Managing Your Practice

My last two columns discussed the complaint patients make most often: waiting too long in the office.

However, another prevalent complaint—and one that shows no sign of improving in many areas of the country—is the inability to get an appointment with a dermatologist within a reasonable period of time.

In general, patients consider any delay longer than a few days—a week at most—unreasonable. And many dermatologists are booked several weeks in advance.

A patient who finds a suspicious-looking mole and wants to see a dermatologist can expect an average wait of 38 days in the United States, and up to 73 days in Boston, according to a study from the University of California, San Francisco.

Such backlogs, besides arousing patients' ire, cost you money: The longer the wait time, the higher the likelihood of cancellations and no-shows. These leave gaps in your supposedly “full” schedule while adding to administrative work, hurting your bottom line, and driving up costs. A 2001 study showed missed appointments result in a loss of 3%–14% of annual revenues.

Backlogs also are a major reason why dermatologists are losing an increasing amount of business to less-qualified practitioners who will see patients sooner.

In the business world, this would be called a supply and demand issue, one that most successful businesses learned long ago to solve. For example, no McDonald's customer ever hears, “We don't have any Big Macs today; come back tomorrow.” Each McDonald's outlet makes certain it can match its supply with its customers' demand at any given time; if it can't, it loses big chunks of business to competitors.

And if dermatologists don't wish to continue losing ever-larger chunks of business to general practitioners and spas, we too will have to learn to balance supply (the number of available physician hours) with demand (the number of patients).

Options for increasing supply are fairly straightforward. You can increase personnel by bringing in a new associate, or hiring a physician assistant or nurse practitioner. Or you can expand appointment slots by adding hours during early mornings, evenings, or weekends.

Alternatively, you can decrease demand by eliminating third-party contracts that pay too poorly or too slowly, or restricting the type or number of new patients your practice accepts. Or you can narrow the scope of your practice: Eliminate surgery, for example, or eliminate everything except surgery, or focus on one type of surgery, such as Mohs or cosmetic procedures. Or concentrate on something in which you have special interest or expertise, such as psoriasis or pediatric dermatology.

You may find it necessary to combine several of these options to work down your backlog of appointments to a manageable level.

Once supply and demand are well balanced, you may wish to consider adopting an increasingly popular system called open-access scheduling. With open access, most patients are seen on the day they call for an appointment regardless of the reason for their visit. And surprisingly enough, when implemented correctly, it works.

Studies have shown open access to be an effective way of cutting wait times in both managed-care and fee-for-service settings. The advantages are obvious: It greatly increases patient satisfaction while making practices more profitable by virtually eliminating the financial drain of cancellations and missed appointments.

While not for everyone, open access is a viable option in many situations. It can be adopted gradually, starting with reserving some slots each day for last-minute appointments, and then gradually increasing the number of same-day slots until everyone is comfortable with them. At that point you can begin offering all patients an appointment on the day they call your office.

Of course, those patients who do not want to be seen on the day they call can be scheduled for an appointment at a time of their choice. (They should not be told to call back on the day they want to be seen.) And, while seeing patients, you will probably want to schedule some surgeries and other procedures as necessary. (Such advance appointments are known in the open access parlance as “good backlog.”)

When properly managed, open access gets high marks from both patients, who are thrilled to be able to get appointments when they want them, and office personnel, who report that the frenetic routine of answering calls, scheduling visits, and providing clinical care takes place at a much calmer pace. The phones are quieter, and schedulers, nurses, physicians, and staff spend much less time dealing with backlog issues, which leaves more time to care for patients.

Of course, eliminating all wait time, cancellations, missed appointments, and loss of patients to other physicians will take more than just creative scheduling. It will take a basic change in the way we think about the business aspects of health care, such as supply and demand, which most physicians think do not apply to them.

 

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

My last two columns discussed the complaint patients make most often: waiting too long in the office.

However, another prevalent complaint—and one that shows no sign of improving in many areas of the country—is the inability to get an appointment with a dermatologist within a reasonable period of time.

In general, patients consider any delay longer than a few days—a week at most—unreasonable. And many dermatologists are booked several weeks in advance.

A patient who finds a suspicious-looking mole and wants to see a dermatologist can expect an average wait of 38 days in the United States, and up to 73 days in Boston, according to a study from the University of California, San Francisco.

Such backlogs, besides arousing patients' ire, cost you money: The longer the wait time, the higher the likelihood of cancellations and no-shows. These leave gaps in your supposedly “full” schedule while adding to administrative work, hurting your bottom line, and driving up costs. A 2001 study showed missed appointments result in a loss of 3%–14% of annual revenues.

Backlogs also are a major reason why dermatologists are losing an increasing amount of business to less-qualified practitioners who will see patients sooner.

In the business world, this would be called a supply and demand issue, one that most successful businesses learned long ago to solve. For example, no McDonald's customer ever hears, “We don't have any Big Macs today; come back tomorrow.” Each McDonald's outlet makes certain it can match its supply with its customers' demand at any given time; if it can't, it loses big chunks of business to competitors.

And if dermatologists don't wish to continue losing ever-larger chunks of business to general practitioners and spas, we too will have to learn to balance supply (the number of available physician hours) with demand (the number of patients).

Options for increasing supply are fairly straightforward. You can increase personnel by bringing in a new associate, or hiring a physician assistant or nurse practitioner. Or you can expand appointment slots by adding hours during early mornings, evenings, or weekends.

Alternatively, you can decrease demand by eliminating third-party contracts that pay too poorly or too slowly, or restricting the type or number of new patients your practice accepts. Or you can narrow the scope of your practice: Eliminate surgery, for example, or eliminate everything except surgery, or focus on one type of surgery, such as Mohs or cosmetic procedures. Or concentrate on something in which you have special interest or expertise, such as psoriasis or pediatric dermatology.

You may find it necessary to combine several of these options to work down your backlog of appointments to a manageable level.

Once supply and demand are well balanced, you may wish to consider adopting an increasingly popular system called open-access scheduling. With open access, most patients are seen on the day they call for an appointment regardless of the reason for their visit. And surprisingly enough, when implemented correctly, it works.

Studies have shown open access to be an effective way of cutting wait times in both managed-care and fee-for-service settings. The advantages are obvious: It greatly increases patient satisfaction while making practices more profitable by virtually eliminating the financial drain of cancellations and missed appointments.

While not for everyone, open access is a viable option in many situations. It can be adopted gradually, starting with reserving some slots each day for last-minute appointments, and then gradually increasing the number of same-day slots until everyone is comfortable with them. At that point you can begin offering all patients an appointment on the day they call your office.

Of course, those patients who do not want to be seen on the day they call can be scheduled for an appointment at a time of their choice. (They should not be told to call back on the day they want to be seen.) And, while seeing patients, you will probably want to schedule some surgeries and other procedures as necessary. (Such advance appointments are known in the open access parlance as “good backlog.”)

When properly managed, open access gets high marks from both patients, who are thrilled to be able to get appointments when they want them, and office personnel, who report that the frenetic routine of answering calls, scheduling visits, and providing clinical care takes place at a much calmer pace. The phones are quieter, and schedulers, nurses, physicians, and staff spend much less time dealing with backlog issues, which leaves more time to care for patients.

Of course, eliminating all wait time, cancellations, missed appointments, and loss of patients to other physicians will take more than just creative scheduling. It will take a basic change in the way we think about the business aspects of health care, such as supply and demand, which most physicians think do not apply to them.

 

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

My last two columns discussed the complaint patients make most often: waiting too long in the office.

However, another prevalent complaint—and one that shows no sign of improving in many areas of the country—is the inability to get an appointment with a dermatologist within a reasonable period of time.

In general, patients consider any delay longer than a few days—a week at most—unreasonable. And many dermatologists are booked several weeks in advance.

A patient who finds a suspicious-looking mole and wants to see a dermatologist can expect an average wait of 38 days in the United States, and up to 73 days in Boston, according to a study from the University of California, San Francisco.

Such backlogs, besides arousing patients' ire, cost you money: The longer the wait time, the higher the likelihood of cancellations and no-shows. These leave gaps in your supposedly “full” schedule while adding to administrative work, hurting your bottom line, and driving up costs. A 2001 study showed missed appointments result in a loss of 3%–14% of annual revenues.

Backlogs also are a major reason why dermatologists are losing an increasing amount of business to less-qualified practitioners who will see patients sooner.

In the business world, this would be called a supply and demand issue, one that most successful businesses learned long ago to solve. For example, no McDonald's customer ever hears, “We don't have any Big Macs today; come back tomorrow.” Each McDonald's outlet makes certain it can match its supply with its customers' demand at any given time; if it can't, it loses big chunks of business to competitors.

And if dermatologists don't wish to continue losing ever-larger chunks of business to general practitioners and spas, we too will have to learn to balance supply (the number of available physician hours) with demand (the number of patients).

Options for increasing supply are fairly straightforward. You can increase personnel by bringing in a new associate, or hiring a physician assistant or nurse practitioner. Or you can expand appointment slots by adding hours during early mornings, evenings, or weekends.

Alternatively, you can decrease demand by eliminating third-party contracts that pay too poorly or too slowly, or restricting the type or number of new patients your practice accepts. Or you can narrow the scope of your practice: Eliminate surgery, for example, or eliminate everything except surgery, or focus on one type of surgery, such as Mohs or cosmetic procedures. Or concentrate on something in which you have special interest or expertise, such as psoriasis or pediatric dermatology.

You may find it necessary to combine several of these options to work down your backlog of appointments to a manageable level.

Once supply and demand are well balanced, you may wish to consider adopting an increasingly popular system called open-access scheduling. With open access, most patients are seen on the day they call for an appointment regardless of the reason for their visit. And surprisingly enough, when implemented correctly, it works.

Studies have shown open access to be an effective way of cutting wait times in both managed-care and fee-for-service settings. The advantages are obvious: It greatly increases patient satisfaction while making practices more profitable by virtually eliminating the financial drain of cancellations and missed appointments.

While not for everyone, open access is a viable option in many situations. It can be adopted gradually, starting with reserving some slots each day for last-minute appointments, and then gradually increasing the number of same-day slots until everyone is comfortable with them. At that point you can begin offering all patients an appointment on the day they call your office.

Of course, those patients who do not want to be seen on the day they call can be scheduled for an appointment at a time of their choice. (They should not be told to call back on the day they want to be seen.) And, while seeing patients, you will probably want to schedule some surgeries and other procedures as necessary. (Such advance appointments are known in the open access parlance as “good backlog.”)

When properly managed, open access gets high marks from both patients, who are thrilled to be able to get appointments when they want them, and office personnel, who report that the frenetic routine of answering calls, scheduling visits, and providing clinical care takes place at a much calmer pace. The phones are quieter, and schedulers, nurses, physicians, and staff spend much less time dealing with backlog issues, which leaves more time to care for patients.

Of course, eliminating all wait time, cancellations, missed appointments, and loss of patients to other physicians will take more than just creative scheduling. It will take a basic change in the way we think about the business aspects of health care, such as supply and demand, which most physicians think do not apply to them.

 

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

Despite record highs in overall life expectancy, serious disparities among racial and ethnic groups persist. African American males in this country have a life expectancy that's 6 years shorter than that of their non-Hispanic white counterparts (70 years vs. 76 years). African American females live 77 years, compared with their non-Hispanic female counterparts' 81 years, according to data from the National Center for Health Statistics.

Data from the National Health Care Disparities Report suggest that the gap between whites and people of color in the majority of core measures has grown worse, not better. Progress is being made in health care overall, but the biggest gaps in quality and access have not been reduced.

While this problem may seem beyond the scope of an office practice, you can do many things to help end these disparities:

▸ Link with community and faith-based organizations that serve people of color, and help them provide screenings for cancer, diabetes, and hypertension.

▸ Seek out social services providers. Prepare a list of resources where people can go for help with food stamps, housing problems, employment, and so on, and keep the list handy in the office. The challenges of poverty affect all aspects of life.

▸ Help uninsured patients find out if they are eligible for public insurance programs. In many states, children are covered by the State Children's Health Insurance Program and should be able to obtain coverage. (For more information, go to www.insurekidsnow.govwww.coverageforall.org

▸ Link with providers at community health centers in your area. Such centers can be located through the Health Resources and Services Administration Web site at www.hrsa.gov

▸ Schedule more frequent visits for patients with chronic illnesses that are not well controlled. These patients will require intensive intervention and health education.

▸ Pay attention to the affordability of medications that you prescribe. We often think that giving people samples of the newest and best-promoted medications helps, but when patients attempt to continue those medications, they often are the least affordable. Instead, consider prescribing suitable generic drugs to get people started on more affordable medications from the outset. When generic drugs are unavailable or unsuitable, contact the drug company's Patient Assistance Program to help your patient access free medications.

▸ For people whose first language is not English, translation is available through AT&T Language Line to help with accurate communication with your patients, although it is quite expensive. Find out if there is a community-based organization in your area that can provide trained volunteers. Using children to translate complex medical issues to their non-English-speaking parents can compromise parent-child relationships and should be avoided.

▸ If you use an electronic health record system, make sure you can capture data on race and primary language. Race data will enable you to look at health care outcomes to make sure you are doing everything possible to reduce disparities. Language data can be used to make sure outreach calls and letters are made in the appropriate language. Everyone can do their part in helping to eliminate racial and ethnic disparities in care.

Despite record highs in overall life expectancy, serious disparities among racial and ethnic groups persist. African American males in this country have a life expectancy that's 6 years shorter than that of their non-Hispanic white counterparts (70 years vs. 76 years). African American females live 77 years, compared with their non-Hispanic female counterparts' 81 years, according to data from the National Center for Health Statistics.

Data from the National Health Care Disparities Report suggest that the gap between whites and people of color in the majority of core measures has grown worse, not better. Progress is being made in health care overall, but the biggest gaps in quality and access have not been reduced.

While this problem may seem beyond the scope of an office practice, you can do many things to help end these disparities:

▸ Link with community and faith-based organizations that serve people of color, and help them provide screenings for cancer, diabetes, and hypertension.

▸ Seek out social services providers. Prepare a list of resources where people can go for help with food stamps, housing problems, employment, and so on, and keep the list handy in the office. The challenges of poverty affect all aspects of life.

▸ Help uninsured patients find out if they are eligible for public insurance programs. In many states, children are covered by the State Children's Health Insurance Program and should be able to obtain coverage. (For more information, go to www.insurekidsnow.govwww.coverageforall.org

▸ Link with providers at community health centers in your area. Such centers can be located through the Health Resources and Services Administration Web site at www.hrsa.gov

▸ Schedule more frequent visits for patients with chronic illnesses that are not well controlled. These patients will require intensive intervention and health education.

▸ Pay attention to the affordability of medications that you prescribe. We often think that giving people samples of the newest and best-promoted medications helps, but when patients attempt to continue those medications, they often are the least affordable. Instead, consider prescribing suitable generic drugs to get people started on more affordable medications from the outset. When generic drugs are unavailable or unsuitable, contact the drug company's Patient Assistance Program to help your patient access free medications.

▸ For people whose first language is not English, translation is available through AT&T Language Line to help with accurate communication with your patients, although it is quite expensive. Find out if there is a community-based organization in your area that can provide trained volunteers. Using children to translate complex medical issues to their non-English-speaking parents can compromise parent-child relationships and should be avoided.

▸ If you use an electronic health record system, make sure you can capture data on race and primary language. Race data will enable you to look at health care outcomes to make sure you are doing everything possible to reduce disparities. Language data can be used to make sure outreach calls and letters are made in the appropriate language. Everyone can do their part in helping to eliminate racial and ethnic disparities in care.

Despite record highs in overall life expectancy, serious disparities among racial and ethnic groups persist. African American males in this country have a life expectancy that's 6 years shorter than that of their non-Hispanic white counterparts (70 years vs. 76 years). African American females live 77 years, compared with their non-Hispanic female counterparts' 81 years, according to data from the National Center for Health Statistics.

Data from the National Health Care Disparities Report suggest that the gap between whites and people of color in the majority of core measures has grown worse, not better. Progress is being made in health care overall, but the biggest gaps in quality and access have not been reduced.

While this problem may seem beyond the scope of an office practice, you can do many things to help end these disparities:

▸ Link with community and faith-based organizations that serve people of color, and help them provide screenings for cancer, diabetes, and hypertension.

▸ Seek out social services providers. Prepare a list of resources where people can go for help with food stamps, housing problems, employment, and so on, and keep the list handy in the office. The challenges of poverty affect all aspects of life.

▸ Help uninsured patients find out if they are eligible for public insurance programs. In many states, children are covered by the State Children's Health Insurance Program and should be able to obtain coverage. (For more information, go to www.insurekidsnow.govwww.coverageforall.org

▸ Link with providers at community health centers in your area. Such centers can be located through the Health Resources and Services Administration Web site at www.hrsa.gov

▸ Schedule more frequent visits for patients with chronic illnesses that are not well controlled. These patients will require intensive intervention and health education.

▸ Pay attention to the affordability of medications that you prescribe. We often think that giving people samples of the newest and best-promoted medications helps, but when patients attempt to continue those medications, they often are the least affordable. Instead, consider prescribing suitable generic drugs to get people started on more affordable medications from the outset. When generic drugs are unavailable or unsuitable, contact the drug company's Patient Assistance Program to help your patient access free medications.

▸ For people whose first language is not English, translation is available through AT&T Language Line to help with accurate communication with your patients, although it is quite expensive. Find out if there is a community-based organization in your area that can provide trained volunteers. Using children to translate complex medical issues to their non-English-speaking parents can compromise parent-child relationships and should be avoided.

▸ If you use an electronic health record system, make sure you can capture data on race and primary language. Race data will enable you to look at health care outcomes to make sure you are doing everything possible to reduce disparities. Language data can be used to make sure outreach calls and letters are made in the appropriate language. Everyone can do their part in helping to eliminate racial and ethnic disparities in care.

Laceration during circumcision calls for 2nd procedure

A 1-DAY-OLD BOY was circumcised using local anesthesia and a Gomco clamp. A 1-cm laceration occurred on the underside of his penis—and was repaired that same day by a consulting urologist. Two years later, follow-up surgery was performed to remove any excess skin at the site.

PATIENT’S CLAIM The boy has permanent scarring and disfigurement. The Gomco clamp was placed improperly during the procedure, and the appropriate amount of skin was not removed.

PHYSICIAN’S DEFENSE The laceration was superficial and is a recognized risk of a Gomco clamp. The cosmetic result is good, and there is no functional impairment.

VERDICT Michigan defense verdict.

Was postop death due to infection—or unrelated illness?

A HYSTERECTOMY with node dissection was performed on a 63-year-old woman with uterine cancer. She was discharged from the hospital 3 days later—and died the following month.

PLAINTIFF’S CLAIM Death was the result of an undiagnosed postoperative intra-abdominal infection.

PHYSICIAN’S DEFENSE The patient had no postoperative infection. Instead, she developed an illness weeks after the surgery, and he was not involved in its management.

VERDICT Connecticut defense verdict.

Is the “blame” on a diabetic patient for her stillborn child?

A 23-YEAR-OLD WOMAN weighed 305 lb and had a glucose level of 218 after 3 months of prenatal care with Dr. A, her obstetrician. He consulted with Dr. B, a maternal–fetal medicine specialist, in diagnosing gestational diabetes. A few days later, the patient was examined by Dr. C, a second maternal–fetal medicine specialist, and was prescribed glyburide.

The following month, a sonogram indicated an estimated fetal weight in the 95th percentile and macrosomia. The dosage of glyburide was increased several times because of elevated glucose levels. One month later, the patient saw both Dr. B and Dr. C, who instructed her about nutrition.

A few weeks later—at 36 3/7 weeks’ gestation and weighing 327 lb—the mother was admitted to the hospital because of a large thigh abscess. She was treated and her blood sugars tested normal.

Two days later, she was discharged. The following month, she presented at the hospital complaining of no fetal movement. No fetal heart tones were found, and a C-section was performed. A 12-lb stillborn baby was delivered.

PATIENT’S CLAIM The defendants failed to monitor her properly and to communicate with each other about her condition.

PHYSICIAN’S DEFENSE The patient failed to follow diet instructions, maintain her blood-glucose logs, and take the glyburide. Appropriate care had been provided by her physicians.

VERDICT Pennsylvania defense verdict. Posttrial motions were pending.

Vacuum extraction, shoulder dystocia, resuscitation…CP

TOWARD THE END OF LABOR, when a woman was about to deliver her first child, the electronic fetal monitor was picking up her heartbeat, not the child’s. This was not recognized. Application of a vacuum extractor resulted in delivery of the head—after six attempts. Then shoulder dystocia occurred. Various maneuvers were tried unsuccessfully, until the body of the infant was finally delivered 7 minutes later: flaccid and extremely depressed, with no heartbeat or respiratory effort. The child required extensive resuscitation and then could not be intubated for 20 minutes. As a result of the birth injury, he suffered cerebral palsy with spastic quadriplegia, developmental delay, and mental retardation.

PATIENT’S CLAIM The vacuum extractor was used too early—when the fetal head was too high in the pelvis—and too many times. Also, both the shoulder dystocia and the resuscitation were mismanaged.

PHYSICIAN’S DEFENSE The vacuum extractor was used properly. The occurrence of shoulder dystocia was unpredictable and unavoidable, and difficult resuscitation was the result of a congenital anomaly of the vocal cords or laryngospasm.

VERDICT $3.25 million California settlement, reached in mediation.

Laceration during circumcision calls for 2nd procedure

A 1-DAY-OLD BOY was circumcised using local anesthesia and a Gomco clamp. A 1-cm laceration occurred on the underside of his penis—and was repaired that same day by a consulting urologist. Two years later, follow-up surgery was performed to remove any excess skin at the site.

PATIENT’S CLAIM The boy has permanent scarring and disfigurement. The Gomco clamp was placed improperly during the procedure, and the appropriate amount of skin was not removed.

PHYSICIAN’S DEFENSE The laceration was superficial and is a recognized risk of a Gomco clamp. The cosmetic result is good, and there is no functional impairment.

VERDICT Michigan defense verdict.

Was postop death due to infection—or unrelated illness?

A HYSTERECTOMY with node dissection was performed on a 63-year-old woman with uterine cancer. She was discharged from the hospital 3 days later—and died the following month.

PLAINTIFF’S CLAIM Death was the result of an undiagnosed postoperative intra-abdominal infection.

PHYSICIAN’S DEFENSE The patient had no postoperative infection. Instead, she developed an illness weeks after the surgery, and he was not involved in its management.

VERDICT Connecticut defense verdict.

Is the “blame” on a diabetic patient for her stillborn child?

A 23-YEAR-OLD WOMAN weighed 305 lb and had a glucose level of 218 after 3 months of prenatal care with Dr. A, her obstetrician. He consulted with Dr. B, a maternal–fetal medicine specialist, in diagnosing gestational diabetes. A few days later, the patient was examined by Dr. C, a second maternal–fetal medicine specialist, and was prescribed glyburide.

The following month, a sonogram indicated an estimated fetal weight in the 95th percentile and macrosomia. The dosage of glyburide was increased several times because of elevated glucose levels. One month later, the patient saw both Dr. B and Dr. C, who instructed her about nutrition.

A few weeks later—at 36 3/7 weeks’ gestation and weighing 327 lb—the mother was admitted to the hospital because of a large thigh abscess. She was treated and her blood sugars tested normal.

Two days later, she was discharged. The following month, she presented at the hospital complaining of no fetal movement. No fetal heart tones were found, and a C-section was performed. A 12-lb stillborn baby was delivered.

PATIENT’S CLAIM The defendants failed to monitor her properly and to communicate with each other about her condition.

PHYSICIAN’S DEFENSE The patient failed to follow diet instructions, maintain her blood-glucose logs, and take the glyburide. Appropriate care had been provided by her physicians.

VERDICT Pennsylvania defense verdict. Posttrial motions were pending.

Vacuum extraction, shoulder dystocia, resuscitation…CP

TOWARD THE END OF LABOR, when a woman was about to deliver her first child, the electronic fetal monitor was picking up her heartbeat, not the child’s. This was not recognized. Application of a vacuum extractor resulted in delivery of the head—after six attempts. Then shoulder dystocia occurred. Various maneuvers were tried unsuccessfully, until the body of the infant was finally delivered 7 minutes later: flaccid and extremely depressed, with no heartbeat or respiratory effort. The child required extensive resuscitation and then could not be intubated for 20 minutes. As a result of the birth injury, he suffered cerebral palsy with spastic quadriplegia, developmental delay, and mental retardation.

PATIENT’S CLAIM The vacuum extractor was used too early—when the fetal head was too high in the pelvis—and too many times. Also, both the shoulder dystocia and the resuscitation were mismanaged.

PHYSICIAN’S DEFENSE The vacuum extractor was used properly. The occurrence of shoulder dystocia was unpredictable and unavoidable, and difficult resuscitation was the result of a congenital anomaly of the vocal cords or laryngospasm.

VERDICT $3.25 million California settlement, reached in mediation.

Laceration during circumcision calls for 2nd procedure

A 1-DAY-OLD BOY was circumcised using local anesthesia and a Gomco clamp. A 1-cm laceration occurred on the underside of his penis—and was repaired that same day by a consulting urologist. Two years later, follow-up surgery was performed to remove any excess skin at the site.

PATIENT’S CLAIM The boy has permanent scarring and disfigurement. The Gomco clamp was placed improperly during the procedure, and the appropriate amount of skin was not removed.

PHYSICIAN’S DEFENSE The laceration was superficial and is a recognized risk of a Gomco clamp. The cosmetic result is good, and there is no functional impairment.

VERDICT Michigan defense verdict.

Was postop death due to infection—or unrelated illness?

A HYSTERECTOMY with node dissection was performed on a 63-year-old woman with uterine cancer. She was discharged from the hospital 3 days later—and died the following month.

PLAINTIFF’S CLAIM Death was the result of an undiagnosed postoperative intra-abdominal infection.

PHYSICIAN’S DEFENSE The patient had no postoperative infection. Instead, she developed an illness weeks after the surgery, and he was not involved in its management.

VERDICT Connecticut defense verdict.

Is the “blame” on a diabetic patient for her stillborn child?

A 23-YEAR-OLD WOMAN weighed 305 lb and had a glucose level of 218 after 3 months of prenatal care with Dr. A, her obstetrician. He consulted with Dr. B, a maternal–fetal medicine specialist, in diagnosing gestational diabetes. A few days later, the patient was examined by Dr. C, a second maternal–fetal medicine specialist, and was prescribed glyburide.

The following month, a sonogram indicated an estimated fetal weight in the 95th percentile and macrosomia. The dosage of glyburide was increased several times because of elevated glucose levels. One month later, the patient saw both Dr. B and Dr. C, who instructed her about nutrition.

A few weeks later—at 36 3/7 weeks’ gestation and weighing 327 lb—the mother was admitted to the hospital because of a large thigh abscess. She was treated and her blood sugars tested normal.

Two days later, she was discharged. The following month, she presented at the hospital complaining of no fetal movement. No fetal heart tones were found, and a C-section was performed. A 12-lb stillborn baby was delivered.

PATIENT’S CLAIM The defendants failed to monitor her properly and to communicate with each other about her condition.

PHYSICIAN’S DEFENSE The patient failed to follow diet instructions, maintain her blood-glucose logs, and take the glyburide. Appropriate care had been provided by her physicians.

VERDICT Pennsylvania defense verdict. Posttrial motions were pending.

Vacuum extraction, shoulder dystocia, resuscitation…CP

TOWARD THE END OF LABOR, when a woman was about to deliver her first child, the electronic fetal monitor was picking up her heartbeat, not the child’s. This was not recognized. Application of a vacuum extractor resulted in delivery of the head—after six attempts. Then shoulder dystocia occurred. Various maneuvers were tried unsuccessfully, until the body of the infant was finally delivered 7 minutes later: flaccid and extremely depressed, with no heartbeat or respiratory effort. The child required extensive resuscitation and then could not be intubated for 20 minutes. As a result of the birth injury, he suffered cerebral palsy with spastic quadriplegia, developmental delay, and mental retardation.

PATIENT’S CLAIM The vacuum extractor was used too early—when the fetal head was too high in the pelvis—and too many times. Also, both the shoulder dystocia and the resuscitation were mismanaged.

PHYSICIAN’S DEFENSE The vacuum extractor was used properly. The occurrence of shoulder dystocia was unpredictable and unavoidable, and difficult resuscitation was the result of a congenital anomaly of the vocal cords or laryngospasm.

VERDICT $3.25 million California settlement, reached in mediation.

Last month, I discussed the complaint patients make most often: waiting too long to see the doctor.

I suggested ways to help you stay on time, but ultimately, your success in staying on schedule depends in large part on your schedule.

No practice can run on schedule every day. There are simply too many uncontrollable variables inherent in the practice of medicine. And no single scheduling system is perfect for every practice.

The most traditional and probably the most popular scheduling system is continuous scheduling. Patients are booked at regular intervals throughout the hour; for example, the first at 9 a.m., the next at 9:15, the next at 9:30, and so on. (In the interests of clarity and simplicity, I am assuming a rate of one patient per 15 minutes. If you schedule two or even three per 15 minutes, adjust the numbers accordingly.)

Continuous scheduling is popular with patients, but it is far less than ideal for most dermatologists running high-volume practices. If the 9-a.m. patient arrives late, your entire half-day is delayed before you even start. Similarly, a single visit that takes longer than anticipated, or one unplanned patient who needs urgent care, will throw off the entire schedule.

Even without late patients or work-ins, continuous scheduling can be inefficient in high-volume offices because the workload tends to pile up toward the end of each hour as new patients arrive and you struggle to keep up.

For many offices, a better system is wave scheduling. Instead of one patient per 15 minutes, you would schedule two or three per half-hour, or three on the hour, two at 20 minutes past, and one at 40 minutes past, so that patients arrive in waves, rather than continuously. In that way, variations in time needed per patient, as well as problems created by the inevitable disruptions, will average out over each hour during the day.

Also, those end-of-hour pileups are minimized because most patients come in early in each hour.

A third, relatively new scheduling option, called open-access scheduling, is gradually gaining in popularity. More about that next month.

No appointment system, though, no matter how efficient, will eliminate the problems created by common disruptions—no-shows, tardy patients, tardy doctors, and “work-ins”—and each must be addressed individually.

Dealing with no-shows is a column in itself—particularly in dermatology, where the no-show rate is much higher than average. That column ran in the December 2004 issue.

To briefly summarize, you can eliminate one of the major reasons patients miss appointments—simple forgetfulness—by calling them the day before. Reasonably priced phone software is available from a variety of vendors to automate this process. You could also hire a teenager to do it after school each day.

Document each missed appointment in the patient's chart; it's important clinical and medicolegal information. A second missed appointment should prompt a warning, either verbal or written, that measures will be taken if it happens again. Such measures might include a charge before future appointments will be accepted, a nonrefundable advance deposit (for surgical procedures), or outright dismissal from the practice. Habitual no-shows should be dismissed. You cannot afford them.

Late-arriving patients need to be politely advised by a staffer that the efficient flow of the office depends on their punctuality. Anyone arriving more than half an hour late should be rescheduled. Treat habitually tardy patients the same way you deal with no-shows.

Of course, patients aren't the only culprits when schedules run late; all too often, it's the physician's fault.

Most patients understand unavoidable delays, but they resent being kept waiting without an explanation. You should never take shortcuts with a patient's care to see the next patient on time, but when it becomes clear that unforeseen issues will cause delays, make sure your staff explains that to patients who will be affected by it. Offer to reschedule them if the delay will be significant.

Unscheduled visits should be permitted only in situations that are truly urgent. As I mentioned last month, work-ins should be inserted as late in the schedule as possible to minimize inconvenience to patients with appointments. And once again, when a work-in does put you behind schedule, make sure the patients who are affected receive a prompt explanation.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

Last month, I discussed the complaint patients make most often: waiting too long to see the doctor.

I suggested ways to help you stay on time, but ultimately, your success in staying on schedule depends in large part on your schedule.

No practice can run on schedule every day. There are simply too many uncontrollable variables inherent in the practice of medicine. And no single scheduling system is perfect for every practice.

The most traditional and probably the most popular scheduling system is continuous scheduling. Patients are booked at regular intervals throughout the hour; for example, the first at 9 a.m., the next at 9:15, the next at 9:30, and so on. (In the interests of clarity and simplicity, I am assuming a rate of one patient per 15 minutes. If you schedule two or even three per 15 minutes, adjust the numbers accordingly.)

Continuous scheduling is popular with patients, but it is far less than ideal for most dermatologists running high-volume practices. If the 9-a.m. patient arrives late, your entire half-day is delayed before you even start. Similarly, a single visit that takes longer than anticipated, or one unplanned patient who needs urgent care, will throw off the entire schedule.

Even without late patients or work-ins, continuous scheduling can be inefficient in high-volume offices because the workload tends to pile up toward the end of each hour as new patients arrive and you struggle to keep up.

For many offices, a better system is wave scheduling. Instead of one patient per 15 minutes, you would schedule two or three per half-hour, or three on the hour, two at 20 minutes past, and one at 40 minutes past, so that patients arrive in waves, rather than continuously. In that way, variations in time needed per patient, as well as problems created by the inevitable disruptions, will average out over each hour during the day.

Also, those end-of-hour pileups are minimized because most patients come in early in each hour.

A third, relatively new scheduling option, called open-access scheduling, is gradually gaining in popularity. More about that next month.

No appointment system, though, no matter how efficient, will eliminate the problems created by common disruptions—no-shows, tardy patients, tardy doctors, and “work-ins”—and each must be addressed individually.

Dealing with no-shows is a column in itself—particularly in dermatology, where the no-show rate is much higher than average. That column ran in the December 2004 issue.

To briefly summarize, you can eliminate one of the major reasons patients miss appointments—simple forgetfulness—by calling them the day before. Reasonably priced phone software is available from a variety of vendors to automate this process. You could also hire a teenager to do it after school each day.

Document each missed appointment in the patient's chart; it's important clinical and medicolegal information. A second missed appointment should prompt a warning, either verbal or written, that measures will be taken if it happens again. Such measures might include a charge before future appointments will be accepted, a nonrefundable advance deposit (for surgical procedures), or outright dismissal from the practice. Habitual no-shows should be dismissed. You cannot afford them.

Late-arriving patients need to be politely advised by a staffer that the efficient flow of the office depends on their punctuality. Anyone arriving more than half an hour late should be rescheduled. Treat habitually tardy patients the same way you deal with no-shows.

Of course, patients aren't the only culprits when schedules run late; all too often, it's the physician's fault.

Most patients understand unavoidable delays, but they resent being kept waiting without an explanation. You should never take shortcuts with a patient's care to see the next patient on time, but when it becomes clear that unforeseen issues will cause delays, make sure your staff explains that to patients who will be affected by it. Offer to reschedule them if the delay will be significant.

Unscheduled visits should be permitted only in situations that are truly urgent. As I mentioned last month, work-ins should be inserted as late in the schedule as possible to minimize inconvenience to patients with appointments. And once again, when a work-in does put you behind schedule, make sure the patients who are affected receive a prompt explanation.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

Last month, I discussed the complaint patients make most often: waiting too long to see the doctor.

I suggested ways to help you stay on time, but ultimately, your success in staying on schedule depends in large part on your schedule.

No practice can run on schedule every day. There are simply too many uncontrollable variables inherent in the practice of medicine. And no single scheduling system is perfect for every practice.

The most traditional and probably the most popular scheduling system is continuous scheduling. Patients are booked at regular intervals throughout the hour; for example, the first at 9 a.m., the next at 9:15, the next at 9:30, and so on. (In the interests of clarity and simplicity, I am assuming a rate of one patient per 15 minutes. If you schedule two or even three per 15 minutes, adjust the numbers accordingly.)

Continuous scheduling is popular with patients, but it is far less than ideal for most dermatologists running high-volume practices. If the 9-a.m. patient arrives late, your entire half-day is delayed before you even start. Similarly, a single visit that takes longer than anticipated, or one unplanned patient who needs urgent care, will throw off the entire schedule.

Even without late patients or work-ins, continuous scheduling can be inefficient in high-volume offices because the workload tends to pile up toward the end of each hour as new patients arrive and you struggle to keep up.

For many offices, a better system is wave scheduling. Instead of one patient per 15 minutes, you would schedule two or three per half-hour, or three on the hour, two at 20 minutes past, and one at 40 minutes past, so that patients arrive in waves, rather than continuously. In that way, variations in time needed per patient, as well as problems created by the inevitable disruptions, will average out over each hour during the day.

Also, those end-of-hour pileups are minimized because most patients come in early in each hour.

A third, relatively new scheduling option, called open-access scheduling, is gradually gaining in popularity. More about that next month.

No appointment system, though, no matter how efficient, will eliminate the problems created by common disruptions—no-shows, tardy patients, tardy doctors, and “work-ins”—and each must be addressed individually.

Dealing with no-shows is a column in itself—particularly in dermatology, where the no-show rate is much higher than average. That column ran in the December 2004 issue.

To briefly summarize, you can eliminate one of the major reasons patients miss appointments—simple forgetfulness—by calling them the day before. Reasonably priced phone software is available from a variety of vendors to automate this process. You could also hire a teenager to do it after school each day.

Document each missed appointment in the patient's chart; it's important clinical and medicolegal information. A second missed appointment should prompt a warning, either verbal or written, that measures will be taken if it happens again. Such measures might include a charge before future appointments will be accepted, a nonrefundable advance deposit (for surgical procedures), or outright dismissal from the practice. Habitual no-shows should be dismissed. You cannot afford them.

Late-arriving patients need to be politely advised by a staffer that the efficient flow of the office depends on their punctuality. Anyone arriving more than half an hour late should be rescheduled. Treat habitually tardy patients the same way you deal with no-shows.

Of course, patients aren't the only culprits when schedules run late; all too often, it's the physician's fault.

Most patients understand unavoidable delays, but they resent being kept waiting without an explanation. You should never take shortcuts with a patient's care to see the next patient on time, but when it becomes clear that unforeseen issues will cause delays, make sure your staff explains that to patients who will be affected by it. Offer to reschedule them if the delay will be significant.

Unscheduled visits should be permitted only in situations that are truly urgent. As I mentioned last month, work-ins should be inserted as late in the schedule as possible to minimize inconvenience to patients with appointments. And once again, when a work-in does put you behind schedule, make sure the patients who are affected receive a prompt explanation.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

If you really want your office staff to be invested in quality improvement and come together as a team, you have to get serious about changing the culture of your practice. That means being honest about how comfortable people are speaking up and challenging your ideas and actions and those of other physicians in the practice.

Five years ago, when our practice became a pilot site for a team-building project funded by a grant from the Institute for Healthcare Improvement, I realized how wide the gap can be between how a physician views his or her practice and what is heard among the office staff in the lunch room.

If you want individuals to be invested in practice improvement, you absolutely must create an environment in which everyone feels truly welcome to present ideas and then you must genuinely listen to what they have to say. Having that openness and readiness to hear what the front desk receptionist has noticed about a patient scheduling problem, and to hear suggestions about how to fix it, is critical for team building. In most offices there is a hierarchy depending on training. We have distinct professional roles. But it is still possible to build a culture of collaboration and learning.

Building teams requires moving away from the traditional notion that excellent health care is provided by excellent doctors. Physicians are trained to be leaders, so their natural definition of a team is a group of people working together to do what they want them to do. But building a solid team is more than just delegating responsibilities. It's about inspiring people to see how they can make a difference.

There's no shortcut around the time and energy this requires—but the payoffs are phenomenal. Once a month our office closes for a 1-hour lunchtime meeting during which everyone discusses what we want to accomplish. The idea is to brainstorm about best practices.

During one meeting, we addressed our management of hypertensive patients. When asked what a best practice would like look, the staff came to the table with a cornucopia of ideas. One individual in the front office took the initiative to investigate exercise resources in the community. She also went to every local pharmacy to see whether they carried recommended home monitors. And since checking the accuracy of home blood pressure monitors was taking too much of our time, she found another avenue: The local fire department provides such services and will send our office the results.

The clinical staff is compiling an informational handout that explains the causes of high blood pressure and provides tips for lowering salt intake.

At the suggestion of the medical assistant staff, protocols have been instituted for all diabetic patients so that they have more clinical responsibilities. They have been trained to conduct foot exams, and give immunizations with standing orders instead of waiting for the physician to initiate this for each patient.

They also follow up on eye exams, faxing the provider for results and scheduling exams, if needed. All of this is done before any physician walks into the exam room.

Protocols are also in place for the clinical staff to print mammogram orders, schedule Pap smears, and provide tetanus immunizations. As a result, our quality measures on preventive care are very high. In certain cases, the staff also handles prescription refills, which is a huge load off of the physician staff.

All of these changes have led to greater satisfaction among the staff. They are much happier because they feel empowered and the difference is already making a measurable improvement in patient care.

If you really want your office staff to be invested in quality improvement and come together as a team, you have to get serious about changing the culture of your practice. That means being honest about how comfortable people are speaking up and challenging your ideas and actions and those of other physicians in the practice.

Five years ago, when our practice became a pilot site for a team-building project funded by a grant from the Institute for Healthcare Improvement, I realized how wide the gap can be between how a physician views his or her practice and what is heard among the office staff in the lunch room.

If you want individuals to be invested in practice improvement, you absolutely must create an environment in which everyone feels truly welcome to present ideas and then you must genuinely listen to what they have to say. Having that openness and readiness to hear what the front desk receptionist has noticed about a patient scheduling problem, and to hear suggestions about how to fix it, is critical for team building. In most offices there is a hierarchy depending on training. We have distinct professional roles. But it is still possible to build a culture of collaboration and learning.

Building teams requires moving away from the traditional notion that excellent health care is provided by excellent doctors. Physicians are trained to be leaders, so their natural definition of a team is a group of people working together to do what they want them to do. But building a solid team is more than just delegating responsibilities. It's about inspiring people to see how they can make a difference.

There's no shortcut around the time and energy this requires—but the payoffs are phenomenal. Once a month our office closes for a 1-hour lunchtime meeting during which everyone discusses what we want to accomplish. The idea is to brainstorm about best practices.

During one meeting, we addressed our management of hypertensive patients. When asked what a best practice would like look, the staff came to the table with a cornucopia of ideas. One individual in the front office took the initiative to investigate exercise resources in the community. She also went to every local pharmacy to see whether they carried recommended home monitors. And since checking the accuracy of home blood pressure monitors was taking too much of our time, she found another avenue: The local fire department provides such services and will send our office the results.

The clinical staff is compiling an informational handout that explains the causes of high blood pressure and provides tips for lowering salt intake.

At the suggestion of the medical assistant staff, protocols have been instituted for all diabetic patients so that they have more clinical responsibilities. They have been trained to conduct foot exams, and give immunizations with standing orders instead of waiting for the physician to initiate this for each patient.

They also follow up on eye exams, faxing the provider for results and scheduling exams, if needed. All of this is done before any physician walks into the exam room.

Protocols are also in place for the clinical staff to print mammogram orders, schedule Pap smears, and provide tetanus immunizations. As a result, our quality measures on preventive care are very high. In certain cases, the staff also handles prescription refills, which is a huge load off of the physician staff.

All of these changes have led to greater satisfaction among the staff. They are much happier because they feel empowered and the difference is already making a measurable improvement in patient care.

If you really want your office staff to be invested in quality improvement and come together as a team, you have to get serious about changing the culture of your practice. That means being honest about how comfortable people are speaking up and challenging your ideas and actions and those of other physicians in the practice.

Five years ago, when our practice became a pilot site for a team-building project funded by a grant from the Institute for Healthcare Improvement, I realized how wide the gap can be between how a physician views his or her practice and what is heard among the office staff in the lunch room.

If you want individuals to be invested in practice improvement, you absolutely must create an environment in which everyone feels truly welcome to present ideas and then you must genuinely listen to what they have to say. Having that openness and readiness to hear what the front desk receptionist has noticed about a patient scheduling problem, and to hear suggestions about how to fix it, is critical for team building. In most offices there is a hierarchy depending on training. We have distinct professional roles. But it is still possible to build a culture of collaboration and learning.

Building teams requires moving away from the traditional notion that excellent health care is provided by excellent doctors. Physicians are trained to be leaders, so their natural definition of a team is a group of people working together to do what they want them to do. But building a solid team is more than just delegating responsibilities. It's about inspiring people to see how they can make a difference.

There's no shortcut around the time and energy this requires—but the payoffs are phenomenal. Once a month our office closes for a 1-hour lunchtime meeting during which everyone discusses what we want to accomplish. The idea is to brainstorm about best practices.

During one meeting, we addressed our management of hypertensive patients. When asked what a best practice would like look, the staff came to the table with a cornucopia of ideas. One individual in the front office took the initiative to investigate exercise resources in the community. She also went to every local pharmacy to see whether they carried recommended home monitors. And since checking the accuracy of home blood pressure monitors was taking too much of our time, she found another avenue: The local fire department provides such services and will send our office the results.

The clinical staff is compiling an informational handout that explains the causes of high blood pressure and provides tips for lowering salt intake.

At the suggestion of the medical assistant staff, protocols have been instituted for all diabetic patients so that they have more clinical responsibilities. They have been trained to conduct foot exams, and give immunizations with standing orders instead of waiting for the physician to initiate this for each patient.

They also follow up on eye exams, faxing the provider for results and scheduling exams, if needed. All of this is done before any physician walks into the exam room.

Protocols are also in place for the clinical staff to print mammogram orders, schedule Pap smears, and provide tetanus immunizations. As a result, our quality measures on preventive care are very high. In certain cases, the staff also handles prescription refills, which is a huge load off of the physician staff.

All of these changes have led to greater satisfaction among the staff. They are much happier because they feel empowered and the difference is already making a measurable improvement in patient care.

Gyn neglected—twice—to read patient’s lab reports

A 51-YEAR-OLD WOMAN went to her gynecologist for her annual pelvic exam. A Pap smear was obtained and sent to the lab. The lab report stated that the smear was within normal limits, and also reported the presence of an incomplete specimen with no endocervical component in a menopausal patient. The gynecologist had the report filed without reading it. The patient was not told about the incomplete Pap smear or offered the chance to have it repeated. When she returned the following year for her exam, the lab reported again that the Pap smear was normal, but mentioned the presence of inflammation and/or infection. Once again, the report was filed without the physician reading it. Four weeks later, the patient had a vaginal hemorrhage and returned to the same gynecologist. A biopsy and other tests indicated stage IIIB cervical cancer. Treatment included chemotherapy, brachytherapy, and external beam radiation. The cancer went into remission, but returned a year later. A total pelvic exenteration was performed. The patient now requires an ileostomy and a urinary conduit.

PATIENT’S CLAIM The gynecologist was negligent for failing to read the reports and failing to perform proper pelvic exams. The lab was negligent for misreading the Pap smears. Also, the first Pap smear showed an unreported high-grade intraepithelial lesion, and the second showed unreported invasive squamous cell carcinoma.

DOCTOR’S DEFENSE The gynecologist admitted that she never read the lab reports as they were filed by another who apparently read them. No further testing was needed as the results were within normal limits.

VERDICT $2.5 million settlement with the laboratory during trial; a $30 million gross New York verdict was returned. A jury found negligence by the gynecologist, and assigned 10% of liability to the laboratory. Net recovery was $29.5 million, reached by offsetting the liability finding and adding the settlement. Pending was a posttrial motion arguing that the verdict was excessive.

Adolescent mom has hysterectomy due to infection

A 16-YEAR-OLD PATIENT presented at the hospital at term for delivery of her infant. Her labor arrested, and a family practitioner delivered a healthy baby by cesarean section. The mother developed a surgical wound infection, which was treated with intravenous antibiotics. She improved initially. One week after surgery, the wound opened and drained spontaneously. Further surgery showed a deep uterine infection or endomyometritis. To save the patient’s life, a hysterectomy was performed. She recovered eventually with no residual problems.

PATIENT’S CLAIM The physician should have administered prophylactic antibiotics at the time of delivery because of the patient’s high risk of infection.

DOCTOR’S DEFENSE Use of prophylactic antibiotics at delivery is not the standard of care. Also, the infection could not have been diagnosed earlier.

VERDICT Illinois defense verdict.

Surgery causes, but can’t fix, foreshortened vagina

A 52-YEAR-OLD WOMAN experiencing urinary incontinence, constipation, and pressure in her pelvis was diagnosed by her ObGyn with a cystocele, rectocele and enterocele. Of two surgical options offered, she chose the one that would allow normal sexual relations. The surgery went well. At her second postop follow-up exam, she was told that everything had healed, the vaginal wall was intact, and she could resume sexual intercourse. But intercourse was impossible due to a foreshortened vagina—only 4 cm—and her incontinence had worsened. Two years later, a second physician performed reconstructive surgery, which corrected the incontinence but only slightly improved the foreshortened vagina.

PATIENT’S CLAIM The ObGyn did not perform the correct procedure; his technique was not good; there was no informed consent; and the procedure caused excessive scarring and removed more than half of the vagina.

DOCTOR’S DEFENSE There was informed consent; excessive scarring is a recognized complication; and the patient failed to return for further follow-up exams and to follow instructions on the use of estrogen and dilators.

VERDICT $1,580,000 Indiana verdict, including $300,000 to the husband for loss of consortium. This was reduced to the statutory cap of $1,250,000.

Gyn neglected—twice—to read patient’s lab reports

A 51-YEAR-OLD WOMAN went to her gynecologist for her annual pelvic exam. A Pap smear was obtained and sent to the lab. The lab report stated that the smear was within normal limits, and also reported the presence of an incomplete specimen with no endocervical component in a menopausal patient. The gynecologist had the report filed without reading it. The patient was not told about the incomplete Pap smear or offered the chance to have it repeated. When she returned the following year for her exam, the lab reported again that the Pap smear was normal, but mentioned the presence of inflammation and/or infection. Once again, the report was filed without the physician reading it. Four weeks later, the patient had a vaginal hemorrhage and returned to the same gynecologist. A biopsy and other tests indicated stage IIIB cervical cancer. Treatment included chemotherapy, brachytherapy, and external beam radiation. The cancer went into remission, but returned a year later. A total pelvic exenteration was performed. The patient now requires an ileostomy and a urinary conduit.

PATIENT’S CLAIM The gynecologist was negligent for failing to read the reports and failing to perform proper pelvic exams. The lab was negligent for misreading the Pap smears. Also, the first Pap smear showed an unreported high-grade intraepithelial lesion, and the second showed unreported invasive squamous cell carcinoma.

DOCTOR’S DEFENSE The gynecologist admitted that she never read the lab reports as they were filed by another who apparently read them. No further testing was needed as the results were within normal limits.

VERDICT $2.5 million settlement with the laboratory during trial; a $30 million gross New York verdict was returned. A jury found negligence by the gynecologist, and assigned 10% of liability to the laboratory. Net recovery was $29.5 million, reached by offsetting the liability finding and adding the settlement. Pending was a posttrial motion arguing that the verdict was excessive.

Adolescent mom has hysterectomy due to infection

A 16-YEAR-OLD PATIENT presented at the hospital at term for delivery of her infant. Her labor arrested, and a family practitioner delivered a healthy baby by cesarean section. The mother developed a surgical wound infection, which was treated with intravenous antibiotics. She improved initially. One week after surgery, the wound opened and drained spontaneously. Further surgery showed a deep uterine infection or endomyometritis. To save the patient’s life, a hysterectomy was performed. She recovered eventually with no residual problems.

PATIENT’S CLAIM The physician should have administered prophylactic antibiotics at the time of delivery because of the patient’s high risk of infection.

DOCTOR’S DEFENSE Use of prophylactic antibiotics at delivery is not the standard of care. Also, the infection could not have been diagnosed earlier.

VERDICT Illinois defense verdict.

Surgery causes, but can’t fix, foreshortened vagina

A 52-YEAR-OLD WOMAN experiencing urinary incontinence, constipation, and pressure in her pelvis was diagnosed by her ObGyn with a cystocele, rectocele and enterocele. Of two surgical options offered, she chose the one that would allow normal sexual relations. The surgery went well. At her second postop follow-up exam, she was told that everything had healed, the vaginal wall was intact, and she could resume sexual intercourse. But intercourse was impossible due to a foreshortened vagina—only 4 cm—and her incontinence had worsened. Two years later, a second physician performed reconstructive surgery, which corrected the incontinence but only slightly improved the foreshortened vagina.

PATIENT’S CLAIM The ObGyn did not perform the correct procedure; his technique was not good; there was no informed consent; and the procedure caused excessive scarring and removed more than half of the vagina.

DOCTOR’S DEFENSE There was informed consent; excessive scarring is a recognized complication; and the patient failed to return for further follow-up exams and to follow instructions on the use of estrogen and dilators.

VERDICT $1,580,000 Indiana verdict, including $300,000 to the husband for loss of consortium. This was reduced to the statutory cap of $1,250,000.

Gyn neglected—twice—to read patient’s lab reports

A 51-YEAR-OLD WOMAN went to her gynecologist for her annual pelvic exam. A Pap smear was obtained and sent to the lab. The lab report stated that the smear was within normal limits, and also reported the presence of an incomplete specimen with no endocervical component in a menopausal patient. The gynecologist had the report filed without reading it. The patient was not told about the incomplete Pap smear or offered the chance to have it repeated. When she returned the following year for her exam, the lab reported again that the Pap smear was normal, but mentioned the presence of inflammation and/or infection. Once again, the report was filed without the physician reading it. Four weeks later, the patient had a vaginal hemorrhage and returned to the same gynecologist. A biopsy and other tests indicated stage IIIB cervical cancer. Treatment included chemotherapy, brachytherapy, and external beam radiation. The cancer went into remission, but returned a year later. A total pelvic exenteration was performed. The patient now requires an ileostomy and a urinary conduit.

PATIENT’S CLAIM The gynecologist was negligent for failing to read the reports and failing to perform proper pelvic exams. The lab was negligent for misreading the Pap smears. Also, the first Pap smear showed an unreported high-grade intraepithelial lesion, and the second showed unreported invasive squamous cell carcinoma.

DOCTOR’S DEFENSE The gynecologist admitted that she never read the lab reports as they were filed by another who apparently read them. No further testing was needed as the results were within normal limits.

VERDICT $2.5 million settlement with the laboratory during trial; a $30 million gross New York verdict was returned. A jury found negligence by the gynecologist, and assigned 10% of liability to the laboratory. Net recovery was $29.5 million, reached by offsetting the liability finding and adding the settlement. Pending was a posttrial motion arguing that the verdict was excessive.

Adolescent mom has hysterectomy due to infection

A 16-YEAR-OLD PATIENT presented at the hospital at term for delivery of her infant. Her labor arrested, and a family practitioner delivered a healthy baby by cesarean section. The mother developed a surgical wound infection, which was treated with intravenous antibiotics. She improved initially. One week after surgery, the wound opened and drained spontaneously. Further surgery showed a deep uterine infection or endomyometritis. To save the patient’s life, a hysterectomy was performed. She recovered eventually with no residual problems.

PATIENT’S CLAIM The physician should have administered prophylactic antibiotics at the time of delivery because of the patient’s high risk of infection.

DOCTOR’S DEFENSE Use of prophylactic antibiotics at delivery is not the standard of care. Also, the infection could not have been diagnosed earlier.

VERDICT Illinois defense verdict.

Surgery causes, but can’t fix, foreshortened vagina

A 52-YEAR-OLD WOMAN experiencing urinary incontinence, constipation, and pressure in her pelvis was diagnosed by her ObGyn with a cystocele, rectocele and enterocele. Of two surgical options offered, she chose the one that would allow normal sexual relations. The surgery went well. At her second postop follow-up exam, she was told that everything had healed, the vaginal wall was intact, and she could resume sexual intercourse. But intercourse was impossible due to a foreshortened vagina—only 4 cm—and her incontinence had worsened. Two years later, a second physician performed reconstructive surgery, which corrected the incontinence but only slightly improved the foreshortened vagina.

PATIENT’S CLAIM The ObGyn did not perform the correct procedure; his technique was not good; there was no informed consent; and the procedure caused excessive scarring and removed more than half of the vagina.

DOCTOR’S DEFENSE There was informed consent; excessive scarring is a recognized complication; and the patient failed to return for further follow-up exams and to follow instructions on the use of estrogen and dilators.

VERDICT $1,580,000 Indiana verdict, including $300,000 to the husband for loss of consortium. This was reduced to the statutory cap of $1,250,000.

Consumer Reports surveyed its readers last year regarding their satisfaction with their medical care and found that the “overwhelming majority … were highly satisfied with their doctors.” Of course, they did have some complaints.

As you might expect, their top complaint about doctors was the time spent waiting to see them: Twenty-four percent said they frequently waited 30 minutes or longer.

I've written about punctuality before, but this is such a ubiquitous problem that it bears repeating.

Here are some suggestions that can help to keep you on track:

Start on time. That seems obvious, but I'm always amazed at the number of doctors who admit to running late who also admit that they start late. If you're in the hole before you even start, you can seldom dig yourself out. Sometimes an on-time start is the solution to the entire problem. If you doubt me, try it.

Book realistically. Everyone works at a different pace. Determine the number of patients you can comfortably see in an hour, and book only that number. If you want to see more patients, the solution is working longer hours or hiring physicians or physician extenders (or both), not overloading your schedule.

Time-stamp each chart. Every office should have a time clock, not only for employees, but for patients as well. As each patient arrives, have your receptionist time-stamp the “encounter form” that goes to the back with the chart. As you take each chart off the door and enter the exam room, one glance at the time stamp will tell you exactly how long that patient has been waiting for you.

Schedule all surgeries. If you haven't scheduled the time necessary for a surgical procedure, don't do it. It's tempting to “squeeze in” an excision because you feel guilty that the patient has already had to wait for you, but every unscheduled surgery puts you that much further behind. And hurrying through a procedure increases the risk of mistakes.

Explain to the patient that surgery requires extra time and it cannot be rushed, so you will have to schedule another appointment.

Work-ins come last, not first. Patients with urgent problems should be seen after scheduled patients.

This may seem counterintuitive. Receptionists often assume it's better to squeeze them in early, while you're still running on time, but doing that guarantees you will run late, and it isn't fair to patients who have appointments and expect to be seen promptly.

Work-ins, on the other hand, expect a wait because they have no appointment. We tell these patients, “Our schedule is full today, but if you come at the end of hours, the doctor will see you. But you may have a wait.” Far from complaining, they invariably thank us for seeing them.

Seize the list. You know which list I mean: “No. 16: My right big toe itches. No. 17: I think I feel something on my back. No. 18: This weird chartreuse thing on my arm. …” One long list can leave an entire half-day schedule in shambles.

When a list is produced, the best option is to take it and read it yourself. Identify the most important two or three problems and address them.

For the rest of the items on the list, I will say, “This group of problems deserves a visit of its own, and we will schedule that visit.”

Then I will ask if I can place the list (or a photocopy) in the patient's chart. It is, after all, important clinical information.

All of the problems on the list are important to the patient and should be addressed—but on your schedule, not on the patient's.

Avoid interruptions. Especially phone calls. Unless it's an emergency or an immediate family member, my receptionists say, “I'm sorry, the doctor is with patients. May I take a message?” Everyone—even other physicians—understands. Just be sure to return those calls promptly.

Pharmaceutical reps should not be allowed to interrupt you, either. Have them make an appointment, just like everybody else.

Don't stop to open the mail, to do paperwork, or to perform any other task that can be delegated.

There will be times, of course, when you run late, but they should be the exception rather than the rule. By streamlining your procedures and avoiding the pitfalls mentioned, you can give almost every patient all the time he or she deserves without keeping the next patient waiting.

Incidentally, the other leading patient complaints in the Consumer Reports survey were: couldn't schedule an appointment within a week (19%), spent too little time with me (9%), didn't provide test results promptly (7%), and didn't respond to my phone calls promptly (6%).

 

Now would be an excellent opportunity to identify and address any of those problems as well.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

Consumer Reports surveyed its readers last year regarding their satisfaction with their medical care and found that the “overwhelming majority … were highly satisfied with their doctors.” Of course, they did have some complaints.

As you might expect, their top complaint about doctors was the time spent waiting to see them: Twenty-four percent said they frequently waited 30 minutes or longer.

I've written about punctuality before, but this is such a ubiquitous problem that it bears repeating.

Here are some suggestions that can help to keep you on track:

Start on time. That seems obvious, but I'm always amazed at the number of doctors who admit to running late who also admit that they start late. If you're in the hole before you even start, you can seldom dig yourself out. Sometimes an on-time start is the solution to the entire problem. If you doubt me, try it.

Book realistically. Everyone works at a different pace. Determine the number of patients you can comfortably see in an hour, and book only that number. If you want to see more patients, the solution is working longer hours or hiring physicians or physician extenders (or both), not overloading your schedule.

Time-stamp each chart. Every office should have a time clock, not only for employees, but for patients as well. As each patient arrives, have your receptionist time-stamp the “encounter form” that goes to the back with the chart. As you take each chart off the door and enter the exam room, one glance at the time stamp will tell you exactly how long that patient has been waiting for you.

Schedule all surgeries. If you haven't scheduled the time necessary for a surgical procedure, don't do it. It's tempting to “squeeze in” an excision because you feel guilty that the patient has already had to wait for you, but every unscheduled surgery puts you that much further behind. And hurrying through a procedure increases the risk of mistakes.

Explain to the patient that surgery requires extra time and it cannot be rushed, so you will have to schedule another appointment.

Work-ins come last, not first. Patients with urgent problems should be seen after scheduled patients.

This may seem counterintuitive. Receptionists often assume it's better to squeeze them in early, while you're still running on time, but doing that guarantees you will run late, and it isn't fair to patients who have appointments and expect to be seen promptly.

Work-ins, on the other hand, expect a wait because they have no appointment. We tell these patients, “Our schedule is full today, but if you come at the end of hours, the doctor will see you. But you may have a wait.” Far from complaining, they invariably thank us for seeing them.

Seize the list. You know which list I mean: “No. 16: My right big toe itches. No. 17: I think I feel something on my back. No. 18: This weird chartreuse thing on my arm. …” One long list can leave an entire half-day schedule in shambles.

When a list is produced, the best option is to take it and read it yourself. Identify the most important two or three problems and address them.

For the rest of the items on the list, I will say, “This group of problems deserves a visit of its own, and we will schedule that visit.”

Then I will ask if I can place the list (or a photocopy) in the patient's chart. It is, after all, important clinical information.

All of the problems on the list are important to the patient and should be addressed—but on your schedule, not on the patient's.

Avoid interruptions. Especially phone calls. Unless it's an emergency or an immediate family member, my receptionists say, “I'm sorry, the doctor is with patients. May I take a message?” Everyone—even other physicians—understands. Just be sure to return those calls promptly.

Pharmaceutical reps should not be allowed to interrupt you, either. Have them make an appointment, just like everybody else.

Don't stop to open the mail, to do paperwork, or to perform any other task that can be delegated.

There will be times, of course, when you run late, but they should be the exception rather than the rule. By streamlining your procedures and avoiding the pitfalls mentioned, you can give almost every patient all the time he or she deserves without keeping the next patient waiting.

Incidentally, the other leading patient complaints in the Consumer Reports survey were: couldn't schedule an appointment within a week (19%), spent too little time with me (9%), didn't provide test results promptly (7%), and didn't respond to my phone calls promptly (6%).

 

Now would be an excellent opportunity to identify and address any of those problems as well.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

Consumer Reports surveyed its readers last year regarding their satisfaction with their medical care and found that the “overwhelming majority … were highly satisfied with their doctors.” Of course, they did have some complaints.

As you might expect, their top complaint about doctors was the time spent waiting to see them: Twenty-four percent said they frequently waited 30 minutes or longer.

I've written about punctuality before, but this is such a ubiquitous problem that it bears repeating.

Here are some suggestions that can help to keep you on track:

Start on time. That seems obvious, but I'm always amazed at the number of doctors who admit to running late who also admit that they start late. If you're in the hole before you even start, you can seldom dig yourself out. Sometimes an on-time start is the solution to the entire problem. If you doubt me, try it.

Book realistically. Everyone works at a different pace. Determine the number of patients you can comfortably see in an hour, and book only that number. If you want to see more patients, the solution is working longer hours or hiring physicians or physician extenders (or both), not overloading your schedule.

Time-stamp each chart. Every office should have a time clock, not only for employees, but for patients as well. As each patient arrives, have your receptionist time-stamp the “encounter form” that goes to the back with the chart. As you take each chart off the door and enter the exam room, one glance at the time stamp will tell you exactly how long that patient has been waiting for you.

Schedule all surgeries. If you haven't scheduled the time necessary for a surgical procedure, don't do it. It's tempting to “squeeze in” an excision because you feel guilty that the patient has already had to wait for you, but every unscheduled surgery puts you that much further behind. And hurrying through a procedure increases the risk of mistakes.

Explain to the patient that surgery requires extra time and it cannot be rushed, so you will have to schedule another appointment.

Work-ins come last, not first. Patients with urgent problems should be seen after scheduled patients.

This may seem counterintuitive. Receptionists often assume it's better to squeeze them in early, while you're still running on time, but doing that guarantees you will run late, and it isn't fair to patients who have appointments and expect to be seen promptly.

Work-ins, on the other hand, expect a wait because they have no appointment. We tell these patients, “Our schedule is full today, but if you come at the end of hours, the doctor will see you. But you may have a wait.” Far from complaining, they invariably thank us for seeing them.

Seize the list. You know which list I mean: “No. 16: My right big toe itches. No. 17: I think I feel something on my back. No. 18: This weird chartreuse thing on my arm. …” One long list can leave an entire half-day schedule in shambles.

When a list is produced, the best option is to take it and read it yourself. Identify the most important two or three problems and address them.

For the rest of the items on the list, I will say, “This group of problems deserves a visit of its own, and we will schedule that visit.”

Then I will ask if I can place the list (or a photocopy) in the patient's chart. It is, after all, important clinical information.

All of the problems on the list are important to the patient and should be addressed—but on your schedule, not on the patient's.

Avoid interruptions. Especially phone calls. Unless it's an emergency or an immediate family member, my receptionists say, “I'm sorry, the doctor is with patients. May I take a message?” Everyone—even other physicians—understands. Just be sure to return those calls promptly.

Pharmaceutical reps should not be allowed to interrupt you, either. Have them make an appointment, just like everybody else.

Don't stop to open the mail, to do paperwork, or to perform any other task that can be delegated.

There will be times, of course, when you run late, but they should be the exception rather than the rule. By streamlining your procedures and avoiding the pitfalls mentioned, you can give almost every patient all the time he or she deserves without keeping the next patient waiting.

Incidentally, the other leading patient complaints in the Consumer Reports survey were: couldn't schedule an appointment within a week (19%), spent too little time with me (9%), didn't provide test results promptly (7%), and didn't respond to my phone calls promptly (6%).

 

Now would be an excellent opportunity to identify and address any of those problems as well.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

Nothing's worse than having the first appointment of your day interrupted by an unexpected—and unpleasant—surprise. Instead of a child who is running a fever or a middle-aged man concerned about his blood pressure, you are faced with a sheriff serving a summons.

Here's a suggestion: Consider that preventive care in the legal world works much the same way as in medicine. Try adopting some common-sense methods, an “eat-right-and-don't-smoke” model of addressing the legal system. This will work to keep lawyers out of your office and out of your life.

The better care you take of yourself legally means the greater your chances of swearing off lawyers forever; the same way that taking care of your body may well mean that you can avoid some medical interventions.

Here are uggestions that we've gathered from the trenches. Some might not apply to your specific situation, but many will:

▸ Return pages from your answering service with your cell phone.

People who sue frequently allege the doctor did not call them back in a timely fashion, or even at all. If you call from a land line, there is no guarantee that a record of the call has been made; call from a cell phone and a record is created. Won't patients abuse the privilege and call you directly on your cell? Generally not.

▸ Document what was said.

It is too easy to give advice and ignore the paper trail. If you use an electronic medical record, log in and record. If you have access to call-in transcription service, use it. If not, create a separate voice mailbox on your office phone to be used for transcription of after-hours messages.

▸ Guarantee to patients they will receive lab and radiology results in a specified time period or their office visit is free.

That's right. If you tell the patient they will hear from you regarding their results, they will never assume that no news is good news. This is a frequent source of litigation, particularly if the test reveals something such as cancer. The doctor often assumes the staff sent information to the patient. The patient assumes the absence of information is positive. Tie your office manager's bonus to how frequently such refunds are tendered, and you will find information gets transferred with near 100% fidelity.

▸ Document what you did NOT do.

Although it sounds counterintuitive, there are times it makes eminent sense to document what was NOT done. Sometimes, there is extensive literature explaining the merits of following a particular guideline for a condition, but, for a variety of reasons, you might choose, in your judgment, to forego such treatments. The default assumption by a plaintiff's attorney will be “that if it was not documented, you were unaware of such standards for treatment, and you didn't even think about it.” But, if you document your reasoning for avoiding such an established treatment, because in your judgment, in this particular case, the risks outweighed the benefits, you will sidestep the allegation you breached the standard of care. It takes 2 minutes to document. If you address it upfront, it's an explanation. If you address it after the fact, it's an excuse.

▸ Think twice before you send a patient to collections for a $22 balance.

First, you'll never see the $22. If the carrier has paid the physician hundreds or thousands, and the patient had an untoward result, the threat to send to collections might not be the best way to engender good will. Patients generally like their physicians. They do not want to sue their doctor. But no one wants to be sent to a collection agency for $22.

Nothing's worse than having the first appointment of your day interrupted by an unexpected—and unpleasant—surprise. Instead of a child who is running a fever or a middle-aged man concerned about his blood pressure, you are faced with a sheriff serving a summons.

Here's a suggestion: Consider that preventive care in the legal world works much the same way as in medicine. Try adopting some common-sense methods, an “eat-right-and-don't-smoke” model of addressing the legal system. This will work to keep lawyers out of your office and out of your life.

The better care you take of yourself legally means the greater your chances of swearing off lawyers forever; the same way that taking care of your body may well mean that you can avoid some medical interventions.

Here are uggestions that we've gathered from the trenches. Some might not apply to your specific situation, but many will:

▸ Return pages from your answering service with your cell phone.

People who sue frequently allege the doctor did not call them back in a timely fashion, or even at all. If you call from a land line, there is no guarantee that a record of the call has been made; call from a cell phone and a record is created. Won't patients abuse the privilege and call you directly on your cell? Generally not.

▸ Document what was said.

It is too easy to give advice and ignore the paper trail. If you use an electronic medical record, log in and record. If you have access to call-in transcription service, use it. If not, create a separate voice mailbox on your office phone to be used for transcription of after-hours messages.

▸ Guarantee to patients they will receive lab and radiology results in a specified time period or their office visit is free.

That's right. If you tell the patient they will hear from you regarding their results, they will never assume that no news is good news. This is a frequent source of litigation, particularly if the test reveals something such as cancer. The doctor often assumes the staff sent information to the patient. The patient assumes the absence of information is positive. Tie your office manager's bonus to how frequently such refunds are tendered, and you will find information gets transferred with near 100% fidelity.

▸ Document what you did NOT do.

Although it sounds counterintuitive, there are times it makes eminent sense to document what was NOT done. Sometimes, there is extensive literature explaining the merits of following a particular guideline for a condition, but, for a variety of reasons, you might choose, in your judgment, to forego such treatments. The default assumption by a plaintiff's attorney will be “that if it was not documented, you were unaware of such standards for treatment, and you didn't even think about it.” But, if you document your reasoning for avoiding such an established treatment, because in your judgment, in this particular case, the risks outweighed the benefits, you will sidestep the allegation you breached the standard of care. It takes 2 minutes to document. If you address it upfront, it's an explanation. If you address it after the fact, it's an excuse.

▸ Think twice before you send a patient to collections for a $22 balance.

First, you'll never see the $22. If the carrier has paid the physician hundreds or thousands, and the patient had an untoward result, the threat to send to collections might not be the best way to engender good will. Patients generally like their physicians. They do not want to sue their doctor. But no one wants to be sent to a collection agency for $22.

Nothing's worse than having the first appointment of your day interrupted by an unexpected—and unpleasant—surprise. Instead of a child who is running a fever or a middle-aged man concerned about his blood pressure, you are faced with a sheriff serving a summons.

Here's a suggestion: Consider that preventive care in the legal world works much the same way as in medicine. Try adopting some common-sense methods, an “eat-right-and-don't-smoke” model of addressing the legal system. This will work to keep lawyers out of your office and out of your life.

The better care you take of yourself legally means the greater your chances of swearing off lawyers forever; the same way that taking care of your body may well mean that you can avoid some medical interventions.

Here are uggestions that we've gathered from the trenches. Some might not apply to your specific situation, but many will:

▸ Return pages from your answering service with your cell phone.

People who sue frequently allege the doctor did not call them back in a timely fashion, or even at all. If you call from a land line, there is no guarantee that a record of the call has been made; call from a cell phone and a record is created. Won't patients abuse the privilege and call you directly on your cell? Generally not.

▸ Document what was said.

It is too easy to give advice and ignore the paper trail. If you use an electronic medical record, log in and record. If you have access to call-in transcription service, use it. If not, create a separate voice mailbox on your office phone to be used for transcription of after-hours messages.

▸ Guarantee to patients they will receive lab and radiology results in a specified time period or their office visit is free.

That's right. If you tell the patient they will hear from you regarding their results, they will never assume that no news is good news. This is a frequent source of litigation, particularly if the test reveals something such as cancer. The doctor often assumes the staff sent information to the patient. The patient assumes the absence of information is positive. Tie your office manager's bonus to how frequently such refunds are tendered, and you will find information gets transferred with near 100% fidelity.

▸ Document what you did NOT do.

Although it sounds counterintuitive, there are times it makes eminent sense to document what was NOT done. Sometimes, there is extensive literature explaining the merits of following a particular guideline for a condition, but, for a variety of reasons, you might choose, in your judgment, to forego such treatments. The default assumption by a plaintiff's attorney will be “that if it was not documented, you were unaware of such standards for treatment, and you didn't even think about it.” But, if you document your reasoning for avoiding such an established treatment, because in your judgment, in this particular case, the risks outweighed the benefits, you will sidestep the allegation you breached the standard of care. It takes 2 minutes to document. If you address it upfront, it's an explanation. If you address it after the fact, it's an excuse.

▸ Think twice before you send a patient to collections for a $22 balance.

First, you'll never see the $22. If the carrier has paid the physician hundreds or thousands, and the patient had an untoward result, the threat to send to collections might not be the best way to engender good will. Patients generally like their physicians. They do not want to sue their doctor. But no one wants to be sent to a collection agency for $22.