Managing Your Practice

The authors report no financial relationships relevant to this article.

CASE: Primigravida with ruptured membranes

A 21-year-old patient was admitted to the labor and delivery suite in active labor. After a reassuring fetal tracing was documented, active management with oxytocin was initiated.

Five hours later, the nurse noted a prolonged deceleration.

Resuscitative efforts failed to alleviate the deceleration. The nurse notified the attending OB of the situation. An emergency cesarean section was called because:

1. of a nonreassuring fetal heart rate tracing and
   
2. delivery was not imminent.
   

Now, the attending leaves her home promptly to perform the cesarean section; the anesthesiologist, who is not in the hospital, is notified.

The team is assembled and the patient is moved to the operating room; 34 minutes have elapsed between the time the decision was made to perform the cesarean section and the time the incision is made on the abdomen.

Two minutes later, the baby is delivered. Apgar scores are as follows: 0 at 1 minute; 0 at 5 minutes; 0 at 10 minutes; and 1 at 15 minutes.

Subsequently, the baby is determined to be severely brain-damaged. The parents file a claim of malpractice.

ObGyns have come to depend on ACOG’s Committee Opinions, Educational Bulletins, Practice Bulletins, Policy Statements, and Technology Assessments to help us take the best care of our patients. To quote the College, each of these documents “is reviewed periodically and either reaffirmed, replaced, or withdrawn to ensure its continued appropriateness to practice.”¹

Sometimes, however, an ACOG bulletin, statement, or assessment may be misinterpreted and can actually contribute to some of the medicolegal problems that we face. The actual clinical situation just described, relating to ACOG’s statement on the so-called decision-to-incision gold standard, is a case in point.

The parties in the case go to trial

During the subsequent trial, the plaintiff alleges negligence by claiming that the defendant:

• did not anticipate or recognize developing fetal problems
  
• failed to perform a C-section within 30 minutes after the decision was made to do so.
  

The defendant counters:

• There was no fetal indication of hypoxia or cause for concern until the fetal bradycardia was noted
  
• Brain damage was caused by an unanticipated event that occurred more than 30 minutes before delivery
  
• The team responded as rapidly as it could given the circumstances of the hospital and staffing patterns.
  

No verdict was reached; instead, the parties agreed to a multimillion-dollar settlement that is based on 1) more than 30 minutes having elapsed from “decision to incision” and 2) the assertion that a 30-minute decision-to-incision time is the standard of care for an emergency C-section.

Are we held to a standard that can’t be met and has no basis in evidence?

To repeat, as reported in hospital records admitted into evidence at trial, the baby was delivered, with a low Apgar score, 34 minutes after the decision was called. The fact that the incision commenced after more than 30 minutes was a major factor contributing to the multimillion-dollar settlement.

That 30-minute mark is taken directly from the fifth edition of ACOG’s Guideline for Perinatal Care:

Any hospital providing obstetric service should have the capability of responding to an obstetric emergency. No data correlate the timing of intervention with outcome, and there is little likelihood that any will be obtained. However, in general, the consensus has been that hospitals should have the capability of beginning a cesarean section within 30 minutes of the decision to operate.²

The interpretation that all C-sections must be performed within 30 minutes of a decision is challenged by a recent study sponsored by The National Institute of Child Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network.³ The design of that study was observational, because no ethical means exist to randomize women to less than or more than 30 minutes from the time of a decision to perform a C-section to the time of the incision.

The data collected came only from primagravid women in active labor who had an infant that had a birth weight of more than 2,500 g. Indications for C-section included: nonreassuring fetal heart rate, umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, and uterine rupture. A total of 11,481 cases were analyzed over a 2-year period, with 2,808 C-sections performed for those indications (a 24.5% rate of C-section). Ninety-four per cent of the C-sections were undertaken because of a nonreassuring fetal heart rate.

 

In a university setting, where one would expect in-house OB coverage and anesthesia to be available, only 65% of emergency C-sections commenced within 30 minutes of a decision (17% in less than 10 minutes; 27% in less than 20 minutes). Investigators also found that, in cases in which a C-section was performed for a nonreassuring fetal heart rate, only 62% were performed in fewer than 30 minutes.

The data are clear: More than one third of all C-sections for these indications did not comply with the “30-minute rule.”

Notably, the study also found that:

• when the decision-to-incision time was less than 30 minutes, the rates of fetal acidemia and intubation in the delivery room were higher
  
• 95% of infants delivered in more than 31 minutes did not experience any of the adverse outcomes listed in the accompanying TABLE
  
• only one of eight neonatal deaths occurred in the group of infants delivered after 31 minutes (at 33 minutes).
  

The investigators also found that decision-to-incision time had no impact on maternal complications.

TABLE

Outcomes are no better when the decision-to-incision time is less than 30 minutes³

OUTCOME	INCIDENCE AT	INCIDENCE AT >30 MIN
Urine pH,	4.8%	1.6%*
Intubation in delivery	3.1%	1.3%*
Hypoxic–ischemic encephalopathy	0.7%	0.5%
Fetal death	0.2%	0%
Neonatal death	0.4%	0.2%
Apgar score at 5 min,	1.0%	0.9%
None of the above	92.6%	95.4%*
*P .05>

30 minutes? It’s not a mandate

The study supported by NICHD shows that:

• the decision-to-incision interval appears to have no impact on maternal complications
  
• an infant delivered within 30 minutes for an emergency indication was more likely to be acidemic and to require intubation than an infant delivered in longer than 30 minutes for an emergency indication
  
• delivery within 30 minutes does not guarantee that there will be no adverse outcome
  
• 95% of infants delivered in more than 30 minutes did not have compromise.
  

Where did it originate? These facts make us wonder: How did the controversial, seemingly random time of 30 minutes crawl into the courtroom and become a benchmark? Why have attorneys and expert witnesses for the plaintiff taken this 30-minute rule to be fact?

The ACOG guideline is, as stated, clearly not a requirement. It does not mandate that all C-sections commence within 30 minutes from the time of the decision to perform one. Rather, the guideline clearly states that the hospital should be capable of performing the procedure within 30 minutes.

To be clear, we are not advocating a guideline or policy of waiting to perform a C-section! We believe rapid delivery is proper. But the optimal time, or even minimal time, to delivery has not been defined by data—and may never be.

What should it really mean? Thirty minutes, therefore, should be a goal, not a finite time. Data published by NICHD should now be used to temper notions that exceeding the so-called 30-minute rule necessarily 1) is an indicator of substandard care and 2) has adverse effects on outcome for the newborn.

Perhaps it’s time for ACOG to review these recent data and then reaffirm, replace, or withdraw the statement from the perinatal guidelines proposing that 30 minutes be the maximum time from decision to incision.¹

Here’s what you should do until the matter is clarified

If you must defend yourself against an accusation of not having performed a C-section in a timely fashion, data from the NICHD Perinatal Collaborative may offer a helpful defense. Because 38% of C-sections for a nonreassuring fetal heart rate tracing are not performed within 30 minutes of a decision to proceed, even in a university setting, this cannot be considered a standard and not meeting this arbitrary time should be looked on as a frequent occurrence.

Based on current data, therefore, any medicolegal case in which the plaintiff’s attorney implies that failure to conform to this putative standard resulted in a bad outcome should be defended vigorously—and should not be settled.

The authors report no financial relationships relevant to this article.

CASE: Primigravida with ruptured membranes

A 21-year-old patient was admitted to the labor and delivery suite in active labor. After a reassuring fetal tracing was documented, active management with oxytocin was initiated.

Five hours later, the nurse noted a prolonged deceleration.

Resuscitative efforts failed to alleviate the deceleration. The nurse notified the attending OB of the situation. An emergency cesarean section was called because:

1. of a nonreassuring fetal heart rate tracing and
   
2. delivery was not imminent.
   

Now, the attending leaves her home promptly to perform the cesarean section; the anesthesiologist, who is not in the hospital, is notified.

The team is assembled and the patient is moved to the operating room; 34 minutes have elapsed between the time the decision was made to perform the cesarean section and the time the incision is made on the abdomen.

Two minutes later, the baby is delivered. Apgar scores are as follows: 0 at 1 minute; 0 at 5 minutes; 0 at 10 minutes; and 1 at 15 minutes.

Subsequently, the baby is determined to be severely brain-damaged. The parents file a claim of malpractice.

ObGyns have come to depend on ACOG’s Committee Opinions, Educational Bulletins, Practice Bulletins, Policy Statements, and Technology Assessments to help us take the best care of our patients. To quote the College, each of these documents “is reviewed periodically and either reaffirmed, replaced, or withdrawn to ensure its continued appropriateness to practice.”¹

Sometimes, however, an ACOG bulletin, statement, or assessment may be misinterpreted and can actually contribute to some of the medicolegal problems that we face. The actual clinical situation just described, relating to ACOG’s statement on the so-called decision-to-incision gold standard, is a case in point.

The parties in the case go to trial

During the subsequent trial, the plaintiff alleges negligence by claiming that the defendant:

• did not anticipate or recognize developing fetal problems
  
• failed to perform a C-section within 30 minutes after the decision was made to do so.
  

The defendant counters:

• There was no fetal indication of hypoxia or cause for concern until the fetal bradycardia was noted
  
• Brain damage was caused by an unanticipated event that occurred more than 30 minutes before delivery
  
• The team responded as rapidly as it could given the circumstances of the hospital and staffing patterns.
  

No verdict was reached; instead, the parties agreed to a multimillion-dollar settlement that is based on 1) more than 30 minutes having elapsed from “decision to incision” and 2) the assertion that a 30-minute decision-to-incision time is the standard of care for an emergency C-section.

Are we held to a standard that can’t be met and has no basis in evidence?

To repeat, as reported in hospital records admitted into evidence at trial, the baby was delivered, with a low Apgar score, 34 minutes after the decision was called. The fact that the incision commenced after more than 30 minutes was a major factor contributing to the multimillion-dollar settlement.

That 30-minute mark is taken directly from the fifth edition of ACOG’s Guideline for Perinatal Care:

Any hospital providing obstetric service should have the capability of responding to an obstetric emergency. No data correlate the timing of intervention with outcome, and there is little likelihood that any will be obtained. However, in general, the consensus has been that hospitals should have the capability of beginning a cesarean section within 30 minutes of the decision to operate.²

The interpretation that all C-sections must be performed within 30 minutes of a decision is challenged by a recent study sponsored by The National Institute of Child Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network.³ The design of that study was observational, because no ethical means exist to randomize women to less than or more than 30 minutes from the time of a decision to perform a C-section to the time of the incision.

The data collected came only from primagravid women in active labor who had an infant that had a birth weight of more than 2,500 g. Indications for C-section included: nonreassuring fetal heart rate, umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, and uterine rupture. A total of 11,481 cases were analyzed over a 2-year period, with 2,808 C-sections performed for those indications (a 24.5% rate of C-section). Ninety-four per cent of the C-sections were undertaken because of a nonreassuring fetal heart rate.

 

In a university setting, where one would expect in-house OB coverage and anesthesia to be available, only 65% of emergency C-sections commenced within 30 minutes of a decision (17% in less than 10 minutes; 27% in less than 20 minutes). Investigators also found that, in cases in which a C-section was performed for a nonreassuring fetal heart rate, only 62% were performed in fewer than 30 minutes.

The data are clear: More than one third of all C-sections for these indications did not comply with the “30-minute rule.”

Notably, the study also found that:

• when the decision-to-incision time was less than 30 minutes, the rates of fetal acidemia and intubation in the delivery room were higher
  
• 95% of infants delivered in more than 31 minutes did not experience any of the adverse outcomes listed in the accompanying TABLE
  
• only one of eight neonatal deaths occurred in the group of infants delivered after 31 minutes (at 33 minutes).
  

The investigators also found that decision-to-incision time had no impact on maternal complications.

TABLE

Outcomes are no better when the decision-to-incision time is less than 30 minutes³

OUTCOME	INCIDENCE AT	INCIDENCE AT >30 MIN
Urine pH,	4.8%	1.6%*
Intubation in delivery	3.1%	1.3%*
Hypoxic–ischemic encephalopathy	0.7%	0.5%
Fetal death	0.2%	0%
Neonatal death	0.4%	0.2%
Apgar score at 5 min,	1.0%	0.9%
None of the above	92.6%	95.4%*
*P .05>

30 minutes? It’s not a mandate

The study supported by NICHD shows that:

• the decision-to-incision interval appears to have no impact on maternal complications
  
• an infant delivered within 30 minutes for an emergency indication was more likely to be acidemic and to require intubation than an infant delivered in longer than 30 minutes for an emergency indication
  
• delivery within 30 minutes does not guarantee that there will be no adverse outcome
  
• 95% of infants delivered in more than 30 minutes did not have compromise.
  

Where did it originate? These facts make us wonder: How did the controversial, seemingly random time of 30 minutes crawl into the courtroom and become a benchmark? Why have attorneys and expert witnesses for the plaintiff taken this 30-minute rule to be fact?

The ACOG guideline is, as stated, clearly not a requirement. It does not mandate that all C-sections commence within 30 minutes from the time of the decision to perform one. Rather, the guideline clearly states that the hospital should be capable of performing the procedure within 30 minutes.

To be clear, we are not advocating a guideline or policy of waiting to perform a C-section! We believe rapid delivery is proper. But the optimal time, or even minimal time, to delivery has not been defined by data—and may never be.

What should it really mean? Thirty minutes, therefore, should be a goal, not a finite time. Data published by NICHD should now be used to temper notions that exceeding the so-called 30-minute rule necessarily 1) is an indicator of substandard care and 2) has adverse effects on outcome for the newborn.

Perhaps it’s time for ACOG to review these recent data and then reaffirm, replace, or withdraw the statement from the perinatal guidelines proposing that 30 minutes be the maximum time from decision to incision.¹

Here’s what you should do until the matter is clarified

If you must defend yourself against an accusation of not having performed a C-section in a timely fashion, data from the NICHD Perinatal Collaborative may offer a helpful defense. Because 38% of C-sections for a nonreassuring fetal heart rate tracing are not performed within 30 minutes of a decision to proceed, even in a university setting, this cannot be considered a standard and not meeting this arbitrary time should be looked on as a frequent occurrence.

Based on current data, therefore, any medicolegal case in which the plaintiff’s attorney implies that failure to conform to this putative standard resulted in a bad outcome should be defended vigorously—and should not be settled.

The authors report no financial relationships relevant to this article.

CASE: Primigravida with ruptured membranes

A 21-year-old patient was admitted to the labor and delivery suite in active labor. After a reassuring fetal tracing was documented, active management with oxytocin was initiated.

Five hours later, the nurse noted a prolonged deceleration.

Resuscitative efforts failed to alleviate the deceleration. The nurse notified the attending OB of the situation. An emergency cesarean section was called because:

1. of a nonreassuring fetal heart rate tracing and
   
2. delivery was not imminent.
   

Now, the attending leaves her home promptly to perform the cesarean section; the anesthesiologist, who is not in the hospital, is notified.

The team is assembled and the patient is moved to the operating room; 34 minutes have elapsed between the time the decision was made to perform the cesarean section and the time the incision is made on the abdomen.

Two minutes later, the baby is delivered. Apgar scores are as follows: 0 at 1 minute; 0 at 5 minutes; 0 at 10 minutes; and 1 at 15 minutes.

Subsequently, the baby is determined to be severely brain-damaged. The parents file a claim of malpractice.

ObGyns have come to depend on ACOG’s Committee Opinions, Educational Bulletins, Practice Bulletins, Policy Statements, and Technology Assessments to help us take the best care of our patients. To quote the College, each of these documents “is reviewed periodically and either reaffirmed, replaced, or withdrawn to ensure its continued appropriateness to practice.”¹

Sometimes, however, an ACOG bulletin, statement, or assessment may be misinterpreted and can actually contribute to some of the medicolegal problems that we face. The actual clinical situation just described, relating to ACOG’s statement on the so-called decision-to-incision gold standard, is a case in point.

The parties in the case go to trial

During the subsequent trial, the plaintiff alleges negligence by claiming that the defendant:

• did not anticipate or recognize developing fetal problems
  
• failed to perform a C-section within 30 minutes after the decision was made to do so.
  

The defendant counters:

• There was no fetal indication of hypoxia or cause for concern until the fetal bradycardia was noted
  
• Brain damage was caused by an unanticipated event that occurred more than 30 minutes before delivery
  
• The team responded as rapidly as it could given the circumstances of the hospital and staffing patterns.
  

No verdict was reached; instead, the parties agreed to a multimillion-dollar settlement that is based on 1) more than 30 minutes having elapsed from “decision to incision” and 2) the assertion that a 30-minute decision-to-incision time is the standard of care for an emergency C-section.

Are we held to a standard that can’t be met and has no basis in evidence?

To repeat, as reported in hospital records admitted into evidence at trial, the baby was delivered, with a low Apgar score, 34 minutes after the decision was called. The fact that the incision commenced after more than 30 minutes was a major factor contributing to the multimillion-dollar settlement.

That 30-minute mark is taken directly from the fifth edition of ACOG’s Guideline for Perinatal Care:

Any hospital providing obstetric service should have the capability of responding to an obstetric emergency. No data correlate the timing of intervention with outcome, and there is little likelihood that any will be obtained. However, in general, the consensus has been that hospitals should have the capability of beginning a cesarean section within 30 minutes of the decision to operate.²

The interpretation that all C-sections must be performed within 30 minutes of a decision is challenged by a recent study sponsored by The National Institute of Child Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network.³ The design of that study was observational, because no ethical means exist to randomize women to less than or more than 30 minutes from the time of a decision to perform a C-section to the time of the incision.

The data collected came only from primagravid women in active labor who had an infant that had a birth weight of more than 2,500 g. Indications for C-section included: nonreassuring fetal heart rate, umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, and uterine rupture. A total of 11,481 cases were analyzed over a 2-year period, with 2,808 C-sections performed for those indications (a 24.5% rate of C-section). Ninety-four per cent of the C-sections were undertaken because of a nonreassuring fetal heart rate.

 

In a university setting, where one would expect in-house OB coverage and anesthesia to be available, only 65% of emergency C-sections commenced within 30 minutes of a decision (17% in less than 10 minutes; 27% in less than 20 minutes). Investigators also found that, in cases in which a C-section was performed for a nonreassuring fetal heart rate, only 62% were performed in fewer than 30 minutes.

The data are clear: More than one third of all C-sections for these indications did not comply with the “30-minute rule.”

Notably, the study also found that:

• when the decision-to-incision time was less than 30 minutes, the rates of fetal acidemia and intubation in the delivery room were higher
  
• 95% of infants delivered in more than 31 minutes did not experience any of the adverse outcomes listed in the accompanying TABLE
  
• only one of eight neonatal deaths occurred in the group of infants delivered after 31 minutes (at 33 minutes).
  

The investigators also found that decision-to-incision time had no impact on maternal complications.

TABLE

Outcomes are no better when the decision-to-incision time is less than 30 minutes³

OUTCOME	INCIDENCE AT	INCIDENCE AT >30 MIN
Urine pH,	4.8%	1.6%*
Intubation in delivery	3.1%	1.3%*
Hypoxic–ischemic encephalopathy	0.7%	0.5%
Fetal death	0.2%	0%
Neonatal death	0.4%	0.2%
Apgar score at 5 min,	1.0%	0.9%
None of the above	92.6%	95.4%*
*P .05>

30 minutes? It’s not a mandate

The study supported by NICHD shows that:

• the decision-to-incision interval appears to have no impact on maternal complications
  
• an infant delivered within 30 minutes for an emergency indication was more likely to be acidemic and to require intubation than an infant delivered in longer than 30 minutes for an emergency indication
  
• delivery within 30 minutes does not guarantee that there will be no adverse outcome
  
• 95% of infants delivered in more than 30 minutes did not have compromise.
  

Where did it originate? These facts make us wonder: How did the controversial, seemingly random time of 30 minutes crawl into the courtroom and become a benchmark? Why have attorneys and expert witnesses for the plaintiff taken this 30-minute rule to be fact?

The ACOG guideline is, as stated, clearly not a requirement. It does not mandate that all C-sections commence within 30 minutes from the time of the decision to perform one. Rather, the guideline clearly states that the hospital should be capable of performing the procedure within 30 minutes.

To be clear, we are not advocating a guideline or policy of waiting to perform a C-section! We believe rapid delivery is proper. But the optimal time, or even minimal time, to delivery has not been defined by data—and may never be.

What should it really mean? Thirty minutes, therefore, should be a goal, not a finite time. Data published by NICHD should now be used to temper notions that exceeding the so-called 30-minute rule necessarily 1) is an indicator of substandard care and 2) has adverse effects on outcome for the newborn.

Perhaps it’s time for ACOG to review these recent data and then reaffirm, replace, or withdraw the statement from the perinatal guidelines proposing that 30 minutes be the maximum time from decision to incision.¹

Here’s what you should do until the matter is clarified

If you must defend yourself against an accusation of not having performed a C-section in a timely fashion, data from the NICHD Perinatal Collaborative may offer a helpful defense. Because 38% of C-sections for a nonreassuring fetal heart rate tracing are not performed within 30 minutes of a decision to proceed, even in a university setting, this cannot be considered a standard and not meeting this arbitrary time should be looked on as a frequent occurrence.

Based on current data, therefore, any medicolegal case in which the plaintiff’s attorney implies that failure to conform to this putative standard resulted in a bad outcome should be defended vigorously—and should not be settled.

In my practice, the open access scheduling system allows a patient to be seen the same day they call for any reason whatsoever. That means if a patient calls at 3 p.m., I'll see that patient that day.

Patients obviously love this because they have their needs met quickly and efficiently. There are no hoops for them to jump through to get an appointment. And when you see them, they still have the problem that prompted their call for an appointment. How many times have you seen a patient who says that the problem they called about last week has gone away? My theory is that these patients keep their appointments because there is a general sense that physician appointments are difficult to get. Open access systems eliminate this sense of scarcity, while at the same time make it easier to meet the needs of our patients.

I love this system because it virtually eliminates the no-shows that cost a practice money. Revenue increases as the workload decreases. How does this occur? When today's work gets done today, there's no backlog, which all too often creates its own set of inefficiencies that lead to extra work. The advantages carry over. In seeing a patient for strep throat, you may notice that his prescription for Lipitor is about to run out. Writing that script when the patient is in front of you prevents phone calls and chores later.

Of course I set limits. I don't do physicals at 10 p.m. I make sure that I have a life after work hours. Most patients don't call late in the day, but often I can see such folks. This prevents unnecessary emergency department visits, which cost more and waste time as well as money. The patient who calls after 5 p.m. can often be managed by a telephone consultation. The goal is to give my patients unfettered access to me, and 99% of the time I am able to meet their needs one way or another. If a patient needs to be seen after 5 p.m., I have found that it's always easier to do so than to put it off until the next day. Doing “today's work today” ultimately decreases a physician's workload.

I do tend to work longer hours during the flu season, but I'm not in burnout mode. And when patient volume is lighter in the summer months, I have a shorter day, which I prefer.

The key to doing open access scheduling is figuring out supply and demand. About 0.75% (or a bit fewer than 1%) of patients in a practice's panel will call on any given day to request an appointment. If the practice does not prebook more than a third of the schedule ahead of time, then patients who call to be seen that day can be easily accommodated.

The trick is knowing when to close the practice to new patients. This requires a look at a number of factors: How many providers are in the practice? What is their practice style? Do they tend to take a lot of time with patients, or are they highly efficient? Is there a staff to whom tasks can be delegated? What percentage of the panel population has complex, chronic conditions that are likely to require longer visits?

I micromanage my practice. I answer the phone and listen to my voice mail during specific breaks in the workday. As a result, I'm able to assess the amount of time a visit is likely to take, and my patients have grown confident that I will get back to them to meet their needs. I have a simple, reliable system that builds confidence. This eliminates the need for patients to make multiple calls to see if their requests were met. In addition, the system can provide better continuity of care, which is higher quality of care. My patients see me—and only me—and they see me on time.

Larger practices have different issues in setting up open access scheduling, but there are many references about successful implementations in various settings.

Open access scheduling and unfettered access to doctors is paradigm-busting work. By reducing waste, we can increase revenues, increase access for patients, decrease time on the phone and evening calls—and, oh yeah, it is really wonderful to be nice to patients.

In my practice, the open access scheduling system allows a patient to be seen the same day they call for any reason whatsoever. That means if a patient calls at 3 p.m., I'll see that patient that day.

Patients obviously love this because they have their needs met quickly and efficiently. There are no hoops for them to jump through to get an appointment. And when you see them, they still have the problem that prompted their call for an appointment. How many times have you seen a patient who says that the problem they called about last week has gone away? My theory is that these patients keep their appointments because there is a general sense that physician appointments are difficult to get. Open access systems eliminate this sense of scarcity, while at the same time make it easier to meet the needs of our patients.

I love this system because it virtually eliminates the no-shows that cost a practice money. Revenue increases as the workload decreases. How does this occur? When today's work gets done today, there's no backlog, which all too often creates its own set of inefficiencies that lead to extra work. The advantages carry over. In seeing a patient for strep throat, you may notice that his prescription for Lipitor is about to run out. Writing that script when the patient is in front of you prevents phone calls and chores later.

Of course I set limits. I don't do physicals at 10 p.m. I make sure that I have a life after work hours. Most patients don't call late in the day, but often I can see such folks. This prevents unnecessary emergency department visits, which cost more and waste time as well as money. The patient who calls after 5 p.m. can often be managed by a telephone consultation. The goal is to give my patients unfettered access to me, and 99% of the time I am able to meet their needs one way or another. If a patient needs to be seen after 5 p.m., I have found that it's always easier to do so than to put it off until the next day. Doing “today's work today” ultimately decreases a physician's workload.

I do tend to work longer hours during the flu season, but I'm not in burnout mode. And when patient volume is lighter in the summer months, I have a shorter day, which I prefer.

The key to doing open access scheduling is figuring out supply and demand. About 0.75% (or a bit fewer than 1%) of patients in a practice's panel will call on any given day to request an appointment. If the practice does not prebook more than a third of the schedule ahead of time, then patients who call to be seen that day can be easily accommodated.

The trick is knowing when to close the practice to new patients. This requires a look at a number of factors: How many providers are in the practice? What is their practice style? Do they tend to take a lot of time with patients, or are they highly efficient? Is there a staff to whom tasks can be delegated? What percentage of the panel population has complex, chronic conditions that are likely to require longer visits?

I micromanage my practice. I answer the phone and listen to my voice mail during specific breaks in the workday. As a result, I'm able to assess the amount of time a visit is likely to take, and my patients have grown confident that I will get back to them to meet their needs. I have a simple, reliable system that builds confidence. This eliminates the need for patients to make multiple calls to see if their requests were met. In addition, the system can provide better continuity of care, which is higher quality of care. My patients see me—and only me—and they see me on time.

Larger practices have different issues in setting up open access scheduling, but there are many references about successful implementations in various settings.

Open access scheduling and unfettered access to doctors is paradigm-busting work. By reducing waste, we can increase revenues, increase access for patients, decrease time on the phone and evening calls—and, oh yeah, it is really wonderful to be nice to patients.

In my practice, the open access scheduling system allows a patient to be seen the same day they call for any reason whatsoever. That means if a patient calls at 3 p.m., I'll see that patient that day.

Patients obviously love this because they have their needs met quickly and efficiently. There are no hoops for them to jump through to get an appointment. And when you see them, they still have the problem that prompted their call for an appointment. How many times have you seen a patient who says that the problem they called about last week has gone away? My theory is that these patients keep their appointments because there is a general sense that physician appointments are difficult to get. Open access systems eliminate this sense of scarcity, while at the same time make it easier to meet the needs of our patients.

I love this system because it virtually eliminates the no-shows that cost a practice money. Revenue increases as the workload decreases. How does this occur? When today's work gets done today, there's no backlog, which all too often creates its own set of inefficiencies that lead to extra work. The advantages carry over. In seeing a patient for strep throat, you may notice that his prescription for Lipitor is about to run out. Writing that script when the patient is in front of you prevents phone calls and chores later.

Of course I set limits. I don't do physicals at 10 p.m. I make sure that I have a life after work hours. Most patients don't call late in the day, but often I can see such folks. This prevents unnecessary emergency department visits, which cost more and waste time as well as money. The patient who calls after 5 p.m. can often be managed by a telephone consultation. The goal is to give my patients unfettered access to me, and 99% of the time I am able to meet their needs one way or another. If a patient needs to be seen after 5 p.m., I have found that it's always easier to do so than to put it off until the next day. Doing “today's work today” ultimately decreases a physician's workload.

I do tend to work longer hours during the flu season, but I'm not in burnout mode. And when patient volume is lighter in the summer months, I have a shorter day, which I prefer.

The key to doing open access scheduling is figuring out supply and demand. About 0.75% (or a bit fewer than 1%) of patients in a practice's panel will call on any given day to request an appointment. If the practice does not prebook more than a third of the schedule ahead of time, then patients who call to be seen that day can be easily accommodated.

The trick is knowing when to close the practice to new patients. This requires a look at a number of factors: How many providers are in the practice? What is their practice style? Do they tend to take a lot of time with patients, or are they highly efficient? Is there a staff to whom tasks can be delegated? What percentage of the panel population has complex, chronic conditions that are likely to require longer visits?

I micromanage my practice. I answer the phone and listen to my voice mail during specific breaks in the workday. As a result, I'm able to assess the amount of time a visit is likely to take, and my patients have grown confident that I will get back to them to meet their needs. I have a simple, reliable system that builds confidence. This eliminates the need for patients to make multiple calls to see if their requests were met. In addition, the system can provide better continuity of care, which is higher quality of care. My patients see me—and only me—and they see me on time.

Larger practices have different issues in setting up open access scheduling, but there are many references about successful implementations in various settings.

Open access scheduling and unfettered access to doctors is paradigm-busting work. By reducing waste, we can increase revenues, increase access for patients, decrease time on the phone and evening calls—and, oh yeah, it is really wonderful to be nice to patients.

I continue to receive questions on the benefits of conventional mail billing versus keeping patient credit card numbers on file, an idea first proposed in this column almost 2 years ago.

(If you missed the original December 2005 column on the subject of credit card billing, or its sequel 3 months later, you can find them at www.skinandallergynews.com

Many physicians, especially those of a traditional bent, continue to resist the idea of accepting credit cards—or even asking patients for payment at the time of service—because it smacks of “store keeping.”

I often hear from physicians who feel more comfortable billing patients but complain that their bills are ignored.

It is much more efficient to collect payment at the time of service, while you still have the patient at hand. With each passing day after office treatment, the likelihood decreases that a patient will pay the bill.

Besides, billing is expensive. When you total the costs of materials, postage, and staff labor, preparing and mailing a bill can cost from $2 to $10. And every minute your office staff spends producing and mailing bills is a minute that could have been spent on more productive work.

Billing services are an alternative, but they are also expensive and those bills get ignored, too.

Credit and debit cards eliminate many of the problems associated with billing. They allow you to collect more fees at the time of service, while patients still think they are important.

An immediate credit or debit card charge reduces the chances of a balance falling through the cracks, getting lost in the mail, or getting embezzled. And they won't bounce like checks. If the patient is delinquent in paying the credit card bill, it's the credit card company's problem, not yours.

Card payments also improve cash flow, which is always welcome.

Credit cards offer more payment flexibility for patients. In the case of a large balance, you can offer the option of putting all the charges onto a credit card, which can then be paid in monthly installments affordable to the patient. Your practice gets reimbursed in full, even as the patient is paying it off at a pace that makes sense for his or her finances.

As described in detail in my December 2005 column, “How to Slash Accounts Receivable,” you can also keep patients' credit card numbers and signatures on file, and use them to bill insurance balances that come in later.

This practice also comes in handy for patients who claim to have come to the office without cash, a checkbook, credit cards, or any other method of payment. In such situations my office manager loves to say, “No problem, we have your credit card information on file!”

Many consultants feel that physicians will have to become increasingly flexible in how they accept payments as the population continues to age.

That flexibility will take on more importance as increasing numbers of patients rely on health savings accounts (HSAs). Many experts predict that the number of HSAs will increase tenfold by the end of this decade. That's a trend you will want to accommodate in any way you can.

Some financial institutions have even begun creating medical credit and debit cards designed specifically to be kept on file at doctors' and dentists' offices.

Like it or not, your practice is a business, and your patients, like all customers, need to be offered every convenience your competitors offer—including credit card services.

How do you go about acquiring credit card services for your office? That's the subject of next month's column.

I continue to receive questions on the benefits of conventional mail billing versus keeping patient credit card numbers on file, an idea first proposed in this column almost 2 years ago.

(If you missed the original December 2005 column on the subject of credit card billing, or its sequel 3 months later, you can find them at www.skinandallergynews.com

Many physicians, especially those of a traditional bent, continue to resist the idea of accepting credit cards—or even asking patients for payment at the time of service—because it smacks of “store keeping.”

I often hear from physicians who feel more comfortable billing patients but complain that their bills are ignored.

It is much more efficient to collect payment at the time of service, while you still have the patient at hand. With each passing day after office treatment, the likelihood decreases that a patient will pay the bill.

Besides, billing is expensive. When you total the costs of materials, postage, and staff labor, preparing and mailing a bill can cost from $2 to $10. And every minute your office staff spends producing and mailing bills is a minute that could have been spent on more productive work.

Billing services are an alternative, but they are also expensive and those bills get ignored, too.

Credit and debit cards eliminate many of the problems associated with billing. They allow you to collect more fees at the time of service, while patients still think they are important.

An immediate credit or debit card charge reduces the chances of a balance falling through the cracks, getting lost in the mail, or getting embezzled. And they won't bounce like checks. If the patient is delinquent in paying the credit card bill, it's the credit card company's problem, not yours.

Card payments also improve cash flow, which is always welcome.

Credit cards offer more payment flexibility for patients. In the case of a large balance, you can offer the option of putting all the charges onto a credit card, which can then be paid in monthly installments affordable to the patient. Your practice gets reimbursed in full, even as the patient is paying it off at a pace that makes sense for his or her finances.

As described in detail in my December 2005 column, “How to Slash Accounts Receivable,” you can also keep patients' credit card numbers and signatures on file, and use them to bill insurance balances that come in later.

This practice also comes in handy for patients who claim to have come to the office without cash, a checkbook, credit cards, or any other method of payment. In such situations my office manager loves to say, “No problem, we have your credit card information on file!”

Many consultants feel that physicians will have to become increasingly flexible in how they accept payments as the population continues to age.

That flexibility will take on more importance as increasing numbers of patients rely on health savings accounts (HSAs). Many experts predict that the number of HSAs will increase tenfold by the end of this decade. That's a trend you will want to accommodate in any way you can.

Some financial institutions have even begun creating medical credit and debit cards designed specifically to be kept on file at doctors' and dentists' offices.

Like it or not, your practice is a business, and your patients, like all customers, need to be offered every convenience your competitors offer—including credit card services.

How do you go about acquiring credit card services for your office? That's the subject of next month's column.

I continue to receive questions on the benefits of conventional mail billing versus keeping patient credit card numbers on file, an idea first proposed in this column almost 2 years ago.

(If you missed the original December 2005 column on the subject of credit card billing, or its sequel 3 months later, you can find them at www.skinandallergynews.com

Many physicians, especially those of a traditional bent, continue to resist the idea of accepting credit cards—or even asking patients for payment at the time of service—because it smacks of “store keeping.”

I often hear from physicians who feel more comfortable billing patients but complain that their bills are ignored.

It is much more efficient to collect payment at the time of service, while you still have the patient at hand. With each passing day after office treatment, the likelihood decreases that a patient will pay the bill.

Besides, billing is expensive. When you total the costs of materials, postage, and staff labor, preparing and mailing a bill can cost from $2 to $10. And every minute your office staff spends producing and mailing bills is a minute that could have been spent on more productive work.

Billing services are an alternative, but they are also expensive and those bills get ignored, too.

Credit and debit cards eliminate many of the problems associated with billing. They allow you to collect more fees at the time of service, while patients still think they are important.

An immediate credit or debit card charge reduces the chances of a balance falling through the cracks, getting lost in the mail, or getting embezzled. And they won't bounce like checks. If the patient is delinquent in paying the credit card bill, it's the credit card company's problem, not yours.

Card payments also improve cash flow, which is always welcome.

Credit cards offer more payment flexibility for patients. In the case of a large balance, you can offer the option of putting all the charges onto a credit card, which can then be paid in monthly installments affordable to the patient. Your practice gets reimbursed in full, even as the patient is paying it off at a pace that makes sense for his or her finances.

As described in detail in my December 2005 column, “How to Slash Accounts Receivable,” you can also keep patients' credit card numbers and signatures on file, and use them to bill insurance balances that come in later.

This practice also comes in handy for patients who claim to have come to the office without cash, a checkbook, credit cards, or any other method of payment. In such situations my office manager loves to say, “No problem, we have your credit card information on file!”

Many consultants feel that physicians will have to become increasingly flexible in how they accept payments as the population continues to age.

That flexibility will take on more importance as increasing numbers of patients rely on health savings accounts (HSAs). Many experts predict that the number of HSAs will increase tenfold by the end of this decade. That's a trend you will want to accommodate in any way you can.

Some financial institutions have even begun creating medical credit and debit cards designed specifically to be kept on file at doctors' and dentists' offices.

Like it or not, your practice is a business, and your patients, like all customers, need to be offered every convenience your competitors offer—including credit card services.

How do you go about acquiring credit card services for your office? That's the subject of next month's column.

Could cerclage have saved her pregnancy?

A woman who had received prenatal care from an ObGyn gave birth to a baby boy at 19 weeks’ gestation, but he died 2 hours later.

Patient’s claim An earlier pregnancy had ended with fetal loss before 20 weeks due to an incompetent cervix, so this pregnancy should have been watched especially carefully. Also, a cervical cerclage should have been used.

Doctor’s defense At first, the ObGyn claimed there could be no death case because the infant was nonviable. When the court denied a motion to dismiss, the ObGyn claimed the care given to the patient was proper and had no impact on the outcome.

Verdict Tennessee defense verdict. The court had denied a motion to dismiss, finding the baby was viable when he was born, no matter what his life expectancy.

Hysterectomy removes “missing” embryo

A 34-year-old woman went to a hospital where she was diagnosed with a life-threatening cervical ectopic pregnancy. After transfer to a second hospital, a physician tried to remove the embryo, but was unable to find it. He assumed that the remnants of the pregnancy had been passed, and sent his report to the patient’s private gynecologist. During a visit to her gynecologist a month later, the woman reported cramps and pain in the abdomen and was sent to the hospital. The ectopic pregnancy was found, and the embryo was removed by performing an emergency hysterectomy.

Patient’s claim The hysterectomy could have been avoided if the embryo had been removed sooner.

Doctor’s defense The patient’s gynecologist should have investigated the findings of the state’s doctor more quickly.

Verdict $750,000 New York settlement.

Hernia after laparoscopic hysterectomy

After a 47-year-old woman underwent a laparoscopic-assisted vaginal hysterectomy, she suffered a hernia and other complications that required three more surgeries. Only the case against the assistant surgeon in the case went to trial.

Patient’s claim The defendants failed to close the portal created during the surgery.

Doctor’s defense There was no negligence, and the opening was properly sutured.

Verdict New York defense verdict. Post-trial motions were pending.

Patient dies after bowel injury

A 58-year-old woman underwent an uneventful laparoscopic hysterectomy and was sent home a few hours later. On each of the next 2 days, she called her ObGyn to report nausea and was prescribed pain medications. When her condition worsened on the second evening, she was sent to the emergency room and then transferred to another hospital. When her condition was unchanged over the next 3 days, an exploratory laparotomy was performed following a surgical consult. transection of the small bowel showed free spillage and necrosis. One month later, the patient died of multiple organ failure secondary to sepsis.

Patient’s claim The defendants were negligent for failing to diagnose the bowel injury sooner.

Doctor’s defense The patient did not show signs of a bowel injury and had sustained torsion injury to her bowel. Also, earlier intervention would have resulted in the same outcome.

Verdict Kentucky defense verdict.

Could cerclage have saved her pregnancy?

A woman who had received prenatal care from an ObGyn gave birth to a baby boy at 19 weeks’ gestation, but he died 2 hours later.

Patient’s claim An earlier pregnancy had ended with fetal loss before 20 weeks due to an incompetent cervix, so this pregnancy should have been watched especially carefully. Also, a cervical cerclage should have been used.

Doctor’s defense At first, the ObGyn claimed there could be no death case because the infant was nonviable. When the court denied a motion to dismiss, the ObGyn claimed the care given to the patient was proper and had no impact on the outcome.

Verdict Tennessee defense verdict. The court had denied a motion to dismiss, finding the baby was viable when he was born, no matter what his life expectancy.

Hysterectomy removes “missing” embryo

A 34-year-old woman went to a hospital where she was diagnosed with a life-threatening cervical ectopic pregnancy. After transfer to a second hospital, a physician tried to remove the embryo, but was unable to find it. He assumed that the remnants of the pregnancy had been passed, and sent his report to the patient’s private gynecologist. During a visit to her gynecologist a month later, the woman reported cramps and pain in the abdomen and was sent to the hospital. The ectopic pregnancy was found, and the embryo was removed by performing an emergency hysterectomy.

Patient’s claim The hysterectomy could have been avoided if the embryo had been removed sooner.

Doctor’s defense The patient’s gynecologist should have investigated the findings of the state’s doctor more quickly.

Verdict $750,000 New York settlement.

Hernia after laparoscopic hysterectomy

After a 47-year-old woman underwent a laparoscopic-assisted vaginal hysterectomy, she suffered a hernia and other complications that required three more surgeries. Only the case against the assistant surgeon in the case went to trial.

Patient’s claim The defendants failed to close the portal created during the surgery.

Doctor’s defense There was no negligence, and the opening was properly sutured.

Verdict New York defense verdict. Post-trial motions were pending.

Patient dies after bowel injury

A 58-year-old woman underwent an uneventful laparoscopic hysterectomy and was sent home a few hours later. On each of the next 2 days, she called her ObGyn to report nausea and was prescribed pain medications. When her condition worsened on the second evening, she was sent to the emergency room and then transferred to another hospital. When her condition was unchanged over the next 3 days, an exploratory laparotomy was performed following a surgical consult. transection of the small bowel showed free spillage and necrosis. One month later, the patient died of multiple organ failure secondary to sepsis.

Patient’s claim The defendants were negligent for failing to diagnose the bowel injury sooner.

Doctor’s defense The patient did not show signs of a bowel injury and had sustained torsion injury to her bowel. Also, earlier intervention would have resulted in the same outcome.

Verdict Kentucky defense verdict.

Could cerclage have saved her pregnancy?

A woman who had received prenatal care from an ObGyn gave birth to a baby boy at 19 weeks’ gestation, but he died 2 hours later.

Patient’s claim An earlier pregnancy had ended with fetal loss before 20 weeks due to an incompetent cervix, so this pregnancy should have been watched especially carefully. Also, a cervical cerclage should have been used.

Doctor’s defense At first, the ObGyn claimed there could be no death case because the infant was nonviable. When the court denied a motion to dismiss, the ObGyn claimed the care given to the patient was proper and had no impact on the outcome.

Verdict Tennessee defense verdict. The court had denied a motion to dismiss, finding the baby was viable when he was born, no matter what his life expectancy.

Hysterectomy removes “missing” embryo

A 34-year-old woman went to a hospital where she was diagnosed with a life-threatening cervical ectopic pregnancy. After transfer to a second hospital, a physician tried to remove the embryo, but was unable to find it. He assumed that the remnants of the pregnancy had been passed, and sent his report to the patient’s private gynecologist. During a visit to her gynecologist a month later, the woman reported cramps and pain in the abdomen and was sent to the hospital. The ectopic pregnancy was found, and the embryo was removed by performing an emergency hysterectomy.

Patient’s claim The hysterectomy could have been avoided if the embryo had been removed sooner.

Doctor’s defense The patient’s gynecologist should have investigated the findings of the state’s doctor more quickly.

Verdict $750,000 New York settlement.

Hernia after laparoscopic hysterectomy

After a 47-year-old woman underwent a laparoscopic-assisted vaginal hysterectomy, she suffered a hernia and other complications that required three more surgeries. Only the case against the assistant surgeon in the case went to trial.

Patient’s claim The defendants failed to close the portal created during the surgery.

Doctor’s defense There was no negligence, and the opening was properly sutured.

Verdict New York defense verdict. Post-trial motions were pending.

Patient dies after bowel injury

A 58-year-old woman underwent an uneventful laparoscopic hysterectomy and was sent home a few hours later. On each of the next 2 days, she called her ObGyn to report nausea and was prescribed pain medications. When her condition worsened on the second evening, she was sent to the emergency room and then transferred to another hospital. When her condition was unchanged over the next 3 days, an exploratory laparotomy was performed following a surgical consult. transection of the small bowel showed free spillage and necrosis. One month later, the patient died of multiple organ failure secondary to sepsis.

Patient’s claim The defendants were negligent for failing to diagnose the bowel injury sooner.

Doctor’s defense The patient did not show signs of a bowel injury and had sustained torsion injury to her bowel. Also, earlier intervention would have resulted in the same outcome.

Verdict Kentucky defense verdict.

Mary Jo Foster, herself a physician, sat down to pen a letter to her former obstetrician. Words flowed easily because, for months, she had thought of little else besides the events of the previous year.

Her letter has been abbreviated, with names and dates altered.

Eric David Foster
Born: May 15, 2003, Died: May 18, 2003

Does that name or do those dates mean anything to you? They should, but I doubt that they do. I, on the other hand, have been haunted by painful and awful memories of those 4 days, as I will be every day for the rest of my life. I hope that you have the courage and integrity to read this letter completely, because this is the only chance I have to reach you.

Do you remember my first visit? I had the impression then that you listened and understood when I related my complicated obstetric history, but that was the first and last time I felt that way. You seemed to forget about the uterine septum until I called you at 25 weeks’ gestation to report that I had gone into labor. My husband and I were so terrified, we left our sleeping 2-year-old son alone in the house to await the nanny in order to get to the hospital as soon as possible. Although we arrived there at 7 AM, we had to wait 2 horrifying hours for you to show up. By then it was too late, and Eric was delivered prematurely with extensive brain damage from ischemia and hemorrhage. Distraught, my heart breaking and my brain dazed from shock, trauma, surgery, and lack of sleep, I then had to plead and fight at the ethics committee meeting for the discontinuation of life support so Eric’s suffering could end.

A strongly worded letter if ever there was one; the patient’s emotional pain comes through loud and clear. Bear in mind that the obstetrician’s voice is silent; we do not hear his perspective.

That is intentional. The aim of this article is not to pass judgment or offer defense, but to draw attention to two specific consequences of a major traumatic experience—incomplete mourning and traumatic stress disorder.

In an earlier article, “The nightmare of litigation: A survivor’s true story,”¹ I presented the case of an obstetrician who was sued for medical malpractice. The trauma of the experience led him to develop an acute stress disorder, which evolved into posttraumatic stress disorder (PTSD). In this article, the focus is on the patient, who also develops PTSD after an adverse outcome—specifically, premature delivery and neonatal death.

A mourning process stuck in the anger stage

Letter continued

For the past year I have wanted to ask you…

• Why did you make me feel invisible during my pregnancy, after I went to so much trouble to explain my special situation?
  
• Why didn’t you seem to notice how terrified we were when I started bleeding? Instead, you took your time getting to the ER.
  
• Why didn’t you come to talk to me later in the day after the cesarean section? When you spoke to my husband, you mentioned that you had removed the uterine septum so I could go on to have a normal full-term pregnancy. How could you begin to talk about another pregnancy while my son was in pain, bleeding into his brain? You wrote him off the minute you left the OR, just like you peeled off your gloves and dropped them into the trash.
  
• Why didn’t you ask the chaplain to be at the ethics hearing as a support for us?
  
• At my postoperative checkup, why did you rip off the dressing and declare me “beautifully healed”? And why did you walk off before I could say anything?
  

A healthy mourning process comprises several stages, including denial, anger, sadness, and meaning-making, followed by acceptance and healing. This harsh letter is an indication that the patient is stuck in anger; healing is a long way off. Beneath the anger are other emotions, including sadness, shame, and guilt.

When the obstetrician ripped off the dressing and declared the patient healed, he was addressing the physical abdominal wound, but he completely overlooked the deeper, invisible, psychospiritual wounds arising from loss of a child—and from loss of safety, power, trust, faith, and meaning. The patient’s feelings are striking in their potency, but the obstetrician remained unaware of them. At the time of her postoperative visit, these psychological wounds had not even begun to heal. The self that had been preparing to be a mother had not yet integrated all the losses and realigned to the grim reality that she was now the parent of a dead baby.

 

Rather than further her healing, the obstetrician’s words alienated her and added yet another layer of wounding.

Letter continued

That hospital was my personal place in hell from the moment I entered until the day I was discharged. You and your office staff seemed totally oblivious to this fact. Now a year has passed—a year of pure devastation—and I still have pain and sadness that cannot be understood by anyone who has not experienced the death of a child. And I have anger at the incompetent ER staff and at myself for being “a good patient” and ignoring my intuition.

I deserved a physician who can remember who I am and my relevant history—one who would come to see me immediately and reassure me that everything possible would be done for my baby and me. I deserved a physician who can acknowledge the awfulness of such a loss and offer sympathy and support. And to make matters worse, you immediately retreated behind the fear of a lawsuit.

Grief, interrupted: When the business-as-usual world interferes

An outpouring of grief in the face of loss is normal; it mobilizes energy and is an integral part of the healing process. Emotional healing may seem protracted when it is viewed in the context of chronological time, and pressing demands frequently interfere with the process. In this case, demands included the need to attend an ethics meeting, arrange a funeral, care for a 2-year-old son, host parents-in-law who had arrived from out of town, and, the following week, throw a birthday party for her son.

Disenfranchised grief: How wrong words, or none, can slow healing

This patient found little validation or support for her grief from those who were around her:

• Medical personnel acted defensively and insensitively.
  
• Her in-laws kept busy, making idle chitchat while they fussed over the party and memorial arrangements.
  
• Her friends plied her with platitudes: “God needs an angel in heaven,” “God needed your son more than you do,” “We can’t know why God makes these decisions.”
  
• The priest performed the memorial service in ritualistic fashion. “He couldn’t even get Eric’s name right,” she lamented.
  
• Her return to work was marked by awkward cheeriness, “as if I had been on vacation.” Her boss’s comment? “Best hop right back in the saddle.”
  

All these people seemed invested in their own coping strategies. None provided comfort; empathy was absent. Any mourning that had to be done was done alone, behind closed doors and a fixed smile. Isolation, the hallmark of trauma, was pronounced. Only after she found a support group several months later was Dr. Foster able to openly mourn.

Three symptom clusters signal PTSD

Dr. Foster’s description of her postdelivery experience suggests to me that she sustained an acute stress disorder—a condition that involves feelings of intense fear, horror, disorientation, and helplessness in response to an unusually traumatic experience that threatens death or serious physical injury to self or others. In Dr. Foster’s case, the stress disorder progressed to PTSD—a pervasive chronic anxiety disorder characterized by three clusters of symptoms:

• Recurrent, intrusive recollections of events; recurrent flashbacks and dreams. “At night, after going to bed, I would see the fetal monitor showing my child’s heart rate running like a video stream in front of my eyes. This went on for months. It would take me 1 to 2 hours to force myself to fall asleep.”
  
• Persistent avoidance of stimuli associated with the event; numbness and detachment. “I had feelings of numbness and unreality but couldn’t really understand or process them. Eating became difficult, and I was unable to experience any pleasure. Survivor’s guilt plagued me. Why am I alive? I asked myself. I had some 30 years, but my son didn’t even have a chance.”
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration. “I returned to work after a month but could not focus or concentrate, so I took 2 additional months off. Whenever I heard the obstetrician paged at the hospital, I had a physical reaction. My muscles clenched, my skin flushed, and my heart raced. Eventually, I stopped working at that hospital because I couldn’t stand being there.”
  

PTSD is not rare in civilian life or in medicine. Journal articles attest to its occurrence in association with major illness and injury,² spontaneous abortion,³ and premature and traumatic birth.^4-8

In Dr. Foster’s case, PTSD went unrecognized and untreated.

How to avert, and alleviate, PTSD

As with any disaster, careful planning can mitigate consequences even though it cannot necessarily prevent PTSD. Prenatal visits offer a unique opportunity to build a trusting partnership with your patient and her partner. Skilled professional communication is essential. Anticipate common themes:

 

• Fear of failure and shame is an issue for many mothers-to-be. Here, your affirmations and good humor are helpful. Be very respectful of the patient’s interpersonal boundaries, both physical and emotional.
  
• Disempowerment is an inherent part of the patient experience; trauma aggravates this dynamic. Whenever feasible, shift some of your power to the patient by eliciting her wishes and offering her choices. Together, create a plan for delivery and postnatal care that reflects her desires. As you demonstrate competence and control, consciously deconstruct the image your patient may have of you as an infallible authority figure by selectively revealing a little of the personality behind the white coat.
  
• Feelings of isolation always occur with trauma. The bonds you cultivate with the patient during her pregnancy will alleviate this isolation, as will your message: You are not alone in this experience; we will deal with this together.
  

Other helpful practices

Allow the grieving couple space and privacy to ventilate and mourn any way they need to. This may include expressions of anger.

Listen silently and attentively even if you feel passive or uncomfortable doing so. Resist the urge to comfort the patient; even well-intentioned comforting can interrupt healing.

Validate the patient’s trauma. Be careful to avoid making the suggestion that you understand. No one but the patient can understand—suffering is always unique and personal.

Express a genuine and carefully worded sense of regret for the patient’s loss. Take care not to express personal negative feelings, such as those regarding a baby’s deformity. Your words may become permanently imprinted.⁹

Present any information and recommendations the patient needs in writing because, when a person is in shock, she may be unable to recall verbal messages. Also give written recommendations to one of the patient’s family members, if possible.

Avoid well-intentioned attempts to reassure a patient or to rationalize or offer premature hope. There is time for such things later.

Cultivate a referral network that includes social workers, chaplains, and psychotherapists trained to work with trauma victims, and when they are necessary, involve them as early as possible. Also familiarize yourself with local support groups and short-term cognitive group-therapy programs for grieving parents.¹⁰

Frame the gesture carefully if you feel the need to refer the patient to a psychotherapist or psychiatrist. It is better to emphasize to the patient that she has sustained a major trauma than to suggest there is something wrong with her. The latter will only add to her sense of personal failure and may trigger resistance or anger.

Take care of yourself! You need your own practices and rituals to sustain you in the work you do. Create your own network of support. Concentrate on expanding your resilience and strive to be comfortable with your emotions. If symptoms of burnout appear, seek help quickly.

The author thanks Amy Hyams and Anne-Marie Jackson, MD, for their assistance.

Recommended reading

• Bub B. Communication Skills That Heal: A Practical Approach to a New Professionalism in Medicine. Abington, UK: Radcliffe Publishing–Oxford; 2005.
  
• Herman J. Trauma and Recovery. London: Rivers Oram Press; 1997.
  
• Schneider J. Finding My Way: Healing and Transformation Through Loss and Grief. Colfax, Wisc: Seasons; 1994.
  

Mary Jo Foster, herself a physician, sat down to pen a letter to her former obstetrician. Words flowed easily because, for months, she had thought of little else besides the events of the previous year.

Her letter has been abbreviated, with names and dates altered.

Eric David Foster
Born: May 15, 2003, Died: May 18, 2003

Does that name or do those dates mean anything to you? They should, but I doubt that they do. I, on the other hand, have been haunted by painful and awful memories of those 4 days, as I will be every day for the rest of my life. I hope that you have the courage and integrity to read this letter completely, because this is the only chance I have to reach you.

Do you remember my first visit? I had the impression then that you listened and understood when I related my complicated obstetric history, but that was the first and last time I felt that way. You seemed to forget about the uterine septum until I called you at 25 weeks’ gestation to report that I had gone into labor. My husband and I were so terrified, we left our sleeping 2-year-old son alone in the house to await the nanny in order to get to the hospital as soon as possible. Although we arrived there at 7 AM, we had to wait 2 horrifying hours for you to show up. By then it was too late, and Eric was delivered prematurely with extensive brain damage from ischemia and hemorrhage. Distraught, my heart breaking and my brain dazed from shock, trauma, surgery, and lack of sleep, I then had to plead and fight at the ethics committee meeting for the discontinuation of life support so Eric’s suffering could end.

A strongly worded letter if ever there was one; the patient’s emotional pain comes through loud and clear. Bear in mind that the obstetrician’s voice is silent; we do not hear his perspective.

That is intentional. The aim of this article is not to pass judgment or offer defense, but to draw attention to two specific consequences of a major traumatic experience—incomplete mourning and traumatic stress disorder.

In an earlier article, “The nightmare of litigation: A survivor’s true story,”¹ I presented the case of an obstetrician who was sued for medical malpractice. The trauma of the experience led him to develop an acute stress disorder, which evolved into posttraumatic stress disorder (PTSD). In this article, the focus is on the patient, who also develops PTSD after an adverse outcome—specifically, premature delivery and neonatal death.

A mourning process stuck in the anger stage

Letter continued

For the past year I have wanted to ask you…

• Why did you make me feel invisible during my pregnancy, after I went to so much trouble to explain my special situation?
  
• Why didn’t you seem to notice how terrified we were when I started bleeding? Instead, you took your time getting to the ER.
  
• Why didn’t you come to talk to me later in the day after the cesarean section? When you spoke to my husband, you mentioned that you had removed the uterine septum so I could go on to have a normal full-term pregnancy. How could you begin to talk about another pregnancy while my son was in pain, bleeding into his brain? You wrote him off the minute you left the OR, just like you peeled off your gloves and dropped them into the trash.
  
• Why didn’t you ask the chaplain to be at the ethics hearing as a support for us?
  
• At my postoperative checkup, why did you rip off the dressing and declare me “beautifully healed”? And why did you walk off before I could say anything?
  

A healthy mourning process comprises several stages, including denial, anger, sadness, and meaning-making, followed by acceptance and healing. This harsh letter is an indication that the patient is stuck in anger; healing is a long way off. Beneath the anger are other emotions, including sadness, shame, and guilt.

When the obstetrician ripped off the dressing and declared the patient healed, he was addressing the physical abdominal wound, but he completely overlooked the deeper, invisible, psychospiritual wounds arising from loss of a child—and from loss of safety, power, trust, faith, and meaning. The patient’s feelings are striking in their potency, but the obstetrician remained unaware of them. At the time of her postoperative visit, these psychological wounds had not even begun to heal. The self that had been preparing to be a mother had not yet integrated all the losses and realigned to the grim reality that she was now the parent of a dead baby.

 

Rather than further her healing, the obstetrician’s words alienated her and added yet another layer of wounding.

Letter continued

That hospital was my personal place in hell from the moment I entered until the day I was discharged. You and your office staff seemed totally oblivious to this fact. Now a year has passed—a year of pure devastation—and I still have pain and sadness that cannot be understood by anyone who has not experienced the death of a child. And I have anger at the incompetent ER staff and at myself for being “a good patient” and ignoring my intuition.

I deserved a physician who can remember who I am and my relevant history—one who would come to see me immediately and reassure me that everything possible would be done for my baby and me. I deserved a physician who can acknowledge the awfulness of such a loss and offer sympathy and support. And to make matters worse, you immediately retreated behind the fear of a lawsuit.

Grief, interrupted: When the business-as-usual world interferes

An outpouring of grief in the face of loss is normal; it mobilizes energy and is an integral part of the healing process. Emotional healing may seem protracted when it is viewed in the context of chronological time, and pressing demands frequently interfere with the process. In this case, demands included the need to attend an ethics meeting, arrange a funeral, care for a 2-year-old son, host parents-in-law who had arrived from out of town, and, the following week, throw a birthday party for her son.

Disenfranchised grief: How wrong words, or none, can slow healing

This patient found little validation or support for her grief from those who were around her:

• Medical personnel acted defensively and insensitively.
  
• Her in-laws kept busy, making idle chitchat while they fussed over the party and memorial arrangements.
  
• Her friends plied her with platitudes: “God needs an angel in heaven,” “God needed your son more than you do,” “We can’t know why God makes these decisions.”
  
• The priest performed the memorial service in ritualistic fashion. “He couldn’t even get Eric’s name right,” she lamented.
  
• Her return to work was marked by awkward cheeriness, “as if I had been on vacation.” Her boss’s comment? “Best hop right back in the saddle.”
  

All these people seemed invested in their own coping strategies. None provided comfort; empathy was absent. Any mourning that had to be done was done alone, behind closed doors and a fixed smile. Isolation, the hallmark of trauma, was pronounced. Only after she found a support group several months later was Dr. Foster able to openly mourn.

Three symptom clusters signal PTSD

Dr. Foster’s description of her postdelivery experience suggests to me that she sustained an acute stress disorder—a condition that involves feelings of intense fear, horror, disorientation, and helplessness in response to an unusually traumatic experience that threatens death or serious physical injury to self or others. In Dr. Foster’s case, the stress disorder progressed to PTSD—a pervasive chronic anxiety disorder characterized by three clusters of symptoms:

• Recurrent, intrusive recollections of events; recurrent flashbacks and dreams. “At night, after going to bed, I would see the fetal monitor showing my child’s heart rate running like a video stream in front of my eyes. This went on for months. It would take me 1 to 2 hours to force myself to fall asleep.”
  
• Persistent avoidance of stimuli associated with the event; numbness and detachment. “I had feelings of numbness and unreality but couldn’t really understand or process them. Eating became difficult, and I was unable to experience any pleasure. Survivor’s guilt plagued me. Why am I alive? I asked myself. I had some 30 years, but my son didn’t even have a chance.”
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration. “I returned to work after a month but could not focus or concentrate, so I took 2 additional months off. Whenever I heard the obstetrician paged at the hospital, I had a physical reaction. My muscles clenched, my skin flushed, and my heart raced. Eventually, I stopped working at that hospital because I couldn’t stand being there.”
  

PTSD is not rare in civilian life or in medicine. Journal articles attest to its occurrence in association with major illness and injury,² spontaneous abortion,³ and premature and traumatic birth.^4-8

In Dr. Foster’s case, PTSD went unrecognized and untreated.

How to avert, and alleviate, PTSD

As with any disaster, careful planning can mitigate consequences even though it cannot necessarily prevent PTSD. Prenatal visits offer a unique opportunity to build a trusting partnership with your patient and her partner. Skilled professional communication is essential. Anticipate common themes:

 

• Fear of failure and shame is an issue for many mothers-to-be. Here, your affirmations and good humor are helpful. Be very respectful of the patient’s interpersonal boundaries, both physical and emotional.
  
• Disempowerment is an inherent part of the patient experience; trauma aggravates this dynamic. Whenever feasible, shift some of your power to the patient by eliciting her wishes and offering her choices. Together, create a plan for delivery and postnatal care that reflects her desires. As you demonstrate competence and control, consciously deconstruct the image your patient may have of you as an infallible authority figure by selectively revealing a little of the personality behind the white coat.
  
• Feelings of isolation always occur with trauma. The bonds you cultivate with the patient during her pregnancy will alleviate this isolation, as will your message: You are not alone in this experience; we will deal with this together.
  

Other helpful practices

Allow the grieving couple space and privacy to ventilate and mourn any way they need to. This may include expressions of anger.

Listen silently and attentively even if you feel passive or uncomfortable doing so. Resist the urge to comfort the patient; even well-intentioned comforting can interrupt healing.

Validate the patient’s trauma. Be careful to avoid making the suggestion that you understand. No one but the patient can understand—suffering is always unique and personal.

Express a genuine and carefully worded sense of regret for the patient’s loss. Take care not to express personal negative feelings, such as those regarding a baby’s deformity. Your words may become permanently imprinted.⁹

Present any information and recommendations the patient needs in writing because, when a person is in shock, she may be unable to recall verbal messages. Also give written recommendations to one of the patient’s family members, if possible.

Avoid well-intentioned attempts to reassure a patient or to rationalize or offer premature hope. There is time for such things later.

Cultivate a referral network that includes social workers, chaplains, and psychotherapists trained to work with trauma victims, and when they are necessary, involve them as early as possible. Also familiarize yourself with local support groups and short-term cognitive group-therapy programs for grieving parents.¹⁰

Frame the gesture carefully if you feel the need to refer the patient to a psychotherapist or psychiatrist. It is better to emphasize to the patient that she has sustained a major trauma than to suggest there is something wrong with her. The latter will only add to her sense of personal failure and may trigger resistance or anger.

Take care of yourself! You need your own practices and rituals to sustain you in the work you do. Create your own network of support. Concentrate on expanding your resilience and strive to be comfortable with your emotions. If symptoms of burnout appear, seek help quickly.

The author thanks Amy Hyams and Anne-Marie Jackson, MD, for their assistance.

Recommended reading

• Bub B. Communication Skills That Heal: A Practical Approach to a New Professionalism in Medicine. Abington, UK: Radcliffe Publishing–Oxford; 2005.
  
• Herman J. Trauma and Recovery. London: Rivers Oram Press; 1997.
  
• Schneider J. Finding My Way: Healing and Transformation Through Loss and Grief. Colfax, Wisc: Seasons; 1994.
  

Mary Jo Foster, herself a physician, sat down to pen a letter to her former obstetrician. Words flowed easily because, for months, she had thought of little else besides the events of the previous year.

Her letter has been abbreviated, with names and dates altered.

Eric David Foster
Born: May 15, 2003, Died: May 18, 2003

Does that name or do those dates mean anything to you? They should, but I doubt that they do. I, on the other hand, have been haunted by painful and awful memories of those 4 days, as I will be every day for the rest of my life. I hope that you have the courage and integrity to read this letter completely, because this is the only chance I have to reach you.

Do you remember my first visit? I had the impression then that you listened and understood when I related my complicated obstetric history, but that was the first and last time I felt that way. You seemed to forget about the uterine septum until I called you at 25 weeks’ gestation to report that I had gone into labor. My husband and I were so terrified, we left our sleeping 2-year-old son alone in the house to await the nanny in order to get to the hospital as soon as possible. Although we arrived there at 7 AM, we had to wait 2 horrifying hours for you to show up. By then it was too late, and Eric was delivered prematurely with extensive brain damage from ischemia and hemorrhage. Distraught, my heart breaking and my brain dazed from shock, trauma, surgery, and lack of sleep, I then had to plead and fight at the ethics committee meeting for the discontinuation of life support so Eric’s suffering could end.

A strongly worded letter if ever there was one; the patient’s emotional pain comes through loud and clear. Bear in mind that the obstetrician’s voice is silent; we do not hear his perspective.

That is intentional. The aim of this article is not to pass judgment or offer defense, but to draw attention to two specific consequences of a major traumatic experience—incomplete mourning and traumatic stress disorder.

In an earlier article, “The nightmare of litigation: A survivor’s true story,”¹ I presented the case of an obstetrician who was sued for medical malpractice. The trauma of the experience led him to develop an acute stress disorder, which evolved into posttraumatic stress disorder (PTSD). In this article, the focus is on the patient, who also develops PTSD after an adverse outcome—specifically, premature delivery and neonatal death.

A mourning process stuck in the anger stage

Letter continued

For the past year I have wanted to ask you…

• Why did you make me feel invisible during my pregnancy, after I went to so much trouble to explain my special situation?
  
• Why didn’t you seem to notice how terrified we were when I started bleeding? Instead, you took your time getting to the ER.
  
• Why didn’t you come to talk to me later in the day after the cesarean section? When you spoke to my husband, you mentioned that you had removed the uterine septum so I could go on to have a normal full-term pregnancy. How could you begin to talk about another pregnancy while my son was in pain, bleeding into his brain? You wrote him off the minute you left the OR, just like you peeled off your gloves and dropped them into the trash.
  
• Why didn’t you ask the chaplain to be at the ethics hearing as a support for us?
  
• At my postoperative checkup, why did you rip off the dressing and declare me “beautifully healed”? And why did you walk off before I could say anything?
  

A healthy mourning process comprises several stages, including denial, anger, sadness, and meaning-making, followed by acceptance and healing. This harsh letter is an indication that the patient is stuck in anger; healing is a long way off. Beneath the anger are other emotions, including sadness, shame, and guilt.

When the obstetrician ripped off the dressing and declared the patient healed, he was addressing the physical abdominal wound, but he completely overlooked the deeper, invisible, psychospiritual wounds arising from loss of a child—and from loss of safety, power, trust, faith, and meaning. The patient’s feelings are striking in their potency, but the obstetrician remained unaware of them. At the time of her postoperative visit, these psychological wounds had not even begun to heal. The self that had been preparing to be a mother had not yet integrated all the losses and realigned to the grim reality that she was now the parent of a dead baby.

 

Rather than further her healing, the obstetrician’s words alienated her and added yet another layer of wounding.

Letter continued

That hospital was my personal place in hell from the moment I entered until the day I was discharged. You and your office staff seemed totally oblivious to this fact. Now a year has passed—a year of pure devastation—and I still have pain and sadness that cannot be understood by anyone who has not experienced the death of a child. And I have anger at the incompetent ER staff and at myself for being “a good patient” and ignoring my intuition.

I deserved a physician who can remember who I am and my relevant history—one who would come to see me immediately and reassure me that everything possible would be done for my baby and me. I deserved a physician who can acknowledge the awfulness of such a loss and offer sympathy and support. And to make matters worse, you immediately retreated behind the fear of a lawsuit.

Grief, interrupted: When the business-as-usual world interferes

An outpouring of grief in the face of loss is normal; it mobilizes energy and is an integral part of the healing process. Emotional healing may seem protracted when it is viewed in the context of chronological time, and pressing demands frequently interfere with the process. In this case, demands included the need to attend an ethics meeting, arrange a funeral, care for a 2-year-old son, host parents-in-law who had arrived from out of town, and, the following week, throw a birthday party for her son.

Disenfranchised grief: How wrong words, or none, can slow healing

This patient found little validation or support for her grief from those who were around her:

• Medical personnel acted defensively and insensitively.
  
• Her in-laws kept busy, making idle chitchat while they fussed over the party and memorial arrangements.
  
• Her friends plied her with platitudes: “God needs an angel in heaven,” “God needed your son more than you do,” “We can’t know why God makes these decisions.”
  
• The priest performed the memorial service in ritualistic fashion. “He couldn’t even get Eric’s name right,” she lamented.
  
• Her return to work was marked by awkward cheeriness, “as if I had been on vacation.” Her boss’s comment? “Best hop right back in the saddle.”
  

All these people seemed invested in their own coping strategies. None provided comfort; empathy was absent. Any mourning that had to be done was done alone, behind closed doors and a fixed smile. Isolation, the hallmark of trauma, was pronounced. Only after she found a support group several months later was Dr. Foster able to openly mourn.

Three symptom clusters signal PTSD

Dr. Foster’s description of her postdelivery experience suggests to me that she sustained an acute stress disorder—a condition that involves feelings of intense fear, horror, disorientation, and helplessness in response to an unusually traumatic experience that threatens death or serious physical injury to self or others. In Dr. Foster’s case, the stress disorder progressed to PTSD—a pervasive chronic anxiety disorder characterized by three clusters of symptoms:

• Recurrent, intrusive recollections of events; recurrent flashbacks and dreams. “At night, after going to bed, I would see the fetal monitor showing my child’s heart rate running like a video stream in front of my eyes. This went on for months. It would take me 1 to 2 hours to force myself to fall asleep.”
  
• Persistent avoidance of stimuli associated with the event; numbness and detachment. “I had feelings of numbness and unreality but couldn’t really understand or process them. Eating became difficult, and I was unable to experience any pleasure. Survivor’s guilt plagued me. Why am I alive? I asked myself. I had some 30 years, but my son didn’t even have a chance.”
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration. “I returned to work after a month but could not focus or concentrate, so I took 2 additional months off. Whenever I heard the obstetrician paged at the hospital, I had a physical reaction. My muscles clenched, my skin flushed, and my heart raced. Eventually, I stopped working at that hospital because I couldn’t stand being there.”
  

PTSD is not rare in civilian life or in medicine. Journal articles attest to its occurrence in association with major illness and injury,² spontaneous abortion,³ and premature and traumatic birth.^4-8

In Dr. Foster’s case, PTSD went unrecognized and untreated.

How to avert, and alleviate, PTSD

As with any disaster, careful planning can mitigate consequences even though it cannot necessarily prevent PTSD. Prenatal visits offer a unique opportunity to build a trusting partnership with your patient and her partner. Skilled professional communication is essential. Anticipate common themes:

 

• Fear of failure and shame is an issue for many mothers-to-be. Here, your affirmations and good humor are helpful. Be very respectful of the patient’s interpersonal boundaries, both physical and emotional.
  
• Disempowerment is an inherent part of the patient experience; trauma aggravates this dynamic. Whenever feasible, shift some of your power to the patient by eliciting her wishes and offering her choices. Together, create a plan for delivery and postnatal care that reflects her desires. As you demonstrate competence and control, consciously deconstruct the image your patient may have of you as an infallible authority figure by selectively revealing a little of the personality behind the white coat.
  
• Feelings of isolation always occur with trauma. The bonds you cultivate with the patient during her pregnancy will alleviate this isolation, as will your message: You are not alone in this experience; we will deal with this together.
  

Other helpful practices

Allow the grieving couple space and privacy to ventilate and mourn any way they need to. This may include expressions of anger.

Listen silently and attentively even if you feel passive or uncomfortable doing so. Resist the urge to comfort the patient; even well-intentioned comforting can interrupt healing.

Validate the patient’s trauma. Be careful to avoid making the suggestion that you understand. No one but the patient can understand—suffering is always unique and personal.

Express a genuine and carefully worded sense of regret for the patient’s loss. Take care not to express personal negative feelings, such as those regarding a baby’s deformity. Your words may become permanently imprinted.⁹

Present any information and recommendations the patient needs in writing because, when a person is in shock, she may be unable to recall verbal messages. Also give written recommendations to one of the patient’s family members, if possible.

Avoid well-intentioned attempts to reassure a patient or to rationalize or offer premature hope. There is time for such things later.

Cultivate a referral network that includes social workers, chaplains, and psychotherapists trained to work with trauma victims, and when they are necessary, involve them as early as possible. Also familiarize yourself with local support groups and short-term cognitive group-therapy programs for grieving parents.¹⁰

Frame the gesture carefully if you feel the need to refer the patient to a psychotherapist or psychiatrist. It is better to emphasize to the patient that she has sustained a major trauma than to suggest there is something wrong with her. The latter will only add to her sense of personal failure and may trigger resistance or anger.

Take care of yourself! You need your own practices and rituals to sustain you in the work you do. Create your own network of support. Concentrate on expanding your resilience and strive to be comfortable with your emotions. If symptoms of burnout appear, seek help quickly.

The author thanks Amy Hyams and Anne-Marie Jackson, MD, for their assistance.

Recommended reading

• Bub B. Communication Skills That Heal: A Practical Approach to a New Professionalism in Medicine. Abington, UK: Radcliffe Publishing–Oxford; 2005.
  
• Herman J. Trauma and Recovery. London: Rivers Oram Press; 1997.
  
• Schneider J. Finding My Way: Healing and Transformation Through Loss and Grief. Colfax, Wisc: Seasons; 1994.
  

No mammogram despite family history

A 36-year-old woman with a family history of breast cancer, fibrocystic breast disease, and galactorrhea had been a patient of the defendant for 5 years. During this time, he had examined her regularly but did not recommend a mammogram. When she finally requested a mammogram, he ordered it. Cancer was indicated by the study, and she was diagnosed with stage IV breast cancer.

Patient’s claim The defendant was negligent for not ordering mammograms sooner.

Doctor’s defense A mammogram has no medical benefit for a 36-year-old, and he had acted properly.

Verdict A $1.25 million New York settlement.

Mother leaves bed, child has brain damage

An obstetric patient at an osteopathic hospital was treated mainly by resident physicians during her pregnancy. Because of mild preeclampsia, she presented for labor induction 1 to 2 weeks before her due date. Her labor was managed by a senior resident according to the protocol for an obstetric clinic patient, but the assigned attending physician never saw or examined her. During labor, variable fetal heart decelerations developed due to cord compression, and became more severe, but the fetus recovered when the mother was repositioned.

The fetal heart monitor was disconnected for 10 minutes to allow the mother to get out of bed to use the bathroom. Following this, reinstitution of fetal monitoring demonstrated a nonreassuring fetal tracing, and the patient had an emergency cesarean section. The cesarean section took 14 minutes to perform. The child suffered severe brain damage. The long-term effects include profound mental retardation, spastic quadriplegia, cerebral palsy, and the need for tube feeding.

Patient’s claim (1) She had a dysfunctional labor pattern because her cervix was not dilating. (2) The option of a cesarean section should have been presented to her. (3) While the monitor was disconnected, the fetus moved, causing cord compression and fetal distress. (4) She should have been catheterized instead of being allowed to leave her bed and go to the bathroom.

Doctor’s defense (1) The patient showed normal labor progress. (2) The fetal monitor indicated good variability and repeated fetal heart rate accelerations, so it was proper to allow the patient to go to the bathroom. (3) A rare type of umbilical cord accident caused the brain damage.

Verdict $15.4 million Michigan verdict against the hospital only.

Can CVS identify Down syndrome in twins?

A 38-year-old woman was pregnant with twins. Because of her age, she was at a higher risk of giving birth to a Down syndrome baby. When her physicians recommended amniocentesis at 16 to 18 weeks’ gestation to test for Down syndrome, she declined because she believed this was too late for her to have an abortion if the test was positive. When a blood screening test at 21 weeks’ gestation indicated an increased risk of fetal Down syndrome, she again declined amniocentesis because she could not end the pregnancy at this late date. When the twins were born, both had Down syndrome.

Patient’s claim The physicians were negligent for failing to inform her of chorionic villus sampling at 11 weeks’ gestation, which could have identified Down syndrome. If she had known, she would have had the test done and then terminated her pregnancy when Down syndrome was found.

Doctor’s defense Their care of the patient was reasonable and proper. The testing they offered was the standard of care. Also, chorionic villus sampling would not have identified Down syndrome. Even if the patient had been informed earlier in the pregnancy, she would not have had an abortion.

Verdict $4 million Virginia verdict.

Did septum in uterus cause fetal loss?

A woman in her 20s was pregnant for the fourth time. Her three previous pregnancies had miscarried—one in the early weeks of pregnancy, and two in the second trimester.

The physician group that was caring for her considered the possibility of an incompetent cervix and requested—but never received—her prior medical records. Because she went into labor and her membranes ruptured before her cervix dilated, her physicians concluded that the miscarriages were inconsistent with an incompetent cervix. She underwent regular ultrasonography during the fourth pregnancy, which progressed normally.

In week 20, she reported a vaginal discharge and was sent to the hospital, where nothing abnormal was found. She was discharged home that day, but returned the following day with a dilated cervix and membranes protruding into the vagina. The fetus died in utero, and her physicians noted that she was a candidate for a cerclage in the future. During litigation, the release of the patient’s subsequent medical records was ordered. She was found to have a septum inside her uterus, causing the uterus to be much smaller than normal.

 

Patient’s claim A cerclage should have been performed, and the septum should have been found and treated. Even with the septum, she could carry a child to term.

Doctor’s defense A cerclage was not a risk-free procedure, and there were no clear signs of an incompetent cervix. The septum made the uterus too small for a pregnancy to be carried to term. Also the septum could not be diagnosed while the woman was still pregnant.

Verdict Michigan defense verdict.

Hysterectomy, then hematuria, then stroke

Following an abdominal hysterectomy, the urine of a 53-year-old patient was found to be bloody, and then she suffered a stroke. After tests were performed, a laceration of the bladder’s dome and posterior wall was repaired in follow-up surgery.

Patient’s claim The laceration occurred during the hysterectomy. She suffered a stroke as a result of blood loss from that injury. She has residual impairment of attention, memory, and vision. There was negligence in performing the surgery and for failing to diagnose and treat the laceration in a timely manner.

Doctor’s defense The laceration happened during the repair surgery—or else a small laceration was made larger by the postoperative diagnostic imaging studies. Also, bleeding, lacerations, and punctures are known risks of abdominal hysterectomy.

Verdict $400,000 New York settlement with the surgeon. The claims against the assisting physician and the hospital were discontinued.

No mammogram despite family history

A 36-year-old woman with a family history of breast cancer, fibrocystic breast disease, and galactorrhea had been a patient of the defendant for 5 years. During this time, he had examined her regularly but did not recommend a mammogram. When she finally requested a mammogram, he ordered it. Cancer was indicated by the study, and she was diagnosed with stage IV breast cancer.

Patient’s claim The defendant was negligent for not ordering mammograms sooner.

Doctor’s defense A mammogram has no medical benefit for a 36-year-old, and he had acted properly.

Verdict A $1.25 million New York settlement.

Mother leaves bed, child has brain damage

An obstetric patient at an osteopathic hospital was treated mainly by resident physicians during her pregnancy. Because of mild preeclampsia, she presented for labor induction 1 to 2 weeks before her due date. Her labor was managed by a senior resident according to the protocol for an obstetric clinic patient, but the assigned attending physician never saw or examined her. During labor, variable fetal heart decelerations developed due to cord compression, and became more severe, but the fetus recovered when the mother was repositioned.

The fetal heart monitor was disconnected for 10 minutes to allow the mother to get out of bed to use the bathroom. Following this, reinstitution of fetal monitoring demonstrated a nonreassuring fetal tracing, and the patient had an emergency cesarean section. The cesarean section took 14 minutes to perform. The child suffered severe brain damage. The long-term effects include profound mental retardation, spastic quadriplegia, cerebral palsy, and the need for tube feeding.

Patient’s claim (1) She had a dysfunctional labor pattern because her cervix was not dilating. (2) The option of a cesarean section should have been presented to her. (3) While the monitor was disconnected, the fetus moved, causing cord compression and fetal distress. (4) She should have been catheterized instead of being allowed to leave her bed and go to the bathroom.

Doctor’s defense (1) The patient showed normal labor progress. (2) The fetal monitor indicated good variability and repeated fetal heart rate accelerations, so it was proper to allow the patient to go to the bathroom. (3) A rare type of umbilical cord accident caused the brain damage.

Verdict $15.4 million Michigan verdict against the hospital only.

Can CVS identify Down syndrome in twins?

A 38-year-old woman was pregnant with twins. Because of her age, she was at a higher risk of giving birth to a Down syndrome baby. When her physicians recommended amniocentesis at 16 to 18 weeks’ gestation to test for Down syndrome, she declined because she believed this was too late for her to have an abortion if the test was positive. When a blood screening test at 21 weeks’ gestation indicated an increased risk of fetal Down syndrome, she again declined amniocentesis because she could not end the pregnancy at this late date. When the twins were born, both had Down syndrome.

Patient’s claim The physicians were negligent for failing to inform her of chorionic villus sampling at 11 weeks’ gestation, which could have identified Down syndrome. If she had known, she would have had the test done and then terminated her pregnancy when Down syndrome was found.

Doctor’s defense Their care of the patient was reasonable and proper. The testing they offered was the standard of care. Also, chorionic villus sampling would not have identified Down syndrome. Even if the patient had been informed earlier in the pregnancy, she would not have had an abortion.

Verdict $4 million Virginia verdict.

Did septum in uterus cause fetal loss?

A woman in her 20s was pregnant for the fourth time. Her three previous pregnancies had miscarried—one in the early weeks of pregnancy, and two in the second trimester.

The physician group that was caring for her considered the possibility of an incompetent cervix and requested—but never received—her prior medical records. Because she went into labor and her membranes ruptured before her cervix dilated, her physicians concluded that the miscarriages were inconsistent with an incompetent cervix. She underwent regular ultrasonography during the fourth pregnancy, which progressed normally.

In week 20, she reported a vaginal discharge and was sent to the hospital, where nothing abnormal was found. She was discharged home that day, but returned the following day with a dilated cervix and membranes protruding into the vagina. The fetus died in utero, and her physicians noted that she was a candidate for a cerclage in the future. During litigation, the release of the patient’s subsequent medical records was ordered. She was found to have a septum inside her uterus, causing the uterus to be much smaller than normal.

 

Patient’s claim A cerclage should have been performed, and the septum should have been found and treated. Even with the septum, she could carry a child to term.

Doctor’s defense A cerclage was not a risk-free procedure, and there were no clear signs of an incompetent cervix. The septum made the uterus too small for a pregnancy to be carried to term. Also the septum could not be diagnosed while the woman was still pregnant.

Verdict Michigan defense verdict.

Hysterectomy, then hematuria, then stroke

Following an abdominal hysterectomy, the urine of a 53-year-old patient was found to be bloody, and then she suffered a stroke. After tests were performed, a laceration of the bladder’s dome and posterior wall was repaired in follow-up surgery.

Patient’s claim The laceration occurred during the hysterectomy. She suffered a stroke as a result of blood loss from that injury. She has residual impairment of attention, memory, and vision. There was negligence in performing the surgery and for failing to diagnose and treat the laceration in a timely manner.

Doctor’s defense The laceration happened during the repair surgery—or else a small laceration was made larger by the postoperative diagnostic imaging studies. Also, bleeding, lacerations, and punctures are known risks of abdominal hysterectomy.

Verdict $400,000 New York settlement with the surgeon. The claims against the assisting physician and the hospital were discontinued.

No mammogram despite family history

A 36-year-old woman with a family history of breast cancer, fibrocystic breast disease, and galactorrhea had been a patient of the defendant for 5 years. During this time, he had examined her regularly but did not recommend a mammogram. When she finally requested a mammogram, he ordered it. Cancer was indicated by the study, and she was diagnosed with stage IV breast cancer.

Patient’s claim The defendant was negligent for not ordering mammograms sooner.

Doctor’s defense A mammogram has no medical benefit for a 36-year-old, and he had acted properly.

Verdict A $1.25 million New York settlement.

Mother leaves bed, child has brain damage

An obstetric patient at an osteopathic hospital was treated mainly by resident physicians during her pregnancy. Because of mild preeclampsia, she presented for labor induction 1 to 2 weeks before her due date. Her labor was managed by a senior resident according to the protocol for an obstetric clinic patient, but the assigned attending physician never saw or examined her. During labor, variable fetal heart decelerations developed due to cord compression, and became more severe, but the fetus recovered when the mother was repositioned.

The fetal heart monitor was disconnected for 10 minutes to allow the mother to get out of bed to use the bathroom. Following this, reinstitution of fetal monitoring demonstrated a nonreassuring fetal tracing, and the patient had an emergency cesarean section. The cesarean section took 14 minutes to perform. The child suffered severe brain damage. The long-term effects include profound mental retardation, spastic quadriplegia, cerebral palsy, and the need for tube feeding.

Patient’s claim (1) She had a dysfunctional labor pattern because her cervix was not dilating. (2) The option of a cesarean section should have been presented to her. (3) While the monitor was disconnected, the fetus moved, causing cord compression and fetal distress. (4) She should have been catheterized instead of being allowed to leave her bed and go to the bathroom.

Doctor’s defense (1) The patient showed normal labor progress. (2) The fetal monitor indicated good variability and repeated fetal heart rate accelerations, so it was proper to allow the patient to go to the bathroom. (3) A rare type of umbilical cord accident caused the brain damage.

Verdict $15.4 million Michigan verdict against the hospital only.

Can CVS identify Down syndrome in twins?

A 38-year-old woman was pregnant with twins. Because of her age, she was at a higher risk of giving birth to a Down syndrome baby. When her physicians recommended amniocentesis at 16 to 18 weeks’ gestation to test for Down syndrome, she declined because she believed this was too late for her to have an abortion if the test was positive. When a blood screening test at 21 weeks’ gestation indicated an increased risk of fetal Down syndrome, she again declined amniocentesis because she could not end the pregnancy at this late date. When the twins were born, both had Down syndrome.

Patient’s claim The physicians were negligent for failing to inform her of chorionic villus sampling at 11 weeks’ gestation, which could have identified Down syndrome. If she had known, she would have had the test done and then terminated her pregnancy when Down syndrome was found.

Doctor’s defense Their care of the patient was reasonable and proper. The testing they offered was the standard of care. Also, chorionic villus sampling would not have identified Down syndrome. Even if the patient had been informed earlier in the pregnancy, she would not have had an abortion.

Verdict $4 million Virginia verdict.

Did septum in uterus cause fetal loss?

A woman in her 20s was pregnant for the fourth time. Her three previous pregnancies had miscarried—one in the early weeks of pregnancy, and two in the second trimester.

The physician group that was caring for her considered the possibility of an incompetent cervix and requested—but never received—her prior medical records. Because she went into labor and her membranes ruptured before her cervix dilated, her physicians concluded that the miscarriages were inconsistent with an incompetent cervix. She underwent regular ultrasonography during the fourth pregnancy, which progressed normally.

In week 20, she reported a vaginal discharge and was sent to the hospital, where nothing abnormal was found. She was discharged home that day, but returned the following day with a dilated cervix and membranes protruding into the vagina. The fetus died in utero, and her physicians noted that she was a candidate for a cerclage in the future. During litigation, the release of the patient’s subsequent medical records was ordered. She was found to have a septum inside her uterus, causing the uterus to be much smaller than normal.

 

Patient’s claim A cerclage should have been performed, and the septum should have been found and treated. Even with the septum, she could carry a child to term.

Doctor’s defense A cerclage was not a risk-free procedure, and there were no clear signs of an incompetent cervix. The septum made the uterus too small for a pregnancy to be carried to term. Also the septum could not be diagnosed while the woman was still pregnant.

Verdict Michigan defense verdict.

Hysterectomy, then hematuria, then stroke

Following an abdominal hysterectomy, the urine of a 53-year-old patient was found to be bloody, and then she suffered a stroke. After tests were performed, a laceration of the bladder’s dome and posterior wall was repaired in follow-up surgery.

Patient’s claim The laceration occurred during the hysterectomy. She suffered a stroke as a result of blood loss from that injury. She has residual impairment of attention, memory, and vision. There was negligence in performing the surgery and for failing to diagnose and treat the laceration in a timely manner.

Doctor’s defense The laceration happened during the repair surgery—or else a small laceration was made larger by the postoperative diagnostic imaging studies. Also, bleeding, lacerations, and punctures are known risks of abdominal hysterectomy.

Verdict $400,000 New York settlement with the surgeon. The claims against the assisting physician and the hospital were discontinued.

The inadequate use of modifiers ranks high on coding expert Emily Hill's list of the top 10 mistakes that physicians make when documenting patient visits. Marrying ICD-9 codes with appropriate CPT codes is tricker than it seems, she says. In this month's column, she gives some common scenarios of what goes wrong.

In most offices I visit, inappropriate use of modifiers is an issue. We see denials based on the lack of medical necessity, when in fact it is solid justification for the care that was given that is lacking.

For most practices, the mistake lies in not having the proper diagnosis associated with the ICD-9 code, or in not knowing how to associate those on the claim form. Using modifiers correctly is critical to the bottom line. Payers expect the CPT (Current Procedural Terminology) code to reflect medical necessity and to justify treatment choice or the course of investigation, so it pays to learn the modifier rules.

The challenge is that many clinical encounters don't follow the expected scenario—patients often have more than one diagnosis—and are thus difficult to modify.

As many as four diagnoses may be listed on the CMS-1500 paper claim form, and just as many diagnosis codes can be linked to each CPT code. However, many payers use only the first ICD-9 code linked to a CPT code, so multiple diagnoses need to be prioritized accurately.

Take the patient who presents with a cough and mild chest pain. Investigating the possibility of pneumonia, you may order an x-ray and some lab work. But that chest pain needs to be investigated as a possible cardiovascular disease. Billing for an EKG will be denied unless an appropriate diagnosis is listed. You would need to associate the EKG with the chest pain and the x-ray with the cough.

Then there is the symptom that is mentioned incidentally. A mother brings her child in for an upper respiratory infection and mentions in passing that the child is wetting the bed. A suspected upper respiratory infection won't justify a urinalysis, so a second diagnosis of enuresis is in order. The ICD for enuresis should be associated with the CPT code for the urinalysis.

Another common mistake occurs when a physician orders several lab tests but lists only a primary diagnosis that does not justify the lab work. So ordering a thyroid panel during a wellness visit may not work if there isn't another diagnosis to justify the panel. If the patient has signs and symptoms suggestive of a thyroid disorder, they must be documented. If the panel is being done for screening purposes, an ICD for screening services must be reported (though some payers may not reimburse for certain screening tests).

Reimbursement denials are inevitable when physicians fail to complete encounter forms thoroughly during the office visit. If there isn't a diagnosis for the office visit on the form when the patient leaves, the claim is more likely to be denied.

Most of the coding changes have introduced greater specificity, so there is now an overwhelming choice of codes. However, most ICD-9 codes do allow options that are unspecified or nonspecific. The temptation is to pick the least specific code. But that in itself can create denials.

Practices should use their billing software to run a production report to find out how many times each ICD-9 code is used. Doing so annually can help you determine if there is a preponderance of nonspecific codes and can help identify opportunities to improve reimbursement. Do the codes reflect the patient population? In a primary care practice, are there enough wellness visits? If there aren't, this could be a flag to a payer that preventive services are not being adequately provided. Also update the encounter form to make it more user friendly and remove codes that are seldom used.

Finally, be sure to keep up to date on coding changes. New ICD-9 codes will go into effect on Oct. 1, so it's important to look for any changes that may alter the specificity. Changes and clarifications to the CPT codes are due out next year.

The inadequate use of modifiers ranks high on coding expert Emily Hill's list of the top 10 mistakes that physicians make when documenting patient visits. Marrying ICD-9 codes with appropriate CPT codes is tricker than it seems, she says. In this month's column, she gives some common scenarios of what goes wrong.

In most offices I visit, inappropriate use of modifiers is an issue. We see denials based on the lack of medical necessity, when in fact it is solid justification for the care that was given that is lacking.

For most practices, the mistake lies in not having the proper diagnosis associated with the ICD-9 code, or in not knowing how to associate those on the claim form. Using modifiers correctly is critical to the bottom line. Payers expect the CPT (Current Procedural Terminology) code to reflect medical necessity and to justify treatment choice or the course of investigation, so it pays to learn the modifier rules.

The challenge is that many clinical encounters don't follow the expected scenario—patients often have more than one diagnosis—and are thus difficult to modify.

As many as four diagnoses may be listed on the CMS-1500 paper claim form, and just as many diagnosis codes can be linked to each CPT code. However, many payers use only the first ICD-9 code linked to a CPT code, so multiple diagnoses need to be prioritized accurately.

Take the patient who presents with a cough and mild chest pain. Investigating the possibility of pneumonia, you may order an x-ray and some lab work. But that chest pain needs to be investigated as a possible cardiovascular disease. Billing for an EKG will be denied unless an appropriate diagnosis is listed. You would need to associate the EKG with the chest pain and the x-ray with the cough.

Then there is the symptom that is mentioned incidentally. A mother brings her child in for an upper respiratory infection and mentions in passing that the child is wetting the bed. A suspected upper respiratory infection won't justify a urinalysis, so a second diagnosis of enuresis is in order. The ICD for enuresis should be associated with the CPT code for the urinalysis.

Another common mistake occurs when a physician orders several lab tests but lists only a primary diagnosis that does not justify the lab work. So ordering a thyroid panel during a wellness visit may not work if there isn't another diagnosis to justify the panel. If the patient has signs and symptoms suggestive of a thyroid disorder, they must be documented. If the panel is being done for screening purposes, an ICD for screening services must be reported (though some payers may not reimburse for certain screening tests).

Reimbursement denials are inevitable when physicians fail to complete encounter forms thoroughly during the office visit. If there isn't a diagnosis for the office visit on the form when the patient leaves, the claim is more likely to be denied.

Most of the coding changes have introduced greater specificity, so there is now an overwhelming choice of codes. However, most ICD-9 codes do allow options that are unspecified or nonspecific. The temptation is to pick the least specific code. But that in itself can create denials.

Practices should use their billing software to run a production report to find out how many times each ICD-9 code is used. Doing so annually can help you determine if there is a preponderance of nonspecific codes and can help identify opportunities to improve reimbursement. Do the codes reflect the patient population? In a primary care practice, are there enough wellness visits? If there aren't, this could be a flag to a payer that preventive services are not being adequately provided. Also update the encounter form to make it more user friendly and remove codes that are seldom used.

Finally, be sure to keep up to date on coding changes. New ICD-9 codes will go into effect on Oct. 1, so it's important to look for any changes that may alter the specificity. Changes and clarifications to the CPT codes are due out next year.

The inadequate use of modifiers ranks high on coding expert Emily Hill's list of the top 10 mistakes that physicians make when documenting patient visits. Marrying ICD-9 codes with appropriate CPT codes is tricker than it seems, she says. In this month's column, she gives some common scenarios of what goes wrong.

In most offices I visit, inappropriate use of modifiers is an issue. We see denials based on the lack of medical necessity, when in fact it is solid justification for the care that was given that is lacking.

For most practices, the mistake lies in not having the proper diagnosis associated with the ICD-9 code, or in not knowing how to associate those on the claim form. Using modifiers correctly is critical to the bottom line. Payers expect the CPT (Current Procedural Terminology) code to reflect medical necessity and to justify treatment choice or the course of investigation, so it pays to learn the modifier rules.

The challenge is that many clinical encounters don't follow the expected scenario—patients often have more than one diagnosis—and are thus difficult to modify.

As many as four diagnoses may be listed on the CMS-1500 paper claim form, and just as many diagnosis codes can be linked to each CPT code. However, many payers use only the first ICD-9 code linked to a CPT code, so multiple diagnoses need to be prioritized accurately.

Take the patient who presents with a cough and mild chest pain. Investigating the possibility of pneumonia, you may order an x-ray and some lab work. But that chest pain needs to be investigated as a possible cardiovascular disease. Billing for an EKG will be denied unless an appropriate diagnosis is listed. You would need to associate the EKG with the chest pain and the x-ray with the cough.

Then there is the symptom that is mentioned incidentally. A mother brings her child in for an upper respiratory infection and mentions in passing that the child is wetting the bed. A suspected upper respiratory infection won't justify a urinalysis, so a second diagnosis of enuresis is in order. The ICD for enuresis should be associated with the CPT code for the urinalysis.

Another common mistake occurs when a physician orders several lab tests but lists only a primary diagnosis that does not justify the lab work. So ordering a thyroid panel during a wellness visit may not work if there isn't another diagnosis to justify the panel. If the patient has signs and symptoms suggestive of a thyroid disorder, they must be documented. If the panel is being done for screening purposes, an ICD for screening services must be reported (though some payers may not reimburse for certain screening tests).

Reimbursement denials are inevitable when physicians fail to complete encounter forms thoroughly during the office visit. If there isn't a diagnosis for the office visit on the form when the patient leaves, the claim is more likely to be denied.

Most of the coding changes have introduced greater specificity, so there is now an overwhelming choice of codes. However, most ICD-9 codes do allow options that are unspecified or nonspecific. The temptation is to pick the least specific code. But that in itself can create denials.

Practices should use their billing software to run a production report to find out how many times each ICD-9 code is used. Doing so annually can help you determine if there is a preponderance of nonspecific codes and can help identify opportunities to improve reimbursement. Do the codes reflect the patient population? In a primary care practice, are there enough wellness visits? If there aren't, this could be a flag to a payer that preventive services are not being adequately provided. Also update the encounter form to make it more user friendly and remove codes that are seldom used.

Finally, be sure to keep up to date on coding changes. New ICD-9 codes will go into effect on Oct. 1, so it's important to look for any changes that may alter the specificity. Changes and clarifications to the CPT codes are due out next year.