza behind the desk: one for what needs action on today, another for 2-4 days, and the third for at a later date.

I take care of the first basket before I leave and as much as the second basket as I have time for. I also have a call-back sheet prepared by the nurse or the receptionist that I check at the end of each day and make notes about the phone responses.  I have a task icon which is also on my EMR making calls and recording actions taken or discussed a part of the EMR, which improves patient safety and good medial-legal protection.

These are only suggestions that have worked for me and my desk.  Of course, if you have other ideas that work for you, please share them with me.

Bottom Line: We are in the business of providing health care.  But we are also in the first impression business and we have to create positive impressions on our patients.  Start with your desk and make sure it reflects your attention to detail and your ability to be organized and clean.  Your patients and your staff will appreciate you for this.

Creating A Positive First Impression

I have heard since I was a little boy how important first impressions are and why it is important to smile and look someone in the eye when you say hello.  I was alos instructed  how important a firm handshake is to creating that first impression.  So how can doctors create that first impression for their patients when the doctor doesn’t see the patient until well into their experience with the practice and the staff?

There’s a lot to be said for first impressions. Scientists say they are made within the first three seconds of meeting someone. We  form our initial opinion of just about everything — a new song, a new place, a new person — in those first three seconds, our senses working in harmony or disharmony.

So here’s a short multiple choice quiz. When do your new patients form their first impressions of you?

A. When you enter the exam room

B. When you introduce yourself

C. When you shake their hand

If you answered A, B, or C, you are wrong. Sorry for the trick question. Each patient makes her first impression of you before she even sees you. There are at least three important opportunities for you to make a good impression before you first meet your patient. Each has the power to affirm a patient’s hope that you offer the answers she seeks or make your encounter an uphill event. If each of these three moments of truth is positive, your patients will have a positive first impression of you even before laying eyes upon you.

This is simple stuff, but it is the stuff we trip over every day.

1. The first first impression — the appointment

A patient’s initial contact with your practice often is by phone. If the patient is greeted brusquely with a “hold please” or has to navigate a list of ten options, or is transferred more than once when just trying to make an appointment, this first impression will be negative. Anyone who answers your phones or makes your appointments must be friendly, professional, and organized.

Friendly, because we are in the caring business; professional, because your staff is an extension of your credentials and training; and organized, because making an appointment should be straightforward and clear.

2. The second first impression — the reception area

Patients also take their cues from the “vibe” of your reception area. That key interaction occurs when they walk into your office for the first time. It happens very quickly. If your waiting room conveys friendliness, professionalism, organization, and neatness, it will be a positive moment of truth.

• Friendliness. Your reception area should be inviting rather than imposing. Patients should feel welcome. A receptionist’s opaque window obscured by tattered notices, “cold” colors, a chipped counter — patients take their initial cue very quickly so make sure it is positive.

• Professionalism. Patients are turned off by soiled carpet, worn-out fabric on chairs, and mismatched furniture. In the mind of a patient, a dirty waiting room raises concerns about the attention to detail of your practice.  Just as passangers on an airplane make assumption about the maintence of the engines when they see dirty drop down trays.

• Organization. A disheveled reception area is a clue to a disheveled practice. Is yours full of old magazines, empty literature racks, and pharma rep propaganda? I hope not.  Patients don’t like to see dead plants or dead fish!

• Neatness.  Most practices have employees check the reception area several times a day for coffee cups that were left behind, magazines that have ended up on the floor, etc. If your reception area looks like a bus station with unbroken rows of chairs, it will leave a poor first impression.

3. The third first impression — the greeting

The first person to greet the patient may be the receptionist or the medical assistant.  Their greeting should be warm, kind, and inviting.  You want to give every patient a positive experience and make every patient feel like a MVP or most valuable patient.

Bottom Line:  You don’t get a second chance to make a good first impression.  Make each of the three encounters count before you, the doctor, sees the patient.

This article was inspired by Lucien W Roberts in Physician’s Practice, October 2012

Disaster Planning-Every One Take Cover

Seven years ago I experienced the wrath of Mother Nature when Katrina devastated the Gulf Coast.  My office experience significant problems and I was not able to return to practice for nearly twelve weeks.  I wrote a book, Disaster Planning For The Healthcare Professional (Jones and Bartlett, 2007) about that experience.  The recent havoc caused by Hurricane Sandy impressed me once again that we are seldom ever secure from a disaster that can impact our medical practices.  Also the complexities of computer technology, which we are all very dependent on, leaves us very vulnerable to loss of data and insertion of barriers to practicing medicine right after a disaster.

After years of discussion about disaster recovery and business continuity best practices—with events such as Hurricane Katrina in 2005 and the massive Tohoku earthquake and tsunami in Japan in 2011 serving as exclamation marks—prevailing wisdom would dictate that businesses would adequately prepare for disruptions and ensure that IT systems are designed to avoid downtime, as well as security breaches.

Here are a few suggestions you should consider when developing a disaster recovery/business continuity plan:

• Have an emergency power source available. It’s impossible to operate computers systems without electrical power. Many practices affected by Katrina and Sandy weren’t physically damaged, but they couldn’t operate for days because power remained off. 

Most practices, particularly small medical practices, have no generator or backup power supply available and no contingency plan for power outages. Unless the business can switch over to another data center, this renders the practice and its computer systems useless.
• Ensure backup Internet connections exist. It’s critical to have multiple Internet connections in place. This might include any combination of fiber, cable, T1 lines, satellite and DSL. That way, if one or two connections fail, another is likely to work and provide baseline service. The ability to stay online can determine whether a business muddles through the disaster or stumbles.
• Develop a communication plan as part of business continuity. Many practices have a practice continuity plan in place, but in a disaster, everything goes out the window. It’s vital that staff, can reach one another. 

Cloud-based and hosted communications systems may prove particularly valuable. However, it also means maintaining a current phone directory and phone tree, as well as having a system in place to send group messages and alerts. It might also involve using GPS and social media tools to locate people.

 

• Beware of the risk of data and security breaches. As businesses come back online after a disaster, it’s crucial to guard against data breaches. “Executives must not let their guard down. Scammers, data thieves and others may use weak links in security and business practices to grab private data. This includes social security cards, credit card numbers and other records that may be sent to insurance companies, government entities and others. 

 It’s also important to remain vigilant and use all possible protections.
• Lessons learned from Hurricane Isaac  We did everything on our checklist for on our disaster plan.  However, we didn’t move the refrigerated medications out of the office.  We were out of the office for five days and we had to discard all of the refrigerated medications.   Neither the pharmaceutical companies nor my business disruption insurance replaced the medications.  This important step has been added to our disaster plan checklist.  A checklist is always an activity under construction.  It’s never final.

Bottom Line: Disasters can impact any practice.  It isn’t just hurricanes that can cause havoc with your practice.  It’s also data theft, power outages, and fires that can cause loss of data that can bring your practice to a halt.  Take time to develop a disaster plan and then update it regularly.

 

Reputation Management-Easier Than You Think

Existing and potential patients can do more than ask friends and family about you and your practice.  Now they can go online and read what others are saying about you.  Interestingly enough, you can have an element of control on your reputation.  It is true that you can’t control everything said about you, you can set the scale of favorable vs. unfavorable comments in your favor with more positive comments than negative ones.

How?

Most online directories allow users to leave reviews about their experience with you and your practice or businesses that they have had an experience with.  It is as easy of just asking for a favorable review.  You can ask for reviews in a polite way.  If a patient mentions something of worth or value, ask them if they would submit their comment to the review site.  Make it easy for them and provide them with the URL of the review site so they can paste it into their browser and easily make a favorable comment.  You can also start with patients in your database that you deem likely to make a positive comment about your practice. 

An easy way is to send patients a post-appointment follow up E-mail requesting a review.  You can thank the patient for coming in, ask them if they have any comments or questions for you, and end by asking for a review.

A sample E-mail to a patient you just saw might be:  “We appreciate your choosing us for your medical needs.  We always strive to provide you with outstanding service and see you in a timely fashion.  We also want to assure you access to our practice with same day or next day appointments for your urgent or emergency needs.  We would like you to share your experience with others by leaving a review with XXXX.com.  Thank you and we look forward to seeing you on your next visit. 

 

Bottom Line:  Online reputation management is going to be an important aspect of any medical practice.  Move the balance scale in your favor by requesting positive reviews.  It’s easy.  Remember, “ask and you shall receive!”

What goes around comes around

I was asked to participate in a legal panel against one of the local physicians in my community.  The panel determined that the physician did not deviate from the local standard of care and the panel unanimously concluded that he met the community standard of care and was not negligent.

After the panel met late in the afternoon, I put in call the same evening for the physician and reported to him the results of the panel.  The doctor said that this was the first time a colleague ever called to notify him that he was exonerated and that even his defense attorney who attended the panel meeting did not give him a call.  He said the call was most appreciated and he was so relieved to hear the favorable outcome.

Bottom Line:  Many of us are going to be asked to weigh in on the clinical actions of our colleagues.  For the most part our colleagues will be vindicated.  However, our colleagues will be anxious and concerned about learning the outcome of the panel.  It is such a nice gesture to give them a call and inform them as soon as possible of the results.  Perhaps when the situation is reversed, they will do the same for us.

Closing the Office For Lunch? Forget About It

I have watched more offices over the past few years close their phones and front desk during the lunch hour. If you close your office for an hour at lunchtime, what message are you sending your patients?  You are declaring that serving your patients takes a back seat to serving yourself and your employees.  Closing your phone lines at lunchtime means that you are creating missed opportunities for a vital 20-25% of your business day.  Remember that a significant number of your patients are gainfully employed and they cannot make calls between 9-12 or 1-4 and the only time available to them is during their lunch hour.  There are going to be a significant number of patients who can only come to the office during their lunch hour and patients will be shunted to practices that are open for business during the lunch hour.

I know that I got push-back from my staff when we decided to keep the phone lines open and be able to see patients during the lunch hour.  My staff have developed camaraderie with each other and enjoy the time together when they are “off the stage” and able to kick back with each other or with a drug rep who often comes to sponsor a lunch.  However, our practice has a production based bonus plan and in order to reach the benchmarks, we need to be able to attract new patients and keep the ones we have by offering lunch time appointments.

How we do it?

We have eight employees and we stagger the lunch with 4 eating lunch and 4 either answering the phone or assisting with patient care.  We use the lunch time to see new patients who want to be seen that day or we see emergencies or urgencies during the lunch hour.  There are usually two patients who meet these criteria and are delighted to have this kind of access to the practice.

Once a month we have a staff meeting and we place the phone on the answering service with a message to the service that if there are emergency calls, they are to contact us on our “back” line.

As a result we are able to see 10-12 new additional patients or urgencies or emergencies each week.  You can do the math and see how this enhances our bottom line.  As a result we have patients who recognize our commitment to patient care, patient access to the practice, and that we place patient needs before our own.  We believe this change has resulted in minor adjustments on the part of our staff but the improvement in productivity and ultimately in staff bonuses have more than compensated for the small sacrifices that the staff have made.

Bottom Line:  Look for ways to be of greater service to your patients.  Modifying your lunch hour is one easy way to be more productive and provide greater service to your patients.

 

When Your Cell Phone Goes MIA

Is there a sicker feeling when you can’t find your cell phone?  I think I’d rather lose my wallet than my cell phone.  Approximately 1 out of 4 cell phones are lost or stolen every year.  If you check the lost and found of any bar or restaurant and you’ll see that it’s not uncommon for people to simply leave their phones behind when they’re out and about. Perhaps advice on alcohol consumption would be one of the caveats about avoiding leaving your cell phone behind.  Hopefully you’ve got everything on your phone backed up so that you don’t have too many hassles when replacing your lost phone.  Here are a few ways that you can make sure you stop losing your phone:

Try the Zomm Wireless Leash. This is a new gadget attached to your keyring designed specifically for people who regularly lose their mobile phone. It’s a good solution for folks who can’t remember to check for their phones on a regular basis (or who just don’t want to be bothered. This is a keyring that is wirelessly connected to your phone. Whenever the keyring or the mobile is lost, the Zomm device will buzz to let you know that you’re leaving the mobile phone behind. This works well unless you happen to leave your mobile phone in the same place as your keys and lose them both at the same time!(For more information go to http://www.zomm.co.uk)

Always put your mobile phone in the same place. This is one of those tips that you should have learned a long time ago about all of your items. If something has a place and you always put it in its place then you’re a lot less likely to lose track of it. Make sure that you have a set place for where you keep your phone when you are out. Always keep it in the same pocket of your purse or in the same section of your briefcase. If you keep it in a jacket pocket then make sure it’s always on the same side. Knowing where your phone is supposed to be will help you easily realize when it’s not there so that you can retrace your steps and find it.

Put an ID label on your mobile phone. One good way to avoid permanently losing your gadgets is to make sure that people who find them have an easy way to get them back to you. Make it easy on them by putting an ID label on the phone so that they know where to return the handset to. Better yet, register your mobile phone with one of the online services that helps connect people to their gadgets and then use the label provided by them to make sure that anyone who finds your phone knows how to return it to you. This protects your anonymity, while making sure to get the phone back to you intact.

 Install tracking software. However, people who have a serious problem with regularly losing their mobile phones might choose to install this tracking software onto their own phones. This way you can get online and check where your mobile phone is when you’ve lost it.

Use Phone Finder applications. These days most of the best things that you can do with your mobile phone are available through app downloads. Finding your lost phone with apps is possible, too. For example, there’s a Windows Mobile phone app called Phone Finder which you install on your phone. If you lose your phone, you simply text it. The app uses the GPS on your phone to tell you where the phone is located once you’ve sent this text. Android users can try WaveSecure which lets you lock down your phone and locate it using your computer.  Find UR Phone (http://findurphone.com/signup.php?aff=wmcp) can easily pull  up a map pinpointing the last known location of your phone.  This service is available for AT&T, Verizon, Sprint, or T-Mobile carriers for $20.00\year.

Bottom Line: We all love technology but keeping all of our toys is a challenge for many of us.  If you have repeatedly lost your phone then consider some of these techniques for keeping your phone from going MIA.