Managing Your Practice

Paps are “normal” despite bleeding and cervical cancer

A ROUTINE PAP SMEAR of a 27-year-old woman showed atypical squamous cells of undetermined significance. Over the next 3 years, the same gynecologist obtained annual Pap smears; pathologists and cytotechnologists interpreted these as being within normal limits. Then the patient reported postcoital bleeding to her gynecologist. Assuming the bleeding to be due to low estrogen associated with her oral contraceptive (OC), he switched her to another OC. Over the next 7 months, the patient reported on six occasions that she was still experiencing significant postcoital bleeding, tenderness during intercourse, and abdominal cramping. A Pap smear on one of those visits indicated no evidence of malignancy. Nine months after the change in OC, cervical cancer was diagnosed. Ten months later, the patient began radiation and chemotherapy because she was found to have metastatic cervical cancer of the rectum, pelvis, and colon. She died 9 months later at age 32.

PLAINTIFF’S CLAIM The first Pap smear actually showed evidence of a low-grade squamous intraepithelial lesion, so further testing was needed to rule out cervical cancer. When the patient reported postcoital bleeding, colposcopy and cervical biopsy should have been performed to determine whether she indeed had cervical cancer.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1.3 million Massachusetts settlement.

Ectopic pregnancy with IUD leads to fallopian tube removal

A FEW WEEKS AFTER IUD PLACEMENT, a 26-year-old woman reported to a hospital complaining of abdominal pain and bleeding. An ObGyn diagnosed an ectopic pregnancy, recommended removal of both fallopian tubes, and then proceeded to remove them.

PATIENT’S CLAIM It was negligent to perform nonemergent surgery when she was unable to consent to it.

PHYSICIAN’S DEFENSE The procedure was proper, as the patient was highly likely to have another ectopic pregnancy. Also, the patient could undergo in vitro fertilization if she wanted to become pregnant.

VERDICT Tennessee defense verdict.

Could retractors have caused right-leg femoral nerve neuropathy?

A 66-YEAR-OLD WOMAN with endometrial cancer underwent hysterectomy and surgical staging. Following the procedure, she suffered complete neuropathy of the femoral nerve in her right leg.

PATIENT’S CLAIM Retractors were used improperly during surgery, causing the injury.

PHYSICIAN’S DEFENSE The neuropathy was not a result of the type of retraction, but was probably due to the patient’s modified lithotomy position during surgery. Such an injury is a known risk of the procedure.

VERDICT $750,000 New York verdict. As the verdict was for all past pain and suffering, the court increased the judgment to $900,000 after the trial to include future pain and suffering.

Was retained clip the reason for kidney failure 12 years later?

BECAUSE OF A TUMOR on her left ovary, a woman’s left ovary and fallopian tube were removed. During surgery, Dr. A found and lysed adhesions around her right ovary. Seventeen months later, the patient underwent laparoscopy and lysis of adhesions as well as biopsy of the right ovary. Dr. B, who performed the procedure, did not note any clip on the left ureter. Three months after that, the patient underwent exploratory laparotomy with lysis of adhesions and right ovarian cystectomy and partial omentectomy—performed by Dr. C. Upon visual inspection, the left kidney appeared to be larger than the right kidney. When the patient complained of left-sided abdominal pain 10 years later, she underwent a CT urogram, which showed a chronically obstructed left kidney—probably related to a surgical clip obstructing the distal third of the left ureter. She was diagnosed with hydronephrosis of the left kidney, which was essentially nonfunctioning. The urologist believed the clip had been left there during the first surgery 12 years earlier.

PATIENT’S CLAIM Dr. A was negligent for placing the clip on the ureter, causing kidney damage.

PHYSICIAN’S DEFENSE Because of the statute of limitation and state of repose, Dr. A moved for dismissal and summary judgment, but the motions were denied. He also claimed that clipping the ureter during the first surgery would have caused immediate excruciating pain. However, he admitted that partial obstruction could occur without pain and in fact lead to total obstruction and death of the kidney years later.

VERDICT $450,000 Massachusetts arbitration award.

Nurses reassure new mother, who then dies from PE

A 25-YEAR-OLD WOMAN GAVE BIRTH to a healthy boy. She did not feel well during the week after hospital discharge. When she called her ObGyn’s office to discuss her complaints, the nurses reassured her. Ten days after delivery, she was taken to the emergency room, where she died from a pulmonary embolism.

PLAINTIFF’S CLAIM The physician and nurses failed to respond properly to the patient’s complaints, which were consistent with a pulmonary embolism.

PHYSICIAN’S DEFENSE The patient was monitored properly. An embolism is a sudden event.

VERDICT $867,273 Tennessee verdict. The physician group was found 70% at fault and the hospital 30% at fault.

Despite US results, birth delayed to 41 weeks

ULTRASONOGRAPHY SHOWED a shortened cervix, a subchorionic hematoma, and a choroid plexus cyst in the fetal brain during a patient’s prenatal care. The ObGyns induced labor at 41 weeks’ gestation and then performed emergent cesarean delivery. The child suffered birth asphyxia, thrombocytopenia, hypocalcemia, and cerebral palsy.

PATIENT’S CLAIM The ObGyns should have induced labor and/or performed cesarean delivery before 39 weeks’ gestation, but they failed to recognize the significance of the mother’s condition.

PHYSICIANS’ DEFENSE Not reported.

VERDICT $1.1 million Michigan settlement.

Sponge emerges 7 months after cesarean delivery

A LAPAROTOMY SPONGE was unknowingly left in the abdomen of a 29-year-old woman who underwent cesarean delivery. Seven months later, she was examined for a stitch abscess. Thinking he was removing a retained stitch, the surgeon pulled out a 12-inch sponge. She was awake at the time and experienced severe pain. The next day, she underwent laparotomy and drains were placed. She remained hospitalized for several days and drainage continued for another 6 days. The patient suffered no permanent injury; incisions for both operations were made at the same site, and she later gave birth without complication.

PATIENT’S CLAIM Leaving a sponge inside her was negligent.

PHYSICIAN’S DEFENSE The nurses who assisted in the surgery were responsible for the retained sponge.

VERDICT $110,410 Illinois verdict against the surgeon. Confidential settlement with the hospital prior to trial.

Would an earlier birth have saved this stillborn child?

WHEN 32 WEEKS’ PREGNANT, a 16-year-old patient repeatedly told her ObGyn she was experiencing bleeding. Later, she reported decreased fetal movement, but a sonogram indicated nothing abnormal. Twenty-three days later, her infant was delivered stillborn.

PATIENT’S CLAIM Placental abruption, which occurred 24 to 96 hours before delivery, caused the stillbirth. Because of her risk factors—bleeding, age, smoking, decreased fetal movement—labor should have been induced or a cesarean delivery performed earlier.

PHYSICIAN’S DEFENSE Ultrasonography did not indicate placental abruption, so delivery at that time was not warranted. An umbilical cord accident—which was unforeseeable and unpreventable—caused the stillbirth.

VERDICT Kentucky defense verdict.

Mother claims she wasn’t told test results for Down syndrome

A TRIPLE SCREEN BLOOD TEST ordered for a patient under prenatal care indicated that she had a 1:37 chance of giving birth to a child with Down syndrome. Six months later, her infant was born with Down syndrome.

PATIENT’S CLAIM The obstetrician failed to inform her that the triple screen test indicated a risk of having a child with Down syndrome. If she had known, she would have undergone an abortion.

PHYSICIAN’S DEFENSE The patient was informed three times of the test results. She was advised to undergo amniocentesis to obtain a definitive diagnosis, but she refused.

VERDICT Maryland defense verdict.

Paps are “normal” despite bleeding and cervical cancer

A ROUTINE PAP SMEAR of a 27-year-old woman showed atypical squamous cells of undetermined significance. Over the next 3 years, the same gynecologist obtained annual Pap smears; pathologists and cytotechnologists interpreted these as being within normal limits. Then the patient reported postcoital bleeding to her gynecologist. Assuming the bleeding to be due to low estrogen associated with her oral contraceptive (OC), he switched her to another OC. Over the next 7 months, the patient reported on six occasions that she was still experiencing significant postcoital bleeding, tenderness during intercourse, and abdominal cramping. A Pap smear on one of those visits indicated no evidence of malignancy. Nine months after the change in OC, cervical cancer was diagnosed. Ten months later, the patient began radiation and chemotherapy because she was found to have metastatic cervical cancer of the rectum, pelvis, and colon. She died 9 months later at age 32.

PLAINTIFF’S CLAIM The first Pap smear actually showed evidence of a low-grade squamous intraepithelial lesion, so further testing was needed to rule out cervical cancer. When the patient reported postcoital bleeding, colposcopy and cervical biopsy should have been performed to determine whether she indeed had cervical cancer.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1.3 million Massachusetts settlement.

Ectopic pregnancy with IUD leads to fallopian tube removal

A FEW WEEKS AFTER IUD PLACEMENT, a 26-year-old woman reported to a hospital complaining of abdominal pain and bleeding. An ObGyn diagnosed an ectopic pregnancy, recommended removal of both fallopian tubes, and then proceeded to remove them.

PATIENT’S CLAIM It was negligent to perform nonemergent surgery when she was unable to consent to it.

PHYSICIAN’S DEFENSE The procedure was proper, as the patient was highly likely to have another ectopic pregnancy. Also, the patient could undergo in vitro fertilization if she wanted to become pregnant.

VERDICT Tennessee defense verdict.

Could retractors have caused right-leg femoral nerve neuropathy?

A 66-YEAR-OLD WOMAN with endometrial cancer underwent hysterectomy and surgical staging. Following the procedure, she suffered complete neuropathy of the femoral nerve in her right leg.

PATIENT’S CLAIM Retractors were used improperly during surgery, causing the injury.

PHYSICIAN’S DEFENSE The neuropathy was not a result of the type of retraction, but was probably due to the patient’s modified lithotomy position during surgery. Such an injury is a known risk of the procedure.

VERDICT $750,000 New York verdict. As the verdict was for all past pain and suffering, the court increased the judgment to $900,000 after the trial to include future pain and suffering.

Was retained clip the reason for kidney failure 12 years later?

BECAUSE OF A TUMOR on her left ovary, a woman’s left ovary and fallopian tube were removed. During surgery, Dr. A found and lysed adhesions around her right ovary. Seventeen months later, the patient underwent laparoscopy and lysis of adhesions as well as biopsy of the right ovary. Dr. B, who performed the procedure, did not note any clip on the left ureter. Three months after that, the patient underwent exploratory laparotomy with lysis of adhesions and right ovarian cystectomy and partial omentectomy—performed by Dr. C. Upon visual inspection, the left kidney appeared to be larger than the right kidney. When the patient complained of left-sided abdominal pain 10 years later, she underwent a CT urogram, which showed a chronically obstructed left kidney—probably related to a surgical clip obstructing the distal third of the left ureter. She was diagnosed with hydronephrosis of the left kidney, which was essentially nonfunctioning. The urologist believed the clip had been left there during the first surgery 12 years earlier.

PATIENT’S CLAIM Dr. A was negligent for placing the clip on the ureter, causing kidney damage.

PHYSICIAN’S DEFENSE Because of the statute of limitation and state of repose, Dr. A moved for dismissal and summary judgment, but the motions were denied. He also claimed that clipping the ureter during the first surgery would have caused immediate excruciating pain. However, he admitted that partial obstruction could occur without pain and in fact lead to total obstruction and death of the kidney years later.

VERDICT $450,000 Massachusetts arbitration award.

Nurses reassure new mother, who then dies from PE

A 25-YEAR-OLD WOMAN GAVE BIRTH to a healthy boy. She did not feel well during the week after hospital discharge. When she called her ObGyn’s office to discuss her complaints, the nurses reassured her. Ten days after delivery, she was taken to the emergency room, where she died from a pulmonary embolism.

PLAINTIFF’S CLAIM The physician and nurses failed to respond properly to the patient’s complaints, which were consistent with a pulmonary embolism.

PHYSICIAN’S DEFENSE The patient was monitored properly. An embolism is a sudden event.

VERDICT $867,273 Tennessee verdict. The physician group was found 70% at fault and the hospital 30% at fault.

Despite US results, birth delayed to 41 weeks

ULTRASONOGRAPHY SHOWED a shortened cervix, a subchorionic hematoma, and a choroid plexus cyst in the fetal brain during a patient’s prenatal care. The ObGyns induced labor at 41 weeks’ gestation and then performed emergent cesarean delivery. The child suffered birth asphyxia, thrombocytopenia, hypocalcemia, and cerebral palsy.

PATIENT’S CLAIM The ObGyns should have induced labor and/or performed cesarean delivery before 39 weeks’ gestation, but they failed to recognize the significance of the mother’s condition.

PHYSICIANS’ DEFENSE Not reported.

VERDICT $1.1 million Michigan settlement.

Sponge emerges 7 months after cesarean delivery

A LAPAROTOMY SPONGE was unknowingly left in the abdomen of a 29-year-old woman who underwent cesarean delivery. Seven months later, she was examined for a stitch abscess. Thinking he was removing a retained stitch, the surgeon pulled out a 12-inch sponge. She was awake at the time and experienced severe pain. The next day, she underwent laparotomy and drains were placed. She remained hospitalized for several days and drainage continued for another 6 days. The patient suffered no permanent injury; incisions for both operations were made at the same site, and she later gave birth without complication.

PATIENT’S CLAIM Leaving a sponge inside her was negligent.

PHYSICIAN’S DEFENSE The nurses who assisted in the surgery were responsible for the retained sponge.

VERDICT $110,410 Illinois verdict against the surgeon. Confidential settlement with the hospital prior to trial.

Would an earlier birth have saved this stillborn child?

WHEN 32 WEEKS’ PREGNANT, a 16-year-old patient repeatedly told her ObGyn she was experiencing bleeding. Later, she reported decreased fetal movement, but a sonogram indicated nothing abnormal. Twenty-three days later, her infant was delivered stillborn.

PATIENT’S CLAIM Placental abruption, which occurred 24 to 96 hours before delivery, caused the stillbirth. Because of her risk factors—bleeding, age, smoking, decreased fetal movement—labor should have been induced or a cesarean delivery performed earlier.

PHYSICIAN’S DEFENSE Ultrasonography did not indicate placental abruption, so delivery at that time was not warranted. An umbilical cord accident—which was unforeseeable and unpreventable—caused the stillbirth.

VERDICT Kentucky defense verdict.

Mother claims she wasn’t told test results for Down syndrome

A TRIPLE SCREEN BLOOD TEST ordered for a patient under prenatal care indicated that she had a 1:37 chance of giving birth to a child with Down syndrome. Six months later, her infant was born with Down syndrome.

PATIENT’S CLAIM The obstetrician failed to inform her that the triple screen test indicated a risk of having a child with Down syndrome. If she had known, she would have undergone an abortion.

PHYSICIAN’S DEFENSE The patient was informed three times of the test results. She was advised to undergo amniocentesis to obtain a definitive diagnosis, but she refused.

VERDICT Maryland defense verdict.

Paps are “normal” despite bleeding and cervical cancer

A ROUTINE PAP SMEAR of a 27-year-old woman showed atypical squamous cells of undetermined significance. Over the next 3 years, the same gynecologist obtained annual Pap smears; pathologists and cytotechnologists interpreted these as being within normal limits. Then the patient reported postcoital bleeding to her gynecologist. Assuming the bleeding to be due to low estrogen associated with her oral contraceptive (OC), he switched her to another OC. Over the next 7 months, the patient reported on six occasions that she was still experiencing significant postcoital bleeding, tenderness during intercourse, and abdominal cramping. A Pap smear on one of those visits indicated no evidence of malignancy. Nine months after the change in OC, cervical cancer was diagnosed. Ten months later, the patient began radiation and chemotherapy because she was found to have metastatic cervical cancer of the rectum, pelvis, and colon. She died 9 months later at age 32.

PLAINTIFF’S CLAIM The first Pap smear actually showed evidence of a low-grade squamous intraepithelial lesion, so further testing was needed to rule out cervical cancer. When the patient reported postcoital bleeding, colposcopy and cervical biopsy should have been performed to determine whether she indeed had cervical cancer.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1.3 million Massachusetts settlement.

Ectopic pregnancy with IUD leads to fallopian tube removal

A FEW WEEKS AFTER IUD PLACEMENT, a 26-year-old woman reported to a hospital complaining of abdominal pain and bleeding. An ObGyn diagnosed an ectopic pregnancy, recommended removal of both fallopian tubes, and then proceeded to remove them.

PATIENT’S CLAIM It was negligent to perform nonemergent surgery when she was unable to consent to it.

PHYSICIAN’S DEFENSE The procedure was proper, as the patient was highly likely to have another ectopic pregnancy. Also, the patient could undergo in vitro fertilization if she wanted to become pregnant.

VERDICT Tennessee defense verdict.

Could retractors have caused right-leg femoral nerve neuropathy?

A 66-YEAR-OLD WOMAN with endometrial cancer underwent hysterectomy and surgical staging. Following the procedure, she suffered complete neuropathy of the femoral nerve in her right leg.

PATIENT’S CLAIM Retractors were used improperly during surgery, causing the injury.

PHYSICIAN’S DEFENSE The neuropathy was not a result of the type of retraction, but was probably due to the patient’s modified lithotomy position during surgery. Such an injury is a known risk of the procedure.

VERDICT $750,000 New York verdict. As the verdict was for all past pain and suffering, the court increased the judgment to $900,000 after the trial to include future pain and suffering.

Was retained clip the reason for kidney failure 12 years later?

BECAUSE OF A TUMOR on her left ovary, a woman’s left ovary and fallopian tube were removed. During surgery, Dr. A found and lysed adhesions around her right ovary. Seventeen months later, the patient underwent laparoscopy and lysis of adhesions as well as biopsy of the right ovary. Dr. B, who performed the procedure, did not note any clip on the left ureter. Three months after that, the patient underwent exploratory laparotomy with lysis of adhesions and right ovarian cystectomy and partial omentectomy—performed by Dr. C. Upon visual inspection, the left kidney appeared to be larger than the right kidney. When the patient complained of left-sided abdominal pain 10 years later, she underwent a CT urogram, which showed a chronically obstructed left kidney—probably related to a surgical clip obstructing the distal third of the left ureter. She was diagnosed with hydronephrosis of the left kidney, which was essentially nonfunctioning. The urologist believed the clip had been left there during the first surgery 12 years earlier.

PATIENT’S CLAIM Dr. A was negligent for placing the clip on the ureter, causing kidney damage.

PHYSICIAN’S DEFENSE Because of the statute of limitation and state of repose, Dr. A moved for dismissal and summary judgment, but the motions were denied. He also claimed that clipping the ureter during the first surgery would have caused immediate excruciating pain. However, he admitted that partial obstruction could occur without pain and in fact lead to total obstruction and death of the kidney years later.

VERDICT $450,000 Massachusetts arbitration award.

Nurses reassure new mother, who then dies from PE

A 25-YEAR-OLD WOMAN GAVE BIRTH to a healthy boy. She did not feel well during the week after hospital discharge. When she called her ObGyn’s office to discuss her complaints, the nurses reassured her. Ten days after delivery, she was taken to the emergency room, where she died from a pulmonary embolism.

PLAINTIFF’S CLAIM The physician and nurses failed to respond properly to the patient’s complaints, which were consistent with a pulmonary embolism.

PHYSICIAN’S DEFENSE The patient was monitored properly. An embolism is a sudden event.

VERDICT $867,273 Tennessee verdict. The physician group was found 70% at fault and the hospital 30% at fault.

Despite US results, birth delayed to 41 weeks

ULTRASONOGRAPHY SHOWED a shortened cervix, a subchorionic hematoma, and a choroid plexus cyst in the fetal brain during a patient’s prenatal care. The ObGyns induced labor at 41 weeks’ gestation and then performed emergent cesarean delivery. The child suffered birth asphyxia, thrombocytopenia, hypocalcemia, and cerebral palsy.

PATIENT’S CLAIM The ObGyns should have induced labor and/or performed cesarean delivery before 39 weeks’ gestation, but they failed to recognize the significance of the mother’s condition.

PHYSICIANS’ DEFENSE Not reported.

VERDICT $1.1 million Michigan settlement.

Sponge emerges 7 months after cesarean delivery

A LAPAROTOMY SPONGE was unknowingly left in the abdomen of a 29-year-old woman who underwent cesarean delivery. Seven months later, she was examined for a stitch abscess. Thinking he was removing a retained stitch, the surgeon pulled out a 12-inch sponge. She was awake at the time and experienced severe pain. The next day, she underwent laparotomy and drains were placed. She remained hospitalized for several days and drainage continued for another 6 days. The patient suffered no permanent injury; incisions for both operations were made at the same site, and she later gave birth without complication.

PATIENT’S CLAIM Leaving a sponge inside her was negligent.

PHYSICIAN’S DEFENSE The nurses who assisted in the surgery were responsible for the retained sponge.

VERDICT $110,410 Illinois verdict against the surgeon. Confidential settlement with the hospital prior to trial.

Would an earlier birth have saved this stillborn child?

WHEN 32 WEEKS’ PREGNANT, a 16-year-old patient repeatedly told her ObGyn she was experiencing bleeding. Later, she reported decreased fetal movement, but a sonogram indicated nothing abnormal. Twenty-three days later, her infant was delivered stillborn.

PATIENT’S CLAIM Placental abruption, which occurred 24 to 96 hours before delivery, caused the stillbirth. Because of her risk factors—bleeding, age, smoking, decreased fetal movement—labor should have been induced or a cesarean delivery performed earlier.

PHYSICIAN’S DEFENSE Ultrasonography did not indicate placental abruption, so delivery at that time was not warranted. An umbilical cord accident—which was unforeseeable and unpreventable—caused the stillbirth.

VERDICT Kentucky defense verdict.

Mother claims she wasn’t told test results for Down syndrome

A TRIPLE SCREEN BLOOD TEST ordered for a patient under prenatal care indicated that she had a 1:37 chance of giving birth to a child with Down syndrome. Six months later, her infant was born with Down syndrome.

PATIENT’S CLAIM The obstetrician failed to inform her that the triple screen test indicated a risk of having a child with Down syndrome. If she had known, she would have undergone an abortion.

PHYSICIAN’S DEFENSE The patient was informed three times of the test results. She was advised to undergo amniocentesis to obtain a definitive diagnosis, but she refused.

VERDICT Maryland defense verdict.

2 CASES: Situations that stun

Your postop patient suffers acute chest pain and dyspnea on the second hospital day, becomes moribund, and dies. Her family, agitated and upset, has gathered in her hospital room. The unit nurse telephones you and asks you to come to the hospital.

Your brother calls to tell you that his teenaged daughter has just been killed in an automobile crash. He is at the emergency room of your local hospital and asks you to join him there.

In both cases, how can you prepare yourself for what you will face, and what you will say, when you arrive at the hospital?

Like all ObGyns, you have experience telling parents about an expected, or unexpected, perinatal death, and bringing news to a family when death comes finally to a patient who has metastatic cancer. But how well are you prepared to handle the two hypothetical scenarios above? Granted, they represent infrequent, if not rare, occurrences for most of us, in or outside our practices—but they happen.

In this article, we offer suggestions—based on extensive experience we’ve gained working with a national organization, the Trauma Intervention Program (TIP)—on how you can provide emotional first aid to family and other loved ones in the hours after your patient has died unexpectedly. We also briefly explain how TIP citizen volunteers can extend the comfort and counsel that you and other hospital team members provide immediately after the death.

After a death, a window opens briefly for crucial action and care

When a patient dies, your role is usually limited to the notification of death and whatever comfort you can provide in the short time you spend with the family and other loved ones (we’ll simply call them all “survivors” here). Most of us have not interacted with grieving survivors beyond that—in the several hours after the immediate time of the death.

But what does, or does not, happen during that subsequent interval has the potential to be healing for survivors or to cause them pain (and, it’s worth noting, to have a positive or a negative impact on your emotional health). In those hours, many thoughts crowd in for survivors: What happened to their loved one; what they were doing and how they were informed; the attitude, behavior, language, and tone of first responders and health care professionals. And all these thoughts become everlasting memories.

After such a traumatic event, those closest to the person who died often feel helpless and confused. Confronted with circumstances for which they are probably wholly unprepared, they are in emotional shock. Their lives have been irreparably altered and their priorities for the upcoming period have shifted.

Shock and confusion notwithstanding, the hours after a death require decision making by survivors. Being organized and decisive can be emotionally challenging and disruptive, and can bring repetitive stress for both family and health care professionals.

A period of turmoil calls for emotional First Aid

Immediately after a death, the family often finds itself surrounded by people who—to be blunt—soon have a job to return to. You and the other health care professionals on your team have other patients; you must get back on service and concentrate on their care.

The coroner or medical examiner’s office may need to determine if an autopsy is mandated.

The survivors have work to do, too: notify extended family and friends; make plans for a service; choose a mortuary for the burial or cremation; and care for young children, to name a few tasks.

Some families call for a personal pastor or a hospital chaplain to be present at this time. Well-meaning friends and family members arrive, too, and they often hold strong opinions about what should or shouldn’t be done next.

All of these activities and personalities have the potential to add unwanted emotional turmoil.

5 skills to master. Whether the caregiver who provided the notification of death is a physician, nurse, social worker, chaplain, or trained citizen volunteer, we have determined that five general skills form the basis for providing emotional first aid to survivors (see “5 basic skills for providing emotional First Aid,”).

In considering the purpose of those five skills, however, consider this overarching tenet: A broken heart cannot be “fixed.” Don’t try! What you can offer to someone who is emotionally devastated is a caring presence. Just being there is powerful and will be experienced by survivors as deeply helpful. It is best, therefore, not to “overcare”—to do too much for them.

Benefits of an expanded team approach. We have found that a hospital crisis response team approach, with an identified role for each team member, can be of great value to survivors. In addition to the deceased patient’s attending physician and primary nurse, the team typically includes a social worker and hospital chaplain.

In many instances, however, these professionals have so many responsibilities that they are precluded from assisting survivors and from being present for more than a short time after the death. Furthermore, shift changes mean team members come and go during the hours crucial for the survivors; and few hospitals employ social workers and chaplains around the clock.

That is why our repeated experience supports an essential role for a certified, trained citizen volunteer whose only responsibility is to assist and support survivors at all times of the day, all week. This caregiver serves as a guide and a buffer to enable survivors to act on their wishes, feelings, values, and beliefs—not according to what others think should be done. The volunteer provides this necessary temporary support until survivors are able to depend reliably on family, friends, neighbors, and others.

This model of a trained volunteer was developed by the Trauma Intervention Program (TIP) with which we work. You can learn about TIP in the box, “Want to learn more about TIP? About becoming certified as a TIP citizen volunteer?,” and at www.tipnational.org/home1.htm.

The value of training and a manual

We strongly recommend that you encourage the administration at your hospital to create a response to expected and unanticipated adult death that includes education—for physicians, nurses, social workers, and hospital clergy—in emotional First Aid. The suggested reading list below forms a good basis for that education.

Last, we encourage hospitals to publish a resource manual for distribution to grieving families as an ongoing source of information. Our recommendations for the contents of such a resource manual appear in “Sample ‘Table of contents’ for a hospital’s resource manual”.

You can obtain a copy of the resource manual that we have found most useful in our work in Orange County (California) by writing to us in care of the Editors at obg@qhc.com. Please provide your name and mailing address with your request.

2 CASES: Situations that stun

Your postop patient suffers acute chest pain and dyspnea on the second hospital day, becomes moribund, and dies. Her family, agitated and upset, has gathered in her hospital room. The unit nurse telephones you and asks you to come to the hospital.

Your brother calls to tell you that his teenaged daughter has just been killed in an automobile crash. He is at the emergency room of your local hospital and asks you to join him there.

In both cases, how can you prepare yourself for what you will face, and what you will say, when you arrive at the hospital?

Like all ObGyns, you have experience telling parents about an expected, or unexpected, perinatal death, and bringing news to a family when death comes finally to a patient who has metastatic cancer. But how well are you prepared to handle the two hypothetical scenarios above? Granted, they represent infrequent, if not rare, occurrences for most of us, in or outside our practices—but they happen.

In this article, we offer suggestions—based on extensive experience we’ve gained working with a national organization, the Trauma Intervention Program (TIP)—on how you can provide emotional first aid to family and other loved ones in the hours after your patient has died unexpectedly. We also briefly explain how TIP citizen volunteers can extend the comfort and counsel that you and other hospital team members provide immediately after the death.

After a death, a window opens briefly for crucial action and care

When a patient dies, your role is usually limited to the notification of death and whatever comfort you can provide in the short time you spend with the family and other loved ones (we’ll simply call them all “survivors” here). Most of us have not interacted with grieving survivors beyond that—in the several hours after the immediate time of the death.

But what does, or does not, happen during that subsequent interval has the potential to be healing for survivors or to cause them pain (and, it’s worth noting, to have a positive or a negative impact on your emotional health). In those hours, many thoughts crowd in for survivors: What happened to their loved one; what they were doing and how they were informed; the attitude, behavior, language, and tone of first responders and health care professionals. And all these thoughts become everlasting memories.

After such a traumatic event, those closest to the person who died often feel helpless and confused. Confronted with circumstances for which they are probably wholly unprepared, they are in emotional shock. Their lives have been irreparably altered and their priorities for the upcoming period have shifted.

Shock and confusion notwithstanding, the hours after a death require decision making by survivors. Being organized and decisive can be emotionally challenging and disruptive, and can bring repetitive stress for both family and health care professionals.

A period of turmoil calls for emotional First Aid

Immediately after a death, the family often finds itself surrounded by people who—to be blunt—soon have a job to return to. You and the other health care professionals on your team have other patients; you must get back on service and concentrate on their care.

The coroner or medical examiner’s office may need to determine if an autopsy is mandated.

The survivors have work to do, too: notify extended family and friends; make plans for a service; choose a mortuary for the burial or cremation; and care for young children, to name a few tasks.

Some families call for a personal pastor or a hospital chaplain to be present at this time. Well-meaning friends and family members arrive, too, and they often hold strong opinions about what should or shouldn’t be done next.

All of these activities and personalities have the potential to add unwanted emotional turmoil.

5 skills to master. Whether the caregiver who provided the notification of death is a physician, nurse, social worker, chaplain, or trained citizen volunteer, we have determined that five general skills form the basis for providing emotional first aid to survivors (see “5 basic skills for providing emotional First Aid,”).

In considering the purpose of those five skills, however, consider this overarching tenet: A broken heart cannot be “fixed.” Don’t try! What you can offer to someone who is emotionally devastated is a caring presence. Just being there is powerful and will be experienced by survivors as deeply helpful. It is best, therefore, not to “overcare”—to do too much for them.

Benefits of an expanded team approach. We have found that a hospital crisis response team approach, with an identified role for each team member, can be of great value to survivors. In addition to the deceased patient’s attending physician and primary nurse, the team typically includes a social worker and hospital chaplain.

In many instances, however, these professionals have so many responsibilities that they are precluded from assisting survivors and from being present for more than a short time after the death. Furthermore, shift changes mean team members come and go during the hours crucial for the survivors; and few hospitals employ social workers and chaplains around the clock.

That is why our repeated experience supports an essential role for a certified, trained citizen volunteer whose only responsibility is to assist and support survivors at all times of the day, all week. This caregiver serves as a guide and a buffer to enable survivors to act on their wishes, feelings, values, and beliefs—not according to what others think should be done. The volunteer provides this necessary temporary support until survivors are able to depend reliably on family, friends, neighbors, and others.

This model of a trained volunteer was developed by the Trauma Intervention Program (TIP) with which we work. You can learn about TIP in the box, “Want to learn more about TIP? About becoming certified as a TIP citizen volunteer?,” and at www.tipnational.org/home1.htm.

The value of training and a manual

We strongly recommend that you encourage the administration at your hospital to create a response to expected and unanticipated adult death that includes education—for physicians, nurses, social workers, and hospital clergy—in emotional First Aid. The suggested reading list below forms a good basis for that education.

Last, we encourage hospitals to publish a resource manual for distribution to grieving families as an ongoing source of information. Our recommendations for the contents of such a resource manual appear in “Sample ‘Table of contents’ for a hospital’s resource manual”.

You can obtain a copy of the resource manual that we have found most useful in our work in Orange County (California) by writing to us in care of the Editors at obg@qhc.com. Please provide your name and mailing address with your request.

2 CASES: Situations that stun

Your postop patient suffers acute chest pain and dyspnea on the second hospital day, becomes moribund, and dies. Her family, agitated and upset, has gathered in her hospital room. The unit nurse telephones you and asks you to come to the hospital.

Your brother calls to tell you that his teenaged daughter has just been killed in an automobile crash. He is at the emergency room of your local hospital and asks you to join him there.

In both cases, how can you prepare yourself for what you will face, and what you will say, when you arrive at the hospital?

Like all ObGyns, you have experience telling parents about an expected, or unexpected, perinatal death, and bringing news to a family when death comes finally to a patient who has metastatic cancer. But how well are you prepared to handle the two hypothetical scenarios above? Granted, they represent infrequent, if not rare, occurrences for most of us, in or outside our practices—but they happen.

In this article, we offer suggestions—based on extensive experience we’ve gained working with a national organization, the Trauma Intervention Program (TIP)—on how you can provide emotional first aid to family and other loved ones in the hours after your patient has died unexpectedly. We also briefly explain how TIP citizen volunteers can extend the comfort and counsel that you and other hospital team members provide immediately after the death.

After a death, a window opens briefly for crucial action and care

When a patient dies, your role is usually limited to the notification of death and whatever comfort you can provide in the short time you spend with the family and other loved ones (we’ll simply call them all “survivors” here). Most of us have not interacted with grieving survivors beyond that—in the several hours after the immediate time of the death.

But what does, or does not, happen during that subsequent interval has the potential to be healing for survivors or to cause them pain (and, it’s worth noting, to have a positive or a negative impact on your emotional health). In those hours, many thoughts crowd in for survivors: What happened to their loved one; what they were doing and how they were informed; the attitude, behavior, language, and tone of first responders and health care professionals. And all these thoughts become everlasting memories.

After such a traumatic event, those closest to the person who died often feel helpless and confused. Confronted with circumstances for which they are probably wholly unprepared, they are in emotional shock. Their lives have been irreparably altered and their priorities for the upcoming period have shifted.

Shock and confusion notwithstanding, the hours after a death require decision making by survivors. Being organized and decisive can be emotionally challenging and disruptive, and can bring repetitive stress for both family and health care professionals.

A period of turmoil calls for emotional First Aid

Immediately after a death, the family often finds itself surrounded by people who—to be blunt—soon have a job to return to. You and the other health care professionals on your team have other patients; you must get back on service and concentrate on their care.

The coroner or medical examiner’s office may need to determine if an autopsy is mandated.

The survivors have work to do, too: notify extended family and friends; make plans for a service; choose a mortuary for the burial or cremation; and care for young children, to name a few tasks.

Some families call for a personal pastor or a hospital chaplain to be present at this time. Well-meaning friends and family members arrive, too, and they often hold strong opinions about what should or shouldn’t be done next.

All of these activities and personalities have the potential to add unwanted emotional turmoil.

5 skills to master. Whether the caregiver who provided the notification of death is a physician, nurse, social worker, chaplain, or trained citizen volunteer, we have determined that five general skills form the basis for providing emotional first aid to survivors (see “5 basic skills for providing emotional First Aid,”).

In considering the purpose of those five skills, however, consider this overarching tenet: A broken heart cannot be “fixed.” Don’t try! What you can offer to someone who is emotionally devastated is a caring presence. Just being there is powerful and will be experienced by survivors as deeply helpful. It is best, therefore, not to “overcare”—to do too much for them.

Benefits of an expanded team approach. We have found that a hospital crisis response team approach, with an identified role for each team member, can be of great value to survivors. In addition to the deceased patient’s attending physician and primary nurse, the team typically includes a social worker and hospital chaplain.

In many instances, however, these professionals have so many responsibilities that they are precluded from assisting survivors and from being present for more than a short time after the death. Furthermore, shift changes mean team members come and go during the hours crucial for the survivors; and few hospitals employ social workers and chaplains around the clock.

That is why our repeated experience supports an essential role for a certified, trained citizen volunteer whose only responsibility is to assist and support survivors at all times of the day, all week. This caregiver serves as a guide and a buffer to enable survivors to act on their wishes, feelings, values, and beliefs—not according to what others think should be done. The volunteer provides this necessary temporary support until survivors are able to depend reliably on family, friends, neighbors, and others.

This model of a trained volunteer was developed by the Trauma Intervention Program (TIP) with which we work. You can learn about TIP in the box, “Want to learn more about TIP? About becoming certified as a TIP citizen volunteer?,” and at www.tipnational.org/home1.htm.

The value of training and a manual

We strongly recommend that you encourage the administration at your hospital to create a response to expected and unanticipated adult death that includes education—for physicians, nurses, social workers, and hospital clergy—in emotional First Aid. The suggested reading list below forms a good basis for that education.

Last, we encourage hospitals to publish a resource manual for distribution to grieving families as an ongoing source of information. Our recommendations for the contents of such a resource manual appear in “Sample ‘Table of contents’ for a hospital’s resource manual”.

You can obtain a copy of the resource manual that we have found most useful in our work in Orange County (California) by writing to us in care of the Editors at obg@qhc.com. Please provide your name and mailing address with your request.

Electronic prescribing was supposed to be standard practice by now. With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would adopt the technology--but the associated costs and hassles dissuaded most.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various "G" codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing. If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort. This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories.

To address the cost and accessibility problems, a coalition of insurance and technology companies called the National e-Prescribing Patient Safety Initiative (NEPSI) has provided $100 million in funding to offer free e-prescribing technology to all doctors nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health. (I have no financial interest in any company or product mentioned in this column.)

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. Setup methods vary, but the concepts and requirements for each company are generally similar. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system. In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection, and a database of patients.

Keep in mind that this will not be a complete transition; you cannot entirely eliminate paper prescriptions from your practice. Beside the 30% of pharmacies not equipped for e-prescribing, Drug Enforcement Administration rules prohibit sending controlled substance prescriptions electronically.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians on e-prescribing. You can find it at www.ehealthinitiative.org/ basics-what-electronic-prescribing.html. You can learn more about NEPSI, and sign up for their free, online-based prescribing software at www.nationalerx.com.

A list of other companies currently offering e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/epre scribe/companylist.aspx.

Details of the CMS incentive program are available at http://www.cms.hhs.gov/ERxIncentive/. The 2% incentive will decrease to 1% in 2011 and 2012, then to 0.5% in 2013. But beginning in 2012 there will be a 1% penalty for not e-prescribing, increasing to 1.5% in 2013 and 2% in 2014 and thereafter.

Bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it is, as outgoing AAD President David Pariser puts it, "a no-brainer" to give e-prescribing a try.

Electronic prescribing was supposed to be standard practice by now. With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would adopt the technology--but the associated costs and hassles dissuaded most.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various "G" codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing. If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort. This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories.

To address the cost and accessibility problems, a coalition of insurance and technology companies called the National e-Prescribing Patient Safety Initiative (NEPSI) has provided $100 million in funding to offer free e-prescribing technology to all doctors nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health. (I have no financial interest in any company or product mentioned in this column.)

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. Setup methods vary, but the concepts and requirements for each company are generally similar. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system. In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection, and a database of patients.

Keep in mind that this will not be a complete transition; you cannot entirely eliminate paper prescriptions from your practice. Beside the 30% of pharmacies not equipped for e-prescribing, Drug Enforcement Administration rules prohibit sending controlled substance prescriptions electronically.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians on e-prescribing. You can find it at www.ehealthinitiative.org/ basics-what-electronic-prescribing.html. You can learn more about NEPSI, and sign up for their free, online-based prescribing software at www.nationalerx.com.

A list of other companies currently offering e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/epre scribe/companylist.aspx.

Details of the CMS incentive program are available at http://www.cms.hhs.gov/ERxIncentive/. The 2% incentive will decrease to 1% in 2011 and 2012, then to 0.5% in 2013. But beginning in 2012 there will be a 1% penalty for not e-prescribing, increasing to 1.5% in 2013 and 2% in 2014 and thereafter.

Bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it is, as outgoing AAD President David Pariser puts it, "a no-brainer" to give e-prescribing a try.

Electronic prescribing was supposed to be standard practice by now. With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would adopt the technology--but the associated costs and hassles dissuaded most.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various "G" codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing. If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort. This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories.

To address the cost and accessibility problems, a coalition of insurance and technology companies called the National e-Prescribing Patient Safety Initiative (NEPSI) has provided $100 million in funding to offer free e-prescribing technology to all doctors nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health. (I have no financial interest in any company or product mentioned in this column.)

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. Setup methods vary, but the concepts and requirements for each company are generally similar. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system. In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection, and a database of patients.

Keep in mind that this will not be a complete transition; you cannot entirely eliminate paper prescriptions from your practice. Beside the 30% of pharmacies not equipped for e-prescribing, Drug Enforcement Administration rules prohibit sending controlled substance prescriptions electronically.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians on e-prescribing. You can find it at www.ehealthinitiative.org/ basics-what-electronic-prescribing.html. You can learn more about NEPSI, and sign up for their free, online-based prescribing software at www.nationalerx.com.

A list of other companies currently offering e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/epre scribe/companylist.aspx.

Details of the CMS incentive program are available at http://www.cms.hhs.gov/ERxIncentive/. The 2% incentive will decrease to 1% in 2011 and 2012, then to 0.5% in 2013. But beginning in 2012 there will be a 1% penalty for not e-prescribing, increasing to 1.5% in 2013 and 2% in 2014 and thereafter.

Bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it is, as outgoing AAD President David Pariser puts it, "a no-brainer" to give e-prescribing a try.

A recent query on the DermChat listserv about the type of music that is most appropriate for medical offices yielded a surprisingly wide range of opinions.

"Doesn't matter to me," said one dermatologist. "I let the staff decide, since they are there all the time, and the patients (hopefully) only for a short time."

"I play what I want to hear," said another. "I play only classical - the most 'recent' composer being Mozart - and have done so since I opened my office. I get compliments all the time about the music."

"Playing overhead music is unprofessional," insisted a third. "No music is the best music.If I played my favorite music (opera), patients would not like it.So why should I be subjected to a similar torture, or why should my patients listen to what my front desk likes?"

"I can't function without music," said yet another."It is like oxygen for me."

The diversity of opinions led me to wonder how my own patients felt about my office music. So I randomly polled several dozen of them over a 2-week period. Most said that our mix was appropriate and pleasant; the rest had no opinion one way or the other. No one said it was annoying or offensive, or that they would prefer no music at all.

Later in the week, one patient followed up with an e-mail message:

"I got to thinking about your questions about your office music, and how the atmosphere in your office is so relaxed, and I realized that the music contributes a lot. It instantly puts me at ease when I walk through the door. Believe me, not every doctor's office does that!"

So, music does seem to make a difference for some patients, at least. I'm happy about that, because, like one of the DermChat respondents, I couldn't work well without it. Besides, I worry less about patients overhearing other patients' conversations.

Your preferences (or your employees' or patients') will determine what kind of music you play. I basically agree that you should pick what you and your staff like to listen to, because you and they listen to it all day while patients come and go.

In my office we play a satellite radio mix of classical, classic rock, and jazz, which varies as the mood strikes us. Those three genres tend to be calm enough to create a serene, relaxed atmosphere without being soporific. Younger patients may prefer more exciting stuff, but I notice that many of them have MP3 players anyway.

Occasionally I bring in a few selections from my extensive, rather eclectic (some say eccentric) vinyl and CD collection to break up the routine.

Each room in the office has its own speakers, with individual volume controls so the music can be "backgrounded" when necessary.

I should point out that there are legal issues involved here: Playing music from a CD, MP3, or regular radio in your office technically requires you to pay royalties to ASCAP (American Society of Composers, Authors, and Publishers), BMI (Broadcast Music Inc.), and SESAC - the agencies that represent the music copyright owners. Using background music to entertain your patients and employees in a commercial setting is considered a public performance of the music, which requires a commercial license be obtained to pay royalty obligations to the artists and the record labels that represent them.

That's one reason (the wide range of musical choices and absence of commercials are others) that I use satellite radio: All licenses and royalties are included in the cost of their commercial subscriptions.

The recordings I bring from home are all classical music, which is in the public domain and not subject to royalty payments.

Although I know of no physician's office that has actually been asked to pay royalties, the possibility exists; it has been known to happen to larger businesses such as department stores and supermarkets.

Whatever venue and genre choices you make, remember that the ultimate goal is to create a more pleasant environment for your patients, employees, and yourself. If that occasionally requires a bit of flexibility, so be it.

The DermChat physician who insists on all classical music, all the time, later told me he has been known to make exceptions. "I did have one very nice fellow bring a boom box, and he played oldies in the waiting room," he said. "But he did it nicely, and he announced he was going to do it. Everyone, including [the receptionist], was boogying like crazy out in the waiting room. It was very entertaining!"

A recent query on the DermChat listserv about the type of music that is most appropriate for medical offices yielded a surprisingly wide range of opinions.

"Doesn't matter to me," said one dermatologist. "I let the staff decide, since they are there all the time, and the patients (hopefully) only for a short time."

"I play what I want to hear," said another. "I play only classical - the most 'recent' composer being Mozart - and have done so since I opened my office. I get compliments all the time about the music."

"Playing overhead music is unprofessional," insisted a third. "No music is the best music.If I played my favorite music (opera), patients would not like it.So why should I be subjected to a similar torture, or why should my patients listen to what my front desk likes?"

"I can't function without music," said yet another."It is like oxygen for me."

The diversity of opinions led me to wonder how my own patients felt about my office music. So I randomly polled several dozen of them over a 2-week period. Most said that our mix was appropriate and pleasant; the rest had no opinion one way or the other. No one said it was annoying or offensive, or that they would prefer no music at all.

Later in the week, one patient followed up with an e-mail message:

"I got to thinking about your questions about your office music, and how the atmosphere in your office is so relaxed, and I realized that the music contributes a lot. It instantly puts me at ease when I walk through the door. Believe me, not every doctor's office does that!"

So, music does seem to make a difference for some patients, at least. I'm happy about that, because, like one of the DermChat respondents, I couldn't work well without it. Besides, I worry less about patients overhearing other patients' conversations.

Your preferences (or your employees' or patients') will determine what kind of music you play. I basically agree that you should pick what you and your staff like to listen to, because you and they listen to it all day while patients come and go.

In my office we play a satellite radio mix of classical, classic rock, and jazz, which varies as the mood strikes us. Those three genres tend to be calm enough to create a serene, relaxed atmosphere without being soporific. Younger patients may prefer more exciting stuff, but I notice that many of them have MP3 players anyway.

Occasionally I bring in a few selections from my extensive, rather eclectic (some say eccentric) vinyl and CD collection to break up the routine.

Each room in the office has its own speakers, with individual volume controls so the music can be "backgrounded" when necessary.

I should point out that there are legal issues involved here: Playing music from a CD, MP3, or regular radio in your office technically requires you to pay royalties to ASCAP (American Society of Composers, Authors, and Publishers), BMI (Broadcast Music Inc.), and SESAC - the agencies that represent the music copyright owners. Using background music to entertain your patients and employees in a commercial setting is considered a public performance of the music, which requires a commercial license be obtained to pay royalty obligations to the artists and the record labels that represent them.

That's one reason (the wide range of musical choices and absence of commercials are others) that I use satellite radio: All licenses and royalties are included in the cost of their commercial subscriptions.

The recordings I bring from home are all classical music, which is in the public domain and not subject to royalty payments.

Although I know of no physician's office that has actually been asked to pay royalties, the possibility exists; it has been known to happen to larger businesses such as department stores and supermarkets.

Whatever venue and genre choices you make, remember that the ultimate goal is to create a more pleasant environment for your patients, employees, and yourself. If that occasionally requires a bit of flexibility, so be it.

The DermChat physician who insists on all classical music, all the time, later told me he has been known to make exceptions. "I did have one very nice fellow bring a boom box, and he played oldies in the waiting room," he said. "But he did it nicely, and he announced he was going to do it. Everyone, including [the receptionist], was boogying like crazy out in the waiting room. It was very entertaining!"

A recent query on the DermChat listserv about the type of music that is most appropriate for medical offices yielded a surprisingly wide range of opinions.

"Doesn't matter to me," said one dermatologist. "I let the staff decide, since they are there all the time, and the patients (hopefully) only for a short time."

"I play what I want to hear," said another. "I play only classical - the most 'recent' composer being Mozart - and have done so since I opened my office. I get compliments all the time about the music."

"Playing overhead music is unprofessional," insisted a third. "No music is the best music.If I played my favorite music (opera), patients would not like it.So why should I be subjected to a similar torture, or why should my patients listen to what my front desk likes?"

"I can't function without music," said yet another."It is like oxygen for me."

The diversity of opinions led me to wonder how my own patients felt about my office music. So I randomly polled several dozen of them over a 2-week period. Most said that our mix was appropriate and pleasant; the rest had no opinion one way or the other. No one said it was annoying or offensive, or that they would prefer no music at all.

Later in the week, one patient followed up with an e-mail message:

"I got to thinking about your questions about your office music, and how the atmosphere in your office is so relaxed, and I realized that the music contributes a lot. It instantly puts me at ease when I walk through the door. Believe me, not every doctor's office does that!"

So, music does seem to make a difference for some patients, at least. I'm happy about that, because, like one of the DermChat respondents, I couldn't work well without it. Besides, I worry less about patients overhearing other patients' conversations.

Your preferences (or your employees' or patients') will determine what kind of music you play. I basically agree that you should pick what you and your staff like to listen to, because you and they listen to it all day while patients come and go.

In my office we play a satellite radio mix of classical, classic rock, and jazz, which varies as the mood strikes us. Those three genres tend to be calm enough to create a serene, relaxed atmosphere without being soporific. Younger patients may prefer more exciting stuff, but I notice that many of them have MP3 players anyway.

Occasionally I bring in a few selections from my extensive, rather eclectic (some say eccentric) vinyl and CD collection to break up the routine.

Each room in the office has its own speakers, with individual volume controls so the music can be "backgrounded" when necessary.

I should point out that there are legal issues involved here: Playing music from a CD, MP3, or regular radio in your office technically requires you to pay royalties to ASCAP (American Society of Composers, Authors, and Publishers), BMI (Broadcast Music Inc.), and SESAC - the agencies that represent the music copyright owners. Using background music to entertain your patients and employees in a commercial setting is considered a public performance of the music, which requires a commercial license be obtained to pay royalty obligations to the artists and the record labels that represent them.

That's one reason (the wide range of musical choices and absence of commercials are others) that I use satellite radio: All licenses and royalties are included in the cost of their commercial subscriptions.

The recordings I bring from home are all classical music, which is in the public domain and not subject to royalty payments.

Although I know of no physician's office that has actually been asked to pay royalties, the possibility exists; it has been known to happen to larger businesses such as department stores and supermarkets.

Whatever venue and genre choices you make, remember that the ultimate goal is to create a more pleasant environment for your patients, employees, and yourself. If that occasionally requires a bit of flexibility, so be it.

The DermChat physician who insists on all classical music, all the time, later told me he has been known to make exceptions. "I did have one very nice fellow bring a boom box, and he played oldies in the waiting room," he said. "But he did it nicely, and he announced he was going to do it. Everyone, including [the receptionist], was boogying like crazy out in the waiting room. It was very entertaining!"

Electronic prescribing was supposed to be standard practice by now.

With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would quickly adopt the new technology—but the associated costs and hassles dissuaded most. And many didn't see any benefits, either for patients or for themselves.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various “G” codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing.

If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort; plus, a consortium of tech companies has made the technology readily accessible and free.

This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories. And they hope you'll see a decrease in pharmacy phone calls, prior authorization nonsense, and treatment delays because of formulary issues. Further, they hope, your patients will appreciate seeing their prescriptions filled faster, with fewer errors.

To address cost and accessibility problems, a coalition of insurance and technology companies, the National e-Prescribing Patient Safety Initiative (NEPSI), has provided $100 million in funding to offer free e-prescribing technology to all phsyicans nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health.

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system.

In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection (not dial-up), and a database of patients.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians who are considering making the switch to e-prescribing, as well as for those who have already switched. You can find it at www.ehealthinitiative.org/basics-what-electronic-prescribing.html

You can learn more about NEPSI and sign up for their free, online-based prescribing software at their Web site, www.nationalerx.com

A list of other companies that currently offer e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/eprescribe/companylist.aspx

Details of the CMS incentive program are available at www.cms.hhs.gov/ERxIncentive/

With cost, accessibility, and hassle roadblocks removed, bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade due to increased use of generic drugs and decreased prescribing errors.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it's a “no-brainer” to give electronic prescribing a try.

Electronic prescribing was supposed to be standard practice by now.

With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would quickly adopt the new technology—but the associated costs and hassles dissuaded most. And many didn't see any benefits, either for patients or for themselves.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various “G” codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing.

If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort; plus, a consortium of tech companies has made the technology readily accessible and free.

This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories. And they hope you'll see a decrease in pharmacy phone calls, prior authorization nonsense, and treatment delays because of formulary issues. Further, they hope, your patients will appreciate seeing their prescriptions filled faster, with fewer errors.

To address cost and accessibility problems, a coalition of insurance and technology companies, the National e-Prescribing Patient Safety Initiative (NEPSI), has provided $100 million in funding to offer free e-prescribing technology to all phsyicans nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health.

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system.

In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection (not dial-up), and a database of patients.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians who are considering making the switch to e-prescribing, as well as for those who have already switched. You can find it at www.ehealthinitiative.org/basics-what-electronic-prescribing.html

You can learn more about NEPSI and sign up for their free, online-based prescribing software at their Web site, www.nationalerx.com

A list of other companies that currently offer e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/eprescribe/companylist.aspx

Details of the CMS incentive program are available at www.cms.hhs.gov/ERxIncentive/

With cost, accessibility, and hassle roadblocks removed, bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade due to increased use of generic drugs and decreased prescribing errors.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it's a “no-brainer” to give electronic prescribing a try.

Electronic prescribing was supposed to be standard practice by now.

With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would quickly adopt the new technology—but the associated costs and hassles dissuaded most. And many didn't see any benefits, either for patients or for themselves.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various “G” codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing.

If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort; plus, a consortium of tech companies has made the technology readily accessible and free.

This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories. And they hope you'll see a decrease in pharmacy phone calls, prior authorization nonsense, and treatment delays because of formulary issues. Further, they hope, your patients will appreciate seeing their prescriptions filled faster, with fewer errors.

To address cost and accessibility problems, a coalition of insurance and technology companies, the National e-Prescribing Patient Safety Initiative (NEPSI), has provided $100 million in funding to offer free e-prescribing technology to all phsyicans nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health.

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system.

In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection (not dial-up), and a database of patients.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians who are considering making the switch to e-prescribing, as well as for those who have already switched. You can find it at www.ehealthinitiative.org/basics-what-electronic-prescribing.html

You can learn more about NEPSI and sign up for their free, online-based prescribing software at their Web site, www.nationalerx.com

A list of other companies that currently offer e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/eprescribe/companylist.aspx

Details of the CMS incentive program are available at www.cms.hhs.gov/ERxIncentive/

With cost, accessibility, and hassle roadblocks removed, bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade due to increased use of generic drugs and decreased prescribing errors.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it's a “no-brainer” to give electronic prescribing a try.