Managing Your Practice

A survey by the Council of Communications Management confirms what any good human resources manager knows: Recognition of a job performed well, not money, is the best motivator of employee performance.

Unfortunately, most physicians do not seem to understand or apply this basic business concept. This is despite the fact that doctors themselves said, in a separate survey, that they much prefer to practice in offices and clinics where their hard work is recognized and rewarded.

In “1001 Ways to Reward Employees” (New York: Workman Publishing, 1994), Bob Nelson said, “While money is important to employees, what tends to motivate them to perform—and to perform at higher levels—is the thoughtful, personal kind of recognition that signifies true appreciation for a job well done.”

Too often, a physician or a boss's idea of a reward is a yearly cash bonus, usually given during the holiday season. But giving the same reward to everyone at the same time every year—often called “jelly bean motivation” by consultants—not only does not inspire employees to work harder and better, but on the contrary, can actually serve as a disincentive to excellent employees who see no appreciation or acknowledgement of their beyond-the-call performance. Even the most mediocre employees don't see it as a reward. Rather, the bonus becomes an entitlement—just an expected, meaningless component of their normal compensation.

Nelson lists three simple guidelines for effectively rewarding employees:

▸ Match the reward to the individual. Reward each person in ways that each individual employee finds rewarding.

▸ Match the reward to the achievement. An employee who successfully completes a 2-year-long medical records reorganization deserves a more substantial reward than does one who simply runs an errand for you.

▸ Be timely and specific. To be effective, rewards must be given as soon as possible after a specific laudable behavior or achievement, and the employee should always be told why he or she is receiving it. Additionally, it's important to keep in mind that rewards that come weeks or months after the fact, and those that seem to be given for no particular reason, do little or nothing to accomplish their desired effect.

So how do you know which rewards your employees will find rewarding? That's easy: Ask them!

I periodically solicit suggestions for nonmonetary rewards from my staff. “I can't give you money,” I tell them, “but I'll consider just about anything else.”

Some of their ideas have been surprisingly creative—and surprisingly cheap. For example, my employees are required to park their cars each day on the other side of the hospital campus from my office building. One of them suggested that a closer parking space would be a good reward. I was able to obtain an extra access card for the doctors' lot right next to my building, and each month one “Employee of the Month” gets to park there. This reward, which costs me nothing, has become the most sought-after in our office.

In fact, there are many effective rewards that cost little or nothing. As Nelson puts it, “A sincere word of thanks from the right person at the right time can mean more to an employee than a raise, a formal award, or a whole wall of certificates or plaques.”

One of the strongest motivators imaginable is the knowledge that you, as the boss, will take a moment to notice a job well done and praise it publicly, in a timely manner.

Time off is another powerful motivator, which surveys show is almost universally popular among employees of all types.

According to Michael LeBoeuf, author of “The Greatest Management Principle in the World” (New York: Putnam, 1985), there are three ways you can use time off as a reward:

▸ If the job permits it, assign a deadline and minimum quality standard to a task. If the task is finished ahead of the deadline, the extra time is the employee's reward.

▸ If allowing employees to leave early is impractical, specify an amount of work you want done by a certain time. If the work is completed on time and satisfactorily, give a predetermined amount of time off as the reward. You can also set up a scoring system in which employees earn an hour off for a specified period of productive work. When they have earned 4 hours they can have a half day off, and 8 hours earns a day off, and so on.

▸ Award time off for improvements in quality, safety, teamwork, or any other behavior you feel is important.

By the way, LeBoeuf's “greatest management principle” is that “the things that get rewarded get done.”

Whatever rewards you choose, monetary or otherwise, always be sure to choose them and award them with sincerity. Cheap wall plaques, lapel pins, and other tchotchkes usually fail to motivate employees in the intended way because they come across as being empty gestures given out in a thoughtless manner. On the other hand, a few very simple and honest words of thanks go much further.

A survey by the Council of Communications Management confirms what any good human resources manager knows: Recognition of a job performed well, not money, is the best motivator of employee performance.

Unfortunately, most physicians do not seem to understand or apply this basic business concept. This is despite the fact that doctors themselves said, in a separate survey, that they much prefer to practice in offices and clinics where their hard work is recognized and rewarded.

In “1001 Ways to Reward Employees” (New York: Workman Publishing, 1994), Bob Nelson said, “While money is important to employees, what tends to motivate them to perform—and to perform at higher levels—is the thoughtful, personal kind of recognition that signifies true appreciation for a job well done.”

Too often, a physician or a boss's idea of a reward is a yearly cash bonus, usually given during the holiday season. But giving the same reward to everyone at the same time every year—often called “jelly bean motivation” by consultants—not only does not inspire employees to work harder and better, but on the contrary, can actually serve as a disincentive to excellent employees who see no appreciation or acknowledgement of their beyond-the-call performance. Even the most mediocre employees don't see it as a reward. Rather, the bonus becomes an entitlement—just an expected, meaningless component of their normal compensation.

Nelson lists three simple guidelines for effectively rewarding employees:

▸ Match the reward to the individual. Reward each person in ways that each individual employee finds rewarding.

▸ Match the reward to the achievement. An employee who successfully completes a 2-year-long medical records reorganization deserves a more substantial reward than does one who simply runs an errand for you.

▸ Be timely and specific. To be effective, rewards must be given as soon as possible after a specific laudable behavior or achievement, and the employee should always be told why he or she is receiving it. Additionally, it's important to keep in mind that rewards that come weeks or months after the fact, and those that seem to be given for no particular reason, do little or nothing to accomplish their desired effect.

So how do you know which rewards your employees will find rewarding? That's easy: Ask them!

I periodically solicit suggestions for nonmonetary rewards from my staff. “I can't give you money,” I tell them, “but I'll consider just about anything else.”

Some of their ideas have been surprisingly creative—and surprisingly cheap. For example, my employees are required to park their cars each day on the other side of the hospital campus from my office building. One of them suggested that a closer parking space would be a good reward. I was able to obtain an extra access card for the doctors' lot right next to my building, and each month one “Employee of the Month” gets to park there. This reward, which costs me nothing, has become the most sought-after in our office.

In fact, there are many effective rewards that cost little or nothing. As Nelson puts it, “A sincere word of thanks from the right person at the right time can mean more to an employee than a raise, a formal award, or a whole wall of certificates or plaques.”

One of the strongest motivators imaginable is the knowledge that you, as the boss, will take a moment to notice a job well done and praise it publicly, in a timely manner.

Time off is another powerful motivator, which surveys show is almost universally popular among employees of all types.

According to Michael LeBoeuf, author of “The Greatest Management Principle in the World” (New York: Putnam, 1985), there are three ways you can use time off as a reward:

▸ If the job permits it, assign a deadline and minimum quality standard to a task. If the task is finished ahead of the deadline, the extra time is the employee's reward.

▸ If allowing employees to leave early is impractical, specify an amount of work you want done by a certain time. If the work is completed on time and satisfactorily, give a predetermined amount of time off as the reward. You can also set up a scoring system in which employees earn an hour off for a specified period of productive work. When they have earned 4 hours they can have a half day off, and 8 hours earns a day off, and so on.

▸ Award time off for improvements in quality, safety, teamwork, or any other behavior you feel is important.

By the way, LeBoeuf's “greatest management principle” is that “the things that get rewarded get done.”

Whatever rewards you choose, monetary or otherwise, always be sure to choose them and award them with sincerity. Cheap wall plaques, lapel pins, and other tchotchkes usually fail to motivate employees in the intended way because they come across as being empty gestures given out in a thoughtless manner. On the other hand, a few very simple and honest words of thanks go much further.

A survey by the Council of Communications Management confirms what any good human resources manager knows: Recognition of a job performed well, not money, is the best motivator of employee performance.

Unfortunately, most physicians do not seem to understand or apply this basic business concept. This is despite the fact that doctors themselves said, in a separate survey, that they much prefer to practice in offices and clinics where their hard work is recognized and rewarded.

In “1001 Ways to Reward Employees” (New York: Workman Publishing, 1994), Bob Nelson said, “While money is important to employees, what tends to motivate them to perform—and to perform at higher levels—is the thoughtful, personal kind of recognition that signifies true appreciation for a job well done.”

Too often, a physician or a boss's idea of a reward is a yearly cash bonus, usually given during the holiday season. But giving the same reward to everyone at the same time every year—often called “jelly bean motivation” by consultants—not only does not inspire employees to work harder and better, but on the contrary, can actually serve as a disincentive to excellent employees who see no appreciation or acknowledgement of their beyond-the-call performance. Even the most mediocre employees don't see it as a reward. Rather, the bonus becomes an entitlement—just an expected, meaningless component of their normal compensation.

Nelson lists three simple guidelines for effectively rewarding employees:

▸ Match the reward to the individual. Reward each person in ways that each individual employee finds rewarding.

▸ Match the reward to the achievement. An employee who successfully completes a 2-year-long medical records reorganization deserves a more substantial reward than does one who simply runs an errand for you.

▸ Be timely and specific. To be effective, rewards must be given as soon as possible after a specific laudable behavior or achievement, and the employee should always be told why he or she is receiving it. Additionally, it's important to keep in mind that rewards that come weeks or months after the fact, and those that seem to be given for no particular reason, do little or nothing to accomplish their desired effect.

So how do you know which rewards your employees will find rewarding? That's easy: Ask them!

I periodically solicit suggestions for nonmonetary rewards from my staff. “I can't give you money,” I tell them, “but I'll consider just about anything else.”

Some of their ideas have been surprisingly creative—and surprisingly cheap. For example, my employees are required to park their cars each day on the other side of the hospital campus from my office building. One of them suggested that a closer parking space would be a good reward. I was able to obtain an extra access card for the doctors' lot right next to my building, and each month one “Employee of the Month” gets to park there. This reward, which costs me nothing, has become the most sought-after in our office.

In fact, there are many effective rewards that cost little or nothing. As Nelson puts it, “A sincere word of thanks from the right person at the right time can mean more to an employee than a raise, a formal award, or a whole wall of certificates or plaques.”

One of the strongest motivators imaginable is the knowledge that you, as the boss, will take a moment to notice a job well done and praise it publicly, in a timely manner.

Time off is another powerful motivator, which surveys show is almost universally popular among employees of all types.

According to Michael LeBoeuf, author of “The Greatest Management Principle in the World” (New York: Putnam, 1985), there are three ways you can use time off as a reward:

▸ If the job permits it, assign a deadline and minimum quality standard to a task. If the task is finished ahead of the deadline, the extra time is the employee's reward.

▸ If allowing employees to leave early is impractical, specify an amount of work you want done by a certain time. If the work is completed on time and satisfactorily, give a predetermined amount of time off as the reward. You can also set up a scoring system in which employees earn an hour off for a specified period of productive work. When they have earned 4 hours they can have a half day off, and 8 hours earns a day off, and so on.

▸ Award time off for improvements in quality, safety, teamwork, or any other behavior you feel is important.

By the way, LeBoeuf's “greatest management principle” is that “the things that get rewarded get done.”

Whatever rewards you choose, monetary or otherwise, always be sure to choose them and award them with sincerity. Cheap wall plaques, lapel pins, and other tchotchkes usually fail to motivate employees in the intended way because they come across as being empty gestures given out in a thoughtless manner. On the other hand, a few very simple and honest words of thanks go much further.

MD fails to check for metastasis of Ca

A woman in her late 50s underwent a total abdominal hysterectomy performed by a gynecologist. The postoperative pathology report indicated cancer. The initial tests showed endometrioid adenocarcinoma, and later tests indicated uterine papillary serous carcinoma (UPSC), a rare and aggressive cancer. The woman returned to the gynecologist twice a year for physical exams, as instructed. A year and a half after the surgery, she went to her family physician complaining of stomach, shoulder, and chest pains. Lesions on her diaphragm, liver, and abdomen, consistent with metastatic disease, were evident on a CT scan. Eventually, the patient died.

Patient’s claim The postoperative pathology report showed two different cancers, but the gynecologist did not inform her of the UPSC. She should have been referred to an oncologist so that she could have been given chemotherapy and had a chance for a prolonged life.

Doctor’s defense He did inform the patient about the UPSC, but she chose not to undergo chemotherapy. At the time, there was no standard of care for UPSC, and when she was healthy for several years, he chose not to check for metastasis of the cancer.

Verdict $575,000 Pennsylvania verdict.

Profound neurologic damage to one triplet

A 48-year-old woman pregnant carrying triplets—conceived through in vitro fertilization—was admitted to the hospital for preterm labor at 20 weeks’ gestation. She was given a diagnosis of insulin-dependent gestational diabetes and sent home. At 31 weeks, she was readmitted for preterm labor and was given magnesium sulfate. After 3 weeks in the hospital, she was moved to labor and delivery when a low heart rate was detected in one fetus. One nurse cared for the mother for several hours, during which late decelerations in the fetal heart pattern were evident. The nurse notified the other defendants, but there was allegedly a delay in responding. When a cesarean section was performed, one of the three babies was born with profound neurologic damage. Diagnosed with spastic diplegia, he cannot walk or stand without help; cannot speak or communicate effectively; and has low vision. He requires physical, occupational, and speech therapy.

Patient’s claim A delay in performing the cesarean section caused the one baby’s neurologic damage.

Doctor’s defense Not reported.

Verdict $4.2 million Massachusetts settlement.

“Stay home,” despite reports of problems

When a woman at 35 weeks’ gestation presented to her physician with signs consistent with premature labor, she was sent home. Later that day she was advised to go to the hospital, where tests conducted over a 72-hour period indicated premature labor and a healthy, viable fetus. Steroids were administered to increase lung maturity. Then the woman was instructed to monitor herself for increased frequency of contractions, decreased fetal movement, or leakage of fluid, and sent home. After 4 days, she reported significantly decreased fetal movement, but was advised to continue monitoring at home. After 2 more days, she reported leakage of fluid, but was again told to stay at home. One week later, she noted no fetal movement. Fetal death was confirmed at the hospital, and the fetus was delivered later that day.

Patient’s claim A nuchal cord led to fetal death. She should have been admitted for monitoring or delivery when she reported decreased fetal movement and fluid leakage.

Doctor’s defense The nuchal cord was an unforeseeable complication.

Verdict $2.5 million Ohio verdict.

Resident asks for help too late in birth

Dr. A, a first-year family practice resident, provided prenatal care to a woman pregnant with her first child; Dr. B was the attending physician. The pregnancy had no serious complications, but the woman had mildly elevated blood pressure and discomfort at the end of the pregnancy. She requested an elective cesarean section several times, but Dr. A declined the request and consulted with neither an OB nor Dr. B. When she noted decreased fetal movement, a fetal non-stress test was done and was nonreactive. A low level of amniotic fluid and low fetal tone were confirmed. The woman was hospitalized and administered oxytocin to stimulate uterine contractions. Intermittent decelerations and diminished variability were evident in the fetal heart rate, but a cesarean section was not discussed. She progressed to active labor. Dr. B was on his way to the hospital as requested by Dr. A, but Dr. A—who had limited obstetrical experience—did not seek the aid of any other physician. He failed to interpret the fetal monitor strip correctly, and the labor and delivery nurse neglected to call a more experienced physician—although one was available. Just prior to delivery the fetal heart rate was not monitored for 20 minutes. At delivery, a nuchal cord was detected, then clamped and cut by Dr. A. The chief resident was called in and completed delivery in 2 minutes. The child was born blue and lifeless. A full neonatal resuscitation team was unavailable, and intubation was performed after 4 minutes. Dr. B arrived 5 minutes after delivery. The child suffered catastrophic brain damage due to hypoxic–ischemic encephalopathy.

Patient’s claim The brain damage occurred just before delivery.

Doctor’s defense Not reported.

Verdict $3.2 million Washington settlement.

MD fails to check for metastasis of Ca

A woman in her late 50s underwent a total abdominal hysterectomy performed by a gynecologist. The postoperative pathology report indicated cancer. The initial tests showed endometrioid adenocarcinoma, and later tests indicated uterine papillary serous carcinoma (UPSC), a rare and aggressive cancer. The woman returned to the gynecologist twice a year for physical exams, as instructed. A year and a half after the surgery, she went to her family physician complaining of stomach, shoulder, and chest pains. Lesions on her diaphragm, liver, and abdomen, consistent with metastatic disease, were evident on a CT scan. Eventually, the patient died.

Patient’s claim The postoperative pathology report showed two different cancers, but the gynecologist did not inform her of the UPSC. She should have been referred to an oncologist so that she could have been given chemotherapy and had a chance for a prolonged life.

Doctor’s defense He did inform the patient about the UPSC, but she chose not to undergo chemotherapy. At the time, there was no standard of care for UPSC, and when she was healthy for several years, he chose not to check for metastasis of the cancer.

Verdict $575,000 Pennsylvania verdict.

Profound neurologic damage to one triplet

A 48-year-old woman pregnant carrying triplets—conceived through in vitro fertilization—was admitted to the hospital for preterm labor at 20 weeks’ gestation. She was given a diagnosis of insulin-dependent gestational diabetes and sent home. At 31 weeks, she was readmitted for preterm labor and was given magnesium sulfate. After 3 weeks in the hospital, she was moved to labor and delivery when a low heart rate was detected in one fetus. One nurse cared for the mother for several hours, during which late decelerations in the fetal heart pattern were evident. The nurse notified the other defendants, but there was allegedly a delay in responding. When a cesarean section was performed, one of the three babies was born with profound neurologic damage. Diagnosed with spastic diplegia, he cannot walk or stand without help; cannot speak or communicate effectively; and has low vision. He requires physical, occupational, and speech therapy.

Patient’s claim A delay in performing the cesarean section caused the one baby’s neurologic damage.

Doctor’s defense Not reported.

Verdict $4.2 million Massachusetts settlement.

“Stay home,” despite reports of problems

When a woman at 35 weeks’ gestation presented to her physician with signs consistent with premature labor, she was sent home. Later that day she was advised to go to the hospital, where tests conducted over a 72-hour period indicated premature labor and a healthy, viable fetus. Steroids were administered to increase lung maturity. Then the woman was instructed to monitor herself for increased frequency of contractions, decreased fetal movement, or leakage of fluid, and sent home. After 4 days, she reported significantly decreased fetal movement, but was advised to continue monitoring at home. After 2 more days, she reported leakage of fluid, but was again told to stay at home. One week later, she noted no fetal movement. Fetal death was confirmed at the hospital, and the fetus was delivered later that day.

Patient’s claim A nuchal cord led to fetal death. She should have been admitted for monitoring or delivery when she reported decreased fetal movement and fluid leakage.

Doctor’s defense The nuchal cord was an unforeseeable complication.

Verdict $2.5 million Ohio verdict.

Resident asks for help too late in birth

Dr. A, a first-year family practice resident, provided prenatal care to a woman pregnant with her first child; Dr. B was the attending physician. The pregnancy had no serious complications, but the woman had mildly elevated blood pressure and discomfort at the end of the pregnancy. She requested an elective cesarean section several times, but Dr. A declined the request and consulted with neither an OB nor Dr. B. When she noted decreased fetal movement, a fetal non-stress test was done and was nonreactive. A low level of amniotic fluid and low fetal tone were confirmed. The woman was hospitalized and administered oxytocin to stimulate uterine contractions. Intermittent decelerations and diminished variability were evident in the fetal heart rate, but a cesarean section was not discussed. She progressed to active labor. Dr. B was on his way to the hospital as requested by Dr. A, but Dr. A—who had limited obstetrical experience—did not seek the aid of any other physician. He failed to interpret the fetal monitor strip correctly, and the labor and delivery nurse neglected to call a more experienced physician—although one was available. Just prior to delivery the fetal heart rate was not monitored for 20 minutes. At delivery, a nuchal cord was detected, then clamped and cut by Dr. A. The chief resident was called in and completed delivery in 2 minutes. The child was born blue and lifeless. A full neonatal resuscitation team was unavailable, and intubation was performed after 4 minutes. Dr. B arrived 5 minutes after delivery. The child suffered catastrophic brain damage due to hypoxic–ischemic encephalopathy.

Patient’s claim The brain damage occurred just before delivery.

Doctor’s defense Not reported.

Verdict $3.2 million Washington settlement.

MD fails to check for metastasis of Ca

A woman in her late 50s underwent a total abdominal hysterectomy performed by a gynecologist. The postoperative pathology report indicated cancer. The initial tests showed endometrioid adenocarcinoma, and later tests indicated uterine papillary serous carcinoma (UPSC), a rare and aggressive cancer. The woman returned to the gynecologist twice a year for physical exams, as instructed. A year and a half after the surgery, she went to her family physician complaining of stomach, shoulder, and chest pains. Lesions on her diaphragm, liver, and abdomen, consistent with metastatic disease, were evident on a CT scan. Eventually, the patient died.

Patient’s claim The postoperative pathology report showed two different cancers, but the gynecologist did not inform her of the UPSC. She should have been referred to an oncologist so that she could have been given chemotherapy and had a chance for a prolonged life.

Doctor’s defense He did inform the patient about the UPSC, but she chose not to undergo chemotherapy. At the time, there was no standard of care for UPSC, and when she was healthy for several years, he chose not to check for metastasis of the cancer.

Verdict $575,000 Pennsylvania verdict.

Profound neurologic damage to one triplet

A 48-year-old woman pregnant carrying triplets—conceived through in vitro fertilization—was admitted to the hospital for preterm labor at 20 weeks’ gestation. She was given a diagnosis of insulin-dependent gestational diabetes and sent home. At 31 weeks, she was readmitted for preterm labor and was given magnesium sulfate. After 3 weeks in the hospital, she was moved to labor and delivery when a low heart rate was detected in one fetus. One nurse cared for the mother for several hours, during which late decelerations in the fetal heart pattern were evident. The nurse notified the other defendants, but there was allegedly a delay in responding. When a cesarean section was performed, one of the three babies was born with profound neurologic damage. Diagnosed with spastic diplegia, he cannot walk or stand without help; cannot speak or communicate effectively; and has low vision. He requires physical, occupational, and speech therapy.

Patient’s claim A delay in performing the cesarean section caused the one baby’s neurologic damage.

Doctor’s defense Not reported.

Verdict $4.2 million Massachusetts settlement.

“Stay home,” despite reports of problems

When a woman at 35 weeks’ gestation presented to her physician with signs consistent with premature labor, she was sent home. Later that day she was advised to go to the hospital, where tests conducted over a 72-hour period indicated premature labor and a healthy, viable fetus. Steroids were administered to increase lung maturity. Then the woman was instructed to monitor herself for increased frequency of contractions, decreased fetal movement, or leakage of fluid, and sent home. After 4 days, she reported significantly decreased fetal movement, but was advised to continue monitoring at home. After 2 more days, she reported leakage of fluid, but was again told to stay at home. One week later, she noted no fetal movement. Fetal death was confirmed at the hospital, and the fetus was delivered later that day.

Patient’s claim A nuchal cord led to fetal death. She should have been admitted for monitoring or delivery when she reported decreased fetal movement and fluid leakage.

Doctor’s defense The nuchal cord was an unforeseeable complication.

Verdict $2.5 million Ohio verdict.

Resident asks for help too late in birth

Dr. A, a first-year family practice resident, provided prenatal care to a woman pregnant with her first child; Dr. B was the attending physician. The pregnancy had no serious complications, but the woman had mildly elevated blood pressure and discomfort at the end of the pregnancy. She requested an elective cesarean section several times, but Dr. A declined the request and consulted with neither an OB nor Dr. B. When she noted decreased fetal movement, a fetal non-stress test was done and was nonreactive. A low level of amniotic fluid and low fetal tone were confirmed. The woman was hospitalized and administered oxytocin to stimulate uterine contractions. Intermittent decelerations and diminished variability were evident in the fetal heart rate, but a cesarean section was not discussed. She progressed to active labor. Dr. B was on his way to the hospital as requested by Dr. A, but Dr. A—who had limited obstetrical experience—did not seek the aid of any other physician. He failed to interpret the fetal monitor strip correctly, and the labor and delivery nurse neglected to call a more experienced physician—although one was available. Just prior to delivery the fetal heart rate was not monitored for 20 minutes. At delivery, a nuchal cord was detected, then clamped and cut by Dr. A. The chief resident was called in and completed delivery in 2 minutes. The child was born blue and lifeless. A full neonatal resuscitation team was unavailable, and intubation was performed after 4 minutes. Dr. B arrived 5 minutes after delivery. The child suffered catastrophic brain damage due to hypoxic–ischemic encephalopathy.

Patient’s claim The brain damage occurred just before delivery.

Doctor’s defense Not reported.

Verdict $3.2 million Washington settlement.

Did gallstones mask perforated bowel?

A woman complained of intermittent gastric pain for 3 days following her abdominal hysterectomy. She also vomited bilious gastric fluid at one point. She was discharged, but was readmitted 30 hours later. A CT scan showed perforation of the small intestine as well as peritonitis.

Patient’s claim The perforation occurred during surgery, and the physician was negligent for failing to note it then or during the immediate postoperative period.

Doctor’s defense The patient’s symptoms were consistent with gallstones, which she had experienced before, and which ultrasonography confirmed during the recovery period. Also, the injury to the bowel was not detectable during surgery and developed after she was discharged.

Verdict An $860,000 Connecticut verdict was returned: $110,000 for medical expenses, $675,000 for noneconomic damages, and $75,000 for the husband’s loss of consortium.

Severe infection, preterm birth—and CP

An 18-year-old woman presented at the hospital at 28 weeks’ gestation with obvious rupture of membranes. She was diagnosed with chorioamnionitis because her temperature, white blood cell count, and band count were elevated. She was given antibiotics, epidural anesthesia, and acetaminophen as needed. Delivery was imminent, so steroids were not given. A nurse documented that the fetal monitor tracing showed a change in heart pattern that was not reassuring for fetal well-being, and that the physicians were aware of this. Oxygen was administered and an internal scalp electrode was placed. A cesarean section was performed an hour later.

The infant, floppy and dusky with no respiratory effort at delivery, was intubated and transferred to the NICU. The placenta was grossly infected; chorioamnionitis with necrosis of the fetal membrane and group B strep were confirmed. A sonogram of the brain indicated Grade-III hemorrhage. The child developed seizure activity and remained metabolically unstable, and was given a diagnosis of cerebral palsy. He is legally blind and significantly developmentally delayed.

Patient’s claim The child should have been delivered earlier.

Doctor’s defense There was no negligence. Brain damage was due to prematurity.

Verdict $3 million Massachusetts settlement.

For more on ruptured membranes, see “PROM dilemmas: Choosing a strategy, knowing when to call it quits,” by M. Sean Esplin, MD.

Teen’s oophorectomy leads to more surgery

A 16-year-old patient underwent left oophorectomy surgery to remove an ovarian cyst. Postoperatively, intra-abdominal bleeding developed but stopped spontaneously. Because of severe infection and abdominal pain, she was readmitted and intra-abdominal abscesses were drained. She was left with pelvic adhesions and impaired fertility.

Patient’s claim The physician was negligent for failing to control postoperative bleeding and to timely diagnose postoperative infection.

Doctor’s defense Not reported.

Verdict Illinois defense verdict.

Did gallstones mask perforated bowel?

A woman complained of intermittent gastric pain for 3 days following her abdominal hysterectomy. She also vomited bilious gastric fluid at one point. She was discharged, but was readmitted 30 hours later. A CT scan showed perforation of the small intestine as well as peritonitis.

Patient’s claim The perforation occurred during surgery, and the physician was negligent for failing to note it then or during the immediate postoperative period.

Doctor’s defense The patient’s symptoms were consistent with gallstones, which she had experienced before, and which ultrasonography confirmed during the recovery period. Also, the injury to the bowel was not detectable during surgery and developed after she was discharged.

Verdict An $860,000 Connecticut verdict was returned: $110,000 for medical expenses, $675,000 for noneconomic damages, and $75,000 for the husband’s loss of consortium.

Severe infection, preterm birth—and CP

An 18-year-old woman presented at the hospital at 28 weeks’ gestation with obvious rupture of membranes. She was diagnosed with chorioamnionitis because her temperature, white blood cell count, and band count were elevated. She was given antibiotics, epidural anesthesia, and acetaminophen as needed. Delivery was imminent, so steroids were not given. A nurse documented that the fetal monitor tracing showed a change in heart pattern that was not reassuring for fetal well-being, and that the physicians were aware of this. Oxygen was administered and an internal scalp electrode was placed. A cesarean section was performed an hour later.

The infant, floppy and dusky with no respiratory effort at delivery, was intubated and transferred to the NICU. The placenta was grossly infected; chorioamnionitis with necrosis of the fetal membrane and group B strep were confirmed. A sonogram of the brain indicated Grade-III hemorrhage. The child developed seizure activity and remained metabolically unstable, and was given a diagnosis of cerebral palsy. He is legally blind and significantly developmentally delayed.

Patient’s claim The child should have been delivered earlier.

Doctor’s defense There was no negligence. Brain damage was due to prematurity.

Verdict $3 million Massachusetts settlement.

For more on ruptured membranes, see “PROM dilemmas: Choosing a strategy, knowing when to call it quits,” by M. Sean Esplin, MD.

Teen’s oophorectomy leads to more surgery

A 16-year-old patient underwent left oophorectomy surgery to remove an ovarian cyst. Postoperatively, intra-abdominal bleeding developed but stopped spontaneously. Because of severe infection and abdominal pain, she was readmitted and intra-abdominal abscesses were drained. She was left with pelvic adhesions and impaired fertility.

Patient’s claim The physician was negligent for failing to control postoperative bleeding and to timely diagnose postoperative infection.

Doctor’s defense Not reported.

Verdict Illinois defense verdict.

Did gallstones mask perforated bowel?

A woman complained of intermittent gastric pain for 3 days following her abdominal hysterectomy. She also vomited bilious gastric fluid at one point. She was discharged, but was readmitted 30 hours later. A CT scan showed perforation of the small intestine as well as peritonitis.

Patient’s claim The perforation occurred during surgery, and the physician was negligent for failing to note it then or during the immediate postoperative period.

Doctor’s defense The patient’s symptoms were consistent with gallstones, which she had experienced before, and which ultrasonography confirmed during the recovery period. Also, the injury to the bowel was not detectable during surgery and developed after she was discharged.

Verdict An $860,000 Connecticut verdict was returned: $110,000 for medical expenses, $675,000 for noneconomic damages, and $75,000 for the husband’s loss of consortium.

Severe infection, preterm birth—and CP

An 18-year-old woman presented at the hospital at 28 weeks’ gestation with obvious rupture of membranes. She was diagnosed with chorioamnionitis because her temperature, white blood cell count, and band count were elevated. She was given antibiotics, epidural anesthesia, and acetaminophen as needed. Delivery was imminent, so steroids were not given. A nurse documented that the fetal monitor tracing showed a change in heart pattern that was not reassuring for fetal well-being, and that the physicians were aware of this. Oxygen was administered and an internal scalp electrode was placed. A cesarean section was performed an hour later.

The infant, floppy and dusky with no respiratory effort at delivery, was intubated and transferred to the NICU. The placenta was grossly infected; chorioamnionitis with necrosis of the fetal membrane and group B strep were confirmed. A sonogram of the brain indicated Grade-III hemorrhage. The child developed seizure activity and remained metabolically unstable, and was given a diagnosis of cerebral palsy. He is legally blind and significantly developmentally delayed.

Patient’s claim The child should have been delivered earlier.

Doctor’s defense There was no negligence. Brain damage was due to prematurity.

Verdict $3 million Massachusetts settlement.

For more on ruptured membranes, see “PROM dilemmas: Choosing a strategy, knowing when to call it quits,” by M. Sean Esplin, MD.

Teen’s oophorectomy leads to more surgery

A 16-year-old patient underwent left oophorectomy surgery to remove an ovarian cyst. Postoperatively, intra-abdominal bleeding developed but stopped spontaneously. Because of severe infection and abdominal pain, she was readmitted and intra-abdominal abscesses were drained. She was left with pelvic adhesions and impaired fertility.

Patient’s claim The physician was negligent for failing to control postoperative bleeding and to timely diagnose postoperative infection.

Doctor’s defense Not reported.

Verdict Illinois defense verdict.

Who is who on the roundtable panel

MODERATOR

G. William Bates, MD, MBA

Vanderbilt University Medical Center, Nashville, Tenn

PANELISTS
Have introduced EMR to their practice

B. David Hall, MD, FACOG

Rowan OB/GYN Associates, Salisbury, NC

Don Shuwarger, MD, FACOG

Forest Women’s Center, Forest, Va

PANELISTS
Have not introduced EMR

Frank O. Page, MD, FACOG

Henderson Walton Women’s Center, Birmingham, Ala

Mark A. VanMeter

Group Practice Manager, Columbus Obstetricians– Gynecologists, Inc., Columbus, Ohio

Are your colleagues in private practice who have made the transition to a system of electronic medical records (EMR) satisfied with their decision and experience? Yes and, on some points, less than yes.

For practices that—perhaps, like yours—haven’t made the leap, the question is: What’s holding them back?

In this concluding installment of a two-part article on EMR, a panel of three ObGyns and one ObGyn practice administrator talk with Moderator G. William Bates, MD, MBA, about, in the case of two practices, the work of bringing EMR into their offices. Two other panelists describe their practices’ calculated reluctance to discard paper processes right now.

Why have you and your partners adopted EMR?

Shuwarger: Our practice quickly identified the direct and indirect benefits of bringing technology to bear on our processes. Paper records were often illegible, misplaced, or being used by another staff member. We recognized that to meet our internal goals for growth, increasing patient safety, and streamlining processes, we would have to adopt an EMR solution that met those needs.

Hall: Our practice was drowning in paperwork. An exam room was recently converted to hold more charts, and two warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to ongoing costs and storage problems.

What efficiency gains have you achieved?

Shuwarger: Forest Women’s Center is able to see more patients in the day because our ObGyn-specific EMR system has a “Patient Portal” that enables patients to enter all their history and complaint-specific information in advance of a visit. Another efficiency is the time gained by never searching for lost or misplaced charts. We also like the ability to access our records 24-7-365.

Hall: The patient’s chart is readily available. Hours of searching have been eliminated, and patients’ questions, lab reports, and prescription refills can be managed with very few steps. The physician can record recommendations and treatment plans, which the staff relays to the patient. Records take about the same time to finish, but they are much more complete and legible, with dramatic gains in safety for the patient and improved liability protection for the physician.

Which features provide the greatest value?

Shuwarger: The patient portal that I mentioned is a great time saver for us. We were amazed at the acceptance and rapid adoption. Even our octogenarians love it. Universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation when it is time to file or appeal claims.

Hall: Immediate access to a clear, legible, and complete patient record provides a solid foundation for our medical decision making.

How have your patients reacted to your conversion from paper to EMR?

Shuwarger: At the beginning, there were people who resisted the patient portal, but when they saw for themselves how it enhances the visit experience and helps their physician address their needs, they became vocal proponents.

Hall: Our patients are impressed with our knowledge of their history, with the fact that reports are immediately available, and with how responsive our staff is to their needs. Rather than creating a barrier to communication, TabletPCs allow them to see images of their own procedures, illustrations, treatment outlines, and even education videos. Flow sheets help mark their progress or encourage them to better adherence. Many seem pleased that their medical records are so cutting-edge. Their confidence in our medical skills appears enhanced.

Has your vendor met expectations?

Shuwarger: No—our vendor exceeded our expectations. We had experience with technology vendors before—“We’ll overpromise and underdeliver” was their mantra! With our EMR vendor, however, our preparation was outstanding, the training was thorough, and implementation went better than any we had experienced. Our uptime has exceeded expectations. Enhancements have been well thought out.

And customer support was good at first but now is even better.

Hall: The program is extremely powerful, with an excellent architecture, but its flexibility is also its main limitation. Recently, core clinical content for primary care medicine has been added, but specialty content remains severely limited. Value-added vendors have developed—at additional cost—excellent form-editing tools and specialty forms, and a vigorous users’ community is generous in sharing forms and workflows. But untold hours were required to develop clinical and office workflows, document templates, and just to discover all the options in the system. The learning curve was huge, and further automation requires the skills of a computer programmer.

Our EMR and practice management systems are interfaced but not integrated—even though the same vendor developed them. The problem is that the interface requires several translation programs and multiple servers to implement. Our dependence on our network engineering firm to maintain our bank of servers and interfaces is worrisome— and costly.

Training on our system was inadequate. The basics of the system were covered but, beyond that, we are just now able to shift into second gear. Much of the system’s potential remains untapped.

What is your approximate return on investment?

Shuwarger: We’ve grown receipts by 20%, year over year, since going with our ObGyn-specific EMR system. The rise in revenue is related directly to increased productivity, a reduction in lost charges, and improved collection from third-party payers because we can provide better documentation. At the least, our EMR system has returned $3 for every $1 spent, not counting intangibles.

Hall: Charge capture is much more complete and accurate, with readily available codes and guidelines. The greatest savings are in chart transcription, management, and storage.

Ongoing maintenance and upgrade costs, including hardware and networking software, have gone far beyond our initial investment, however. Problems with training and initial workflow design have slowed our return on investment. But we’re making progress in that direction.

Are features lacking that would bring greater efficiency?

Shuwarger: Our labor suite wants data from our ACOG obstetric record to flow into its system to avoid the need to reenter data manually. And our practice’s physicians want the labor and delivery summary to populate our EMR. These issues of interconnection will be worked out as CCHIT certification (see “EMR certifying body arises from the private sector,” page 62) brings disparate systems into proximity.

Hall: Physicians aren’t computer programmers. We practice medicine, not EMR system development, and we are rarely on top of the “best practices” in practice workflow. Many of us who work with EMR may wish to customize a system to the way we practice, but that is not the best way to proceed. A robust and comprehensive specialty-specific set of clinical content that can be loaded as a unit and easily updated is going to provide far greater efficiency than an infinitely customizable basic program.

I look forward to being able to integrate our private medical record with a central data repository, in which interactions with other specialists and medical centers—not the faulty memory of patients—provide a more accurate background and reduce costly duplication of our increasingly stretched medical resources.

Why haven’t you and your partners adopted EMR?

Page: We recently converted to a new practice management software system, and we want to have all systems working properly and efficiently before implementing an EMR system. All options and processes must be reviewed before we implement EMR for the practice. These options include voice-activation software integrated with the EMR, practice process changes, and practice workflow adaptation.

VanMeter: For our independent practice, with five locations, the initial cost of hardware and software is clearly an early concern. With a rapidly changing hardware environment, once a decision is made, the technology that was proposed may be obsolete before being implemented. Then the continuing cost of hardware and software upgrades—read: “the newest gadget”—and maintenance is also a major budgetary item that we need to consider.

As with most medical practices, our organizational structure is flat. If we were to implement a client-server application, we’d need a systems administrator—and that again increases the cost to the practice. Then we’re faced with the question of how we best utilize this person. Or do we outsource this function? And outsourcing then raises a concern of timely responsiveness to major system problems that may extend downtime, prohibiting the use of your EMR system.

Today, telecommunication costs have plummeted, so the costs of a T-1 line [for high-volume Internet access] and high-speed Internet service are not as onerous as they once were. But a major expense will be to retrofit all our offices (wiring, etc.) to adapt to an electronic environment.

Overall, this is a young industry. I compare it to what we saw with video-tape technology in the 1970s: You had to choose between Beta and VHS formats. Once you made that decision, you paid a premium for the early technology.

Similarly, no one knows which EMR system will prevail over time. The early players are paying for the cost of startup and research and development. As time goes on, we all know that costs should fall—significantly.

Another concern that we have is the long-term viability of the software vendor. Until recently, most applications were developed by small independent firms. Their product was a proprietary one—for which only they have the code and only they could manipulate. If that vendor goes out of business, we’d be left to find a new system, and incur all those implementation costs again.

I think we’ll see a major consolidation of vendors over the next several years— one that leaves only premier vendors with superior products in the market.

As a final concern, and perhaps most important, the role of the federal government weighs heavily on our minds. We believe that, very soon, Washington will mandate EMR and how they are to be accomplished. We also believe that the feds will require integration of medical practice EMR systems with the systems of hospitals, third-party payers, and other medical providers. Our belief is that money may become available—like the funding recently authorized for hospitals to subsidize software and maintenance costs—that will defray the cost of implementing an EMR system in our practice. When this comes to pass, we don’t want to have to reinvent the wheel.

What economic barriers does EMR present?

Page: The economic barrier is really not capital expense but the perception that, for a significant period, EMR will require additional time from the medical staff, which reduces the number of patients seen by a physician and, therefore, affects compensation.”

VanMeter: It seems that, when you purchase an EMR system, you have to comply with the way it works. The tail wags the dog. More flexibility in how a system works at the level of the individual provider would make it more economical in terms of productivity.

What features are lacking that causes you to delay adoption?

Page: Successful voice activation and complete handwriting functionality from laptop to chart.

Are there political barriers to adoption?

Page: EMR represents change, and this is always difficult for larger physician groups. Some physicians are still hesitant to make the transition to an EMR from a paper chart, even when the benefit of EMR is proven. Others are hesitant because they are not acclimated to using a computer in the setting of a patient visit.

VanMeter: First, and foremost, the buy-in of all physicians in a group is needed. In my group of 16 physicians and two nurse practitioners, this is tough—especially when age ranges from 31 to 67 years (four in their 60s and close to retirement). Finding consensus on a system will be difficult for that reason alone.

Second, for physicians who are in the twilight of their career, there’s hesitancy to spend a large sum on a new system that, for them, is going to have a relatively short life span.

Third, and last, I am concerned about up-coding. Although an EMR system may allow you to document a level-4 or level-5 service, is that truly necessary for the patient’s problem? With a yeast infection, for example, is a level-4 or level-5 service appropriate, even if the documentation supports it?

Who is who on the roundtable panel

MODERATOR

G. William Bates, MD, MBA

Vanderbilt University Medical Center, Nashville, Tenn

PANELISTS
Have introduced EMR to their practice

B. David Hall, MD, FACOG

Rowan OB/GYN Associates, Salisbury, NC

Don Shuwarger, MD, FACOG

Forest Women’s Center, Forest, Va

PANELISTS
Have not introduced EMR

Frank O. Page, MD, FACOG

Henderson Walton Women’s Center, Birmingham, Ala

Mark A. VanMeter

Group Practice Manager, Columbus Obstetricians– Gynecologists, Inc., Columbus, Ohio

Are your colleagues in private practice who have made the transition to a system of electronic medical records (EMR) satisfied with their decision and experience? Yes and, on some points, less than yes.

For practices that—perhaps, like yours—haven’t made the leap, the question is: What’s holding them back?

In this concluding installment of a two-part article on EMR, a panel of three ObGyns and one ObGyn practice administrator talk with Moderator G. William Bates, MD, MBA, about, in the case of two practices, the work of bringing EMR into their offices. Two other panelists describe their practices’ calculated reluctance to discard paper processes right now.

Why have you and your partners adopted EMR?

Shuwarger: Our practice quickly identified the direct and indirect benefits of bringing technology to bear on our processes. Paper records were often illegible, misplaced, or being used by another staff member. We recognized that to meet our internal goals for growth, increasing patient safety, and streamlining processes, we would have to adopt an EMR solution that met those needs.

Hall: Our practice was drowning in paperwork. An exam room was recently converted to hold more charts, and two warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to ongoing costs and storage problems.

What efficiency gains have you achieved?

Shuwarger: Forest Women’s Center is able to see more patients in the day because our ObGyn-specific EMR system has a “Patient Portal” that enables patients to enter all their history and complaint-specific information in advance of a visit. Another efficiency is the time gained by never searching for lost or misplaced charts. We also like the ability to access our records 24-7-365.

Hall: The patient’s chart is readily available. Hours of searching have been eliminated, and patients’ questions, lab reports, and prescription refills can be managed with very few steps. The physician can record recommendations and treatment plans, which the staff relays to the patient. Records take about the same time to finish, but they are much more complete and legible, with dramatic gains in safety for the patient and improved liability protection for the physician.

Which features provide the greatest value?

Shuwarger: The patient portal that I mentioned is a great time saver for us. We were amazed at the acceptance and rapid adoption. Even our octogenarians love it. Universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation when it is time to file or appeal claims.

Hall: Immediate access to a clear, legible, and complete patient record provides a solid foundation for our medical decision making.

How have your patients reacted to your conversion from paper to EMR?

Shuwarger: At the beginning, there were people who resisted the patient portal, but when they saw for themselves how it enhances the visit experience and helps their physician address their needs, they became vocal proponents.

Hall: Our patients are impressed with our knowledge of their history, with the fact that reports are immediately available, and with how responsive our staff is to their needs. Rather than creating a barrier to communication, TabletPCs allow them to see images of their own procedures, illustrations, treatment outlines, and even education videos. Flow sheets help mark their progress or encourage them to better adherence. Many seem pleased that their medical records are so cutting-edge. Their confidence in our medical skills appears enhanced.

Has your vendor met expectations?

Shuwarger: No—our vendor exceeded our expectations. We had experience with technology vendors before—“We’ll overpromise and underdeliver” was their mantra! With our EMR vendor, however, our preparation was outstanding, the training was thorough, and implementation went better than any we had experienced. Our uptime has exceeded expectations. Enhancements have been well thought out.

And customer support was good at first but now is even better.

Hall: The program is extremely powerful, with an excellent architecture, but its flexibility is also its main limitation. Recently, core clinical content for primary care medicine has been added, but specialty content remains severely limited. Value-added vendors have developed—at additional cost—excellent form-editing tools and specialty forms, and a vigorous users’ community is generous in sharing forms and workflows. But untold hours were required to develop clinical and office workflows, document templates, and just to discover all the options in the system. The learning curve was huge, and further automation requires the skills of a computer programmer.

Our EMR and practice management systems are interfaced but not integrated—even though the same vendor developed them. The problem is that the interface requires several translation programs and multiple servers to implement. Our dependence on our network engineering firm to maintain our bank of servers and interfaces is worrisome— and costly.

Training on our system was inadequate. The basics of the system were covered but, beyond that, we are just now able to shift into second gear. Much of the system’s potential remains untapped.

What is your approximate return on investment?

Shuwarger: We’ve grown receipts by 20%, year over year, since going with our ObGyn-specific EMR system. The rise in revenue is related directly to increased productivity, a reduction in lost charges, and improved collection from third-party payers because we can provide better documentation. At the least, our EMR system has returned $3 for every $1 spent, not counting intangibles.

Hall: Charge capture is much more complete and accurate, with readily available codes and guidelines. The greatest savings are in chart transcription, management, and storage.

Ongoing maintenance and upgrade costs, including hardware and networking software, have gone far beyond our initial investment, however. Problems with training and initial workflow design have slowed our return on investment. But we’re making progress in that direction.

Are features lacking that would bring greater efficiency?

Shuwarger: Our labor suite wants data from our ACOG obstetric record to flow into its system to avoid the need to reenter data manually. And our practice’s physicians want the labor and delivery summary to populate our EMR. These issues of interconnection will be worked out as CCHIT certification (see “EMR certifying body arises from the private sector,” page 62) brings disparate systems into proximity.

Hall: Physicians aren’t computer programmers. We practice medicine, not EMR system development, and we are rarely on top of the “best practices” in practice workflow. Many of us who work with EMR may wish to customize a system to the way we practice, but that is not the best way to proceed. A robust and comprehensive specialty-specific set of clinical content that can be loaded as a unit and easily updated is going to provide far greater efficiency than an infinitely customizable basic program.

I look forward to being able to integrate our private medical record with a central data repository, in which interactions with other specialists and medical centers—not the faulty memory of patients—provide a more accurate background and reduce costly duplication of our increasingly stretched medical resources.

Why haven’t you and your partners adopted EMR?

Page: We recently converted to a new practice management software system, and we want to have all systems working properly and efficiently before implementing an EMR system. All options and processes must be reviewed before we implement EMR for the practice. These options include voice-activation software integrated with the EMR, practice process changes, and practice workflow adaptation.

VanMeter: For our independent practice, with five locations, the initial cost of hardware and software is clearly an early concern. With a rapidly changing hardware environment, once a decision is made, the technology that was proposed may be obsolete before being implemented. Then the continuing cost of hardware and software upgrades—read: “the newest gadget”—and maintenance is also a major budgetary item that we need to consider.

As with most medical practices, our organizational structure is flat. If we were to implement a client-server application, we’d need a systems administrator—and that again increases the cost to the practice. Then we’re faced with the question of how we best utilize this person. Or do we outsource this function? And outsourcing then raises a concern of timely responsiveness to major system problems that may extend downtime, prohibiting the use of your EMR system.

Today, telecommunication costs have plummeted, so the costs of a T-1 line [for high-volume Internet access] and high-speed Internet service are not as onerous as they once were. But a major expense will be to retrofit all our offices (wiring, etc.) to adapt to an electronic environment.

Overall, this is a young industry. I compare it to what we saw with video-tape technology in the 1970s: You had to choose between Beta and VHS formats. Once you made that decision, you paid a premium for the early technology.

Similarly, no one knows which EMR system will prevail over time. The early players are paying for the cost of startup and research and development. As time goes on, we all know that costs should fall—significantly.

Another concern that we have is the long-term viability of the software vendor. Until recently, most applications were developed by small independent firms. Their product was a proprietary one—for which only they have the code and only they could manipulate. If that vendor goes out of business, we’d be left to find a new system, and incur all those implementation costs again.

I think we’ll see a major consolidation of vendors over the next several years— one that leaves only premier vendors with superior products in the market.

As a final concern, and perhaps most important, the role of the federal government weighs heavily on our minds. We believe that, very soon, Washington will mandate EMR and how they are to be accomplished. We also believe that the feds will require integration of medical practice EMR systems with the systems of hospitals, third-party payers, and other medical providers. Our belief is that money may become available—like the funding recently authorized for hospitals to subsidize software and maintenance costs—that will defray the cost of implementing an EMR system in our practice. When this comes to pass, we don’t want to have to reinvent the wheel.

What economic barriers does EMR present?

Page: The economic barrier is really not capital expense but the perception that, for a significant period, EMR will require additional time from the medical staff, which reduces the number of patients seen by a physician and, therefore, affects compensation.”

VanMeter: It seems that, when you purchase an EMR system, you have to comply with the way it works. The tail wags the dog. More flexibility in how a system works at the level of the individual provider would make it more economical in terms of productivity.

What features are lacking that causes you to delay adoption?

Page: Successful voice activation and complete handwriting functionality from laptop to chart.

Are there political barriers to adoption?

Page: EMR represents change, and this is always difficult for larger physician groups. Some physicians are still hesitant to make the transition to an EMR from a paper chart, even when the benefit of EMR is proven. Others are hesitant because they are not acclimated to using a computer in the setting of a patient visit.

VanMeter: First, and foremost, the buy-in of all physicians in a group is needed. In my group of 16 physicians and two nurse practitioners, this is tough—especially when age ranges from 31 to 67 years (four in their 60s and close to retirement). Finding consensus on a system will be difficult for that reason alone.

Second, for physicians who are in the twilight of their career, there’s hesitancy to spend a large sum on a new system that, for them, is going to have a relatively short life span.

Third, and last, I am concerned about up-coding. Although an EMR system may allow you to document a level-4 or level-5 service, is that truly necessary for the patient’s problem? With a yeast infection, for example, is a level-4 or level-5 service appropriate, even if the documentation supports it?

Who is who on the roundtable panel

MODERATOR

G. William Bates, MD, MBA

Vanderbilt University Medical Center, Nashville, Tenn

PANELISTS
Have introduced EMR to their practice

B. David Hall, MD, FACOG

Rowan OB/GYN Associates, Salisbury, NC

Don Shuwarger, MD, FACOG

Forest Women’s Center, Forest, Va

PANELISTS
Have not introduced EMR

Frank O. Page, MD, FACOG

Henderson Walton Women’s Center, Birmingham, Ala

Mark A. VanMeter

Group Practice Manager, Columbus Obstetricians– Gynecologists, Inc., Columbus, Ohio

Are your colleagues in private practice who have made the transition to a system of electronic medical records (EMR) satisfied with their decision and experience? Yes and, on some points, less than yes.

For practices that—perhaps, like yours—haven’t made the leap, the question is: What’s holding them back?

In this concluding installment of a two-part article on EMR, a panel of three ObGyns and one ObGyn practice administrator talk with Moderator G. William Bates, MD, MBA, about, in the case of two practices, the work of bringing EMR into their offices. Two other panelists describe their practices’ calculated reluctance to discard paper processes right now.

Why have you and your partners adopted EMR?

Shuwarger: Our practice quickly identified the direct and indirect benefits of bringing technology to bear on our processes. Paper records were often illegible, misplaced, or being used by another staff member. We recognized that to meet our internal goals for growth, increasing patient safety, and streamlining processes, we would have to adopt an EMR solution that met those needs.

Hall: Our practice was drowning in paperwork. An exam room was recently converted to hold more charts, and two warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to ongoing costs and storage problems.

What efficiency gains have you achieved?

Shuwarger: Forest Women’s Center is able to see more patients in the day because our ObGyn-specific EMR system has a “Patient Portal” that enables patients to enter all their history and complaint-specific information in advance of a visit. Another efficiency is the time gained by never searching for lost or misplaced charts. We also like the ability to access our records 24-7-365.

Hall: The patient’s chart is readily available. Hours of searching have been eliminated, and patients’ questions, lab reports, and prescription refills can be managed with very few steps. The physician can record recommendations and treatment plans, which the staff relays to the patient. Records take about the same time to finish, but they are much more complete and legible, with dramatic gains in safety for the patient and improved liability protection for the physician.

Which features provide the greatest value?

Shuwarger: The patient portal that I mentioned is a great time saver for us. We were amazed at the acceptance and rapid adoption. Even our octogenarians love it. Universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation when it is time to file or appeal claims.

Hall: Immediate access to a clear, legible, and complete patient record provides a solid foundation for our medical decision making.

How have your patients reacted to your conversion from paper to EMR?

Shuwarger: At the beginning, there were people who resisted the patient portal, but when they saw for themselves how it enhances the visit experience and helps their physician address their needs, they became vocal proponents.

Hall: Our patients are impressed with our knowledge of their history, with the fact that reports are immediately available, and with how responsive our staff is to their needs. Rather than creating a barrier to communication, TabletPCs allow them to see images of their own procedures, illustrations, treatment outlines, and even education videos. Flow sheets help mark their progress or encourage them to better adherence. Many seem pleased that their medical records are so cutting-edge. Their confidence in our medical skills appears enhanced.

Has your vendor met expectations?

Shuwarger: No—our vendor exceeded our expectations. We had experience with technology vendors before—“We’ll overpromise and underdeliver” was their mantra! With our EMR vendor, however, our preparation was outstanding, the training was thorough, and implementation went better than any we had experienced. Our uptime has exceeded expectations. Enhancements have been well thought out.

And customer support was good at first but now is even better.

Hall: The program is extremely powerful, with an excellent architecture, but its flexibility is also its main limitation. Recently, core clinical content for primary care medicine has been added, but specialty content remains severely limited. Value-added vendors have developed—at additional cost—excellent form-editing tools and specialty forms, and a vigorous users’ community is generous in sharing forms and workflows. But untold hours were required to develop clinical and office workflows, document templates, and just to discover all the options in the system. The learning curve was huge, and further automation requires the skills of a computer programmer.

Our EMR and practice management systems are interfaced but not integrated—even though the same vendor developed them. The problem is that the interface requires several translation programs and multiple servers to implement. Our dependence on our network engineering firm to maintain our bank of servers and interfaces is worrisome— and costly.

Training on our system was inadequate. The basics of the system were covered but, beyond that, we are just now able to shift into second gear. Much of the system’s potential remains untapped.

What is your approximate return on investment?

Shuwarger: We’ve grown receipts by 20%, year over year, since going with our ObGyn-specific EMR system. The rise in revenue is related directly to increased productivity, a reduction in lost charges, and improved collection from third-party payers because we can provide better documentation. At the least, our EMR system has returned $3 for every $1 spent, not counting intangibles.

Hall: Charge capture is much more complete and accurate, with readily available codes and guidelines. The greatest savings are in chart transcription, management, and storage.

Ongoing maintenance and upgrade costs, including hardware and networking software, have gone far beyond our initial investment, however. Problems with training and initial workflow design have slowed our return on investment. But we’re making progress in that direction.

Are features lacking that would bring greater efficiency?

Shuwarger: Our labor suite wants data from our ACOG obstetric record to flow into its system to avoid the need to reenter data manually. And our practice’s physicians want the labor and delivery summary to populate our EMR. These issues of interconnection will be worked out as CCHIT certification (see “EMR certifying body arises from the private sector,” page 62) brings disparate systems into proximity.

Hall: Physicians aren’t computer programmers. We practice medicine, not EMR system development, and we are rarely on top of the “best practices” in practice workflow. Many of us who work with EMR may wish to customize a system to the way we practice, but that is not the best way to proceed. A robust and comprehensive specialty-specific set of clinical content that can be loaded as a unit and easily updated is going to provide far greater efficiency than an infinitely customizable basic program.

I look forward to being able to integrate our private medical record with a central data repository, in which interactions with other specialists and medical centers—not the faulty memory of patients—provide a more accurate background and reduce costly duplication of our increasingly stretched medical resources.

Why haven’t you and your partners adopted EMR?

Page: We recently converted to a new practice management software system, and we want to have all systems working properly and efficiently before implementing an EMR system. All options and processes must be reviewed before we implement EMR for the practice. These options include voice-activation software integrated with the EMR, practice process changes, and practice workflow adaptation.

VanMeter: For our independent practice, with five locations, the initial cost of hardware and software is clearly an early concern. With a rapidly changing hardware environment, once a decision is made, the technology that was proposed may be obsolete before being implemented. Then the continuing cost of hardware and software upgrades—read: “the newest gadget”—and maintenance is also a major budgetary item that we need to consider.

As with most medical practices, our organizational structure is flat. If we were to implement a client-server application, we’d need a systems administrator—and that again increases the cost to the practice. Then we’re faced with the question of how we best utilize this person. Or do we outsource this function? And outsourcing then raises a concern of timely responsiveness to major system problems that may extend downtime, prohibiting the use of your EMR system.

Today, telecommunication costs have plummeted, so the costs of a T-1 line [for high-volume Internet access] and high-speed Internet service are not as onerous as they once were. But a major expense will be to retrofit all our offices (wiring, etc.) to adapt to an electronic environment.

Overall, this is a young industry. I compare it to what we saw with video-tape technology in the 1970s: You had to choose between Beta and VHS formats. Once you made that decision, you paid a premium for the early technology.

Similarly, no one knows which EMR system will prevail over time. The early players are paying for the cost of startup and research and development. As time goes on, we all know that costs should fall—significantly.

Another concern that we have is the long-term viability of the software vendor. Until recently, most applications were developed by small independent firms. Their product was a proprietary one—for which only they have the code and only they could manipulate. If that vendor goes out of business, we’d be left to find a new system, and incur all those implementation costs again.

I think we’ll see a major consolidation of vendors over the next several years— one that leaves only premier vendors with superior products in the market.

As a final concern, and perhaps most important, the role of the federal government weighs heavily on our minds. We believe that, very soon, Washington will mandate EMR and how they are to be accomplished. We also believe that the feds will require integration of medical practice EMR systems with the systems of hospitals, third-party payers, and other medical providers. Our belief is that money may become available—like the funding recently authorized for hospitals to subsidize software and maintenance costs—that will defray the cost of implementing an EMR system in our practice. When this comes to pass, we don’t want to have to reinvent the wheel.

What economic barriers does EMR present?

Page: The economic barrier is really not capital expense but the perception that, for a significant period, EMR will require additional time from the medical staff, which reduces the number of patients seen by a physician and, therefore, affects compensation.”

VanMeter: It seems that, when you purchase an EMR system, you have to comply with the way it works. The tail wags the dog. More flexibility in how a system works at the level of the individual provider would make it more economical in terms of productivity.

What features are lacking that causes you to delay adoption?

Page: Successful voice activation and complete handwriting functionality from laptop to chart.

Are there political barriers to adoption?

Page: EMR represents change, and this is always difficult for larger physician groups. Some physicians are still hesitant to make the transition to an EMR from a paper chart, even when the benefit of EMR is proven. Others are hesitant because they are not acclimated to using a computer in the setting of a patient visit.

VanMeter: First, and foremost, the buy-in of all physicians in a group is needed. In my group of 16 physicians and two nurse practitioners, this is tough—especially when age ranges from 31 to 67 years (four in their 60s and close to retirement). Finding consensus on a system will be difficult for that reason alone.

Second, for physicians who are in the twilight of their career, there’s hesitancy to spend a large sum on a new system that, for them, is going to have a relatively short life span.

Third, and last, I am concerned about up-coding. Although an EMR system may allow you to document a level-4 or level-5 service, is that truly necessary for the patient’s problem? With a yeast infection, for example, is a level-4 or level-5 service appropriate, even if the documentation supports it?

Five years ago, Dr. Brent Greenberg's practice was running into the red. After years of doing well financially in a full-risk practice, the budget got out of control around the time his firm spun off a second business that offered billing services to other practices. That's when his practice, Penn Elm Medical Group in Escondido, Calif., turned to a medical practice management consulting firm. In this month's column, Dr. Greenberg shares his advice on working with a third party.

In our situation, it was clear there were significant fiscal challenges that needed to be addressed or our doors would close. But without such a clear-cut crisis, when cash flow is high and bills are easily covered, most physicians don't appreciate the benefit of digging deeply into their budgets to truly appreciate their cash flow.

Nor do they realize the opportunities that could make a significant difference to their bottom line. If you're curious about taking a fresh look at your budget and work flow, then there's no shortage of medical practice management firms with persuasive presentations about what they can do for you. Before hiring any firm, insist on contacting a list of former clients who have a similar patient demographic and insurance mix.

Don't spend a dime on a consulting firm unless you and your partners are willing to make some changes. That may sound obvious, but in my search for a consultant, one former client I spoke with was unhappy with the experience. The reason: The consulting firm had recommended creating a budget, a solution that lacked the easy-fix, wow factor that the client was expecting.

Find out what methodology the firm uses to evaluate the practice and reach its recommendations. The firm we hired, the Sage Group, spent 3 days interviewing senior physicians, front-office staff, and nurses separately. Another 3 hours were devoted to a group session to assess staff interaction. And 2 hours were devoted to discussing the findings of the report with the shareholders of the practice. A large part of the assessment was spent monitoring how time is spent and the flow of patient visits, from sign-in to exit.

A simple, yet invaluable recommendation was to upgrade our phone system to one that allows us to monitor the number of calls received, the wait times, and the number of hang-ups. One look at those data, and we realized that we were losing business.

The consultants helped leverage efficiencies. When confronted with the numbers, the outliers who routinely spent 1 hour on visits that should have taken 15 minutes of physician time were finally convinced of the value of delegating more tasks to nurses and using their time more strategically.

The consulting firm's three-person team included a financial expert who analyzed our contracts with insurance companies as well as our accounts receivable and our means and methods for bill collection.

All of this information was compiled to compare us with Medical Group Management Association industry benchmarks, which enabled us to spot opportunities for improvement relative to peer practices in the region.

The consultants even tapped into the emotional interaction among the members of our eight-physician practice, something we had not expected. Initially, philosophical questions such as “what do you want to achieve?” and “what do you need to be happy?” seemed off base. But ultimately, they proved to be beneficial.

The process helped us openly acknowledge that we have a mix of physicians with different goals. Some value free time over money at this point in their careers, and others still have medical school debt and young families to raise. Much like marriage counselors, the consultants helped us untangle the divergent desires of our multiple-partner marriage. In our case, we acknowledged the need to structure our bonus distribution more fairly.

All told, the fee was $7,800. Keeping our doors open for business and learning to work harmoniously: priceless.

Five years ago, Dr. Brent Greenberg's practice was running into the red. After years of doing well financially in a full-risk practice, the budget got out of control around the time his firm spun off a second business that offered billing services to other practices. That's when his practice, Penn Elm Medical Group in Escondido, Calif., turned to a medical practice management consulting firm. In this month's column, Dr. Greenberg shares his advice on working with a third party.

In our situation, it was clear there were significant fiscal challenges that needed to be addressed or our doors would close. But without such a clear-cut crisis, when cash flow is high and bills are easily covered, most physicians don't appreciate the benefit of digging deeply into their budgets to truly appreciate their cash flow.

Nor do they realize the opportunities that could make a significant difference to their bottom line. If you're curious about taking a fresh look at your budget and work flow, then there's no shortage of medical practice management firms with persuasive presentations about what they can do for you. Before hiring any firm, insist on contacting a list of former clients who have a similar patient demographic and insurance mix.

Don't spend a dime on a consulting firm unless you and your partners are willing to make some changes. That may sound obvious, but in my search for a consultant, one former client I spoke with was unhappy with the experience. The reason: The consulting firm had recommended creating a budget, a solution that lacked the easy-fix, wow factor that the client was expecting.

Find out what methodology the firm uses to evaluate the practice and reach its recommendations. The firm we hired, the Sage Group, spent 3 days interviewing senior physicians, front-office staff, and nurses separately. Another 3 hours were devoted to a group session to assess staff interaction. And 2 hours were devoted to discussing the findings of the report with the shareholders of the practice. A large part of the assessment was spent monitoring how time is spent and the flow of patient visits, from sign-in to exit.

A simple, yet invaluable recommendation was to upgrade our phone system to one that allows us to monitor the number of calls received, the wait times, and the number of hang-ups. One look at those data, and we realized that we were losing business.

The consultants helped leverage efficiencies. When confronted with the numbers, the outliers who routinely spent 1 hour on visits that should have taken 15 minutes of physician time were finally convinced of the value of delegating more tasks to nurses and using their time more strategically.

The consulting firm's three-person team included a financial expert who analyzed our contracts with insurance companies as well as our accounts receivable and our means and methods for bill collection.

All of this information was compiled to compare us with Medical Group Management Association industry benchmarks, which enabled us to spot opportunities for improvement relative to peer practices in the region.

The consultants even tapped into the emotional interaction among the members of our eight-physician practice, something we had not expected. Initially, philosophical questions such as “what do you want to achieve?” and “what do you need to be happy?” seemed off base. But ultimately, they proved to be beneficial.

The process helped us openly acknowledge that we have a mix of physicians with different goals. Some value free time over money at this point in their careers, and others still have medical school debt and young families to raise. Much like marriage counselors, the consultants helped us untangle the divergent desires of our multiple-partner marriage. In our case, we acknowledged the need to structure our bonus distribution more fairly.

All told, the fee was $7,800. Keeping our doors open for business and learning to work harmoniously: priceless.

Five years ago, Dr. Brent Greenberg's practice was running into the red. After years of doing well financially in a full-risk practice, the budget got out of control around the time his firm spun off a second business that offered billing services to other practices. That's when his practice, Penn Elm Medical Group in Escondido, Calif., turned to a medical practice management consulting firm. In this month's column, Dr. Greenberg shares his advice on working with a third party.

In our situation, it was clear there were significant fiscal challenges that needed to be addressed or our doors would close. But without such a clear-cut crisis, when cash flow is high and bills are easily covered, most physicians don't appreciate the benefit of digging deeply into their budgets to truly appreciate their cash flow.

Nor do they realize the opportunities that could make a significant difference to their bottom line. If you're curious about taking a fresh look at your budget and work flow, then there's no shortage of medical practice management firms with persuasive presentations about what they can do for you. Before hiring any firm, insist on contacting a list of former clients who have a similar patient demographic and insurance mix.

Don't spend a dime on a consulting firm unless you and your partners are willing to make some changes. That may sound obvious, but in my search for a consultant, one former client I spoke with was unhappy with the experience. The reason: The consulting firm had recommended creating a budget, a solution that lacked the easy-fix, wow factor that the client was expecting.

Find out what methodology the firm uses to evaluate the practice and reach its recommendations. The firm we hired, the Sage Group, spent 3 days interviewing senior physicians, front-office staff, and nurses separately. Another 3 hours were devoted to a group session to assess staff interaction. And 2 hours were devoted to discussing the findings of the report with the shareholders of the practice. A large part of the assessment was spent monitoring how time is spent and the flow of patient visits, from sign-in to exit.

A simple, yet invaluable recommendation was to upgrade our phone system to one that allows us to monitor the number of calls received, the wait times, and the number of hang-ups. One look at those data, and we realized that we were losing business.

The consultants helped leverage efficiencies. When confronted with the numbers, the outliers who routinely spent 1 hour on visits that should have taken 15 minutes of physician time were finally convinced of the value of delegating more tasks to nurses and using their time more strategically.

The consulting firm's three-person team included a financial expert who analyzed our contracts with insurance companies as well as our accounts receivable and our means and methods for bill collection.

All of this information was compiled to compare us with Medical Group Management Association industry benchmarks, which enabled us to spot opportunities for improvement relative to peer practices in the region.

The consultants even tapped into the emotional interaction among the members of our eight-physician practice, something we had not expected. Initially, philosophical questions such as “what do you want to achieve?” and “what do you need to be happy?” seemed off base. But ultimately, they proved to be beneficial.

The process helped us openly acknowledge that we have a mix of physicians with different goals. Some value free time over money at this point in their careers, and others still have medical school debt and young families to raise. Much like marriage counselors, the consultants helped us untangle the divergent desires of our multiple-partner marriage. In our case, we acknowledged the need to structure our bonus distribution more fairly.

All told, the fee was $7,800. Keeping our doors open for business and learning to work harmoniously: priceless.

The questions don't stop when it comes to the mechanics of hiring new associates. Several readers have written to ask when to add new employees and how much to pay them.

Generally, it shouldn't be too difficult to determine if you need a new associate. Just look at your appointment book. How many slots are open? How long does a new patient have to wait for an appointment? Practice experts differ on rules of thumb, but in my opinion, if it takes 3 weeks or longer for a new patient to get an appointment, you are almost certainly losing patients and referrals to your competitors.

Another red flag may come from your referrers. If you are beginning to hear complaints that you are not as available as you once were, or that your reports are not prepared in as timely a manner, it is important to address these concerns before your referrers begin sending their patients elsewhere.

Young associates also ensure that your practice will continue to thrive. Your long-time referrers will eventually retire, and the young newcomers who replace them will naturally tend to refer to specialists closer to their age, leaving your practice to stagnate if younger physicians are not a part of it.

Additionally, expanding your practice may enable you to negotiate better terms in your managed care contracts by offering more hours and services.

If you are referring out substantial quantities of subspecialty services, such as laser or cosmetic work or Mohs surgery, you might want to recruit an associate who is specially trained in those services to keep those patients in-house.

Before you begin recruiting, however, make sure that all of the current physicians are in agreement that another physician is necessary.

It is worth considering the possibility that your practice needs something other than a new physician. If physicians are doing administrative tasks when they could be practicing medicine, consider hiring a practice administrator to manage your business and finances.

You may want to consider bringing in a nurse practitioner or physician assistant to do acne follow-ups and other routine duties, freeing physician time for more specialized procedures. (If you missed the column I wrote last year addressing this subject in detail, go to www.skinandallergynews.com

If indeed it is a new physician that you believe your practice needs, consider all of the costs related to hiring and supporting him or her for at least the first year. (Once again, check out the online archives for a previous column addressing this subject in more detail.)

You must also remember to include the costs of additional support personnel; additional examination or procedure rooms; a larger reception area; and the associated mortgage or leasehold improvement costs, overhead expenses, payroll taxes, and lawyer fees.

If the new physician provides services that are new to your practice, you will most likely need new equipment. This means that you must factor quotes from suppliers into your calculations.

Then, there is always the question of just how these additional costs will be met. No matter how large their current backlog, many dermatologists worry that their practices won't have enough additional patients to support a new doctor.

You can remove much of the guesswork by estimating how many additional patients your practice will need to break even. Do that by dividing your previous year's total revenues by the total number of patient visits to determine average revenue per visit. Then divide the total estimated cost of hiring a new physician by your revenue per visit. This is the approximate number of additional visits that must be generated for the new associate's costs to be covered.

The calculations will, of course, become more complex if the new physician will be doing only Mohs or cosmetic procedures, but you get the idea.

How much you pay a new associate will depend heavily on your location and individual circumstances. Find out what nearby practices are paying their recruits, and ask applicants themselves how much they expect to be paid.

The ultimate determination may require the services of an experienced practice consultant who is familiar with your practice area.

Many candidates will also expect incentive compensation for exceeding their revenue-generation goals.

You should also consider rewarding other performance achievements, including relationship building, teamwork, practice promotion, and attraction of new referrers.

Remember to factor in the fringe benefits that your practice provides. Most compensation packages include such standard benefits as paid time off, health insurance, society dues, hospital staff fees, CME costs, subscriptions, retirement plan contributions (when eligible), and malpractice insurance.

Lastly, you may also want to consider covering the physician's moving expenses, especially if it would help close the deal.

The questions don't stop when it comes to the mechanics of hiring new associates. Several readers have written to ask when to add new employees and how much to pay them.

Generally, it shouldn't be too difficult to determine if you need a new associate. Just look at your appointment book. How many slots are open? How long does a new patient have to wait for an appointment? Practice experts differ on rules of thumb, but in my opinion, if it takes 3 weeks or longer for a new patient to get an appointment, you are almost certainly losing patients and referrals to your competitors.

Another red flag may come from your referrers. If you are beginning to hear complaints that you are not as available as you once were, or that your reports are not prepared in as timely a manner, it is important to address these concerns before your referrers begin sending their patients elsewhere.

Young associates also ensure that your practice will continue to thrive. Your long-time referrers will eventually retire, and the young newcomers who replace them will naturally tend to refer to specialists closer to their age, leaving your practice to stagnate if younger physicians are not a part of it.

Additionally, expanding your practice may enable you to negotiate better terms in your managed care contracts by offering more hours and services.

If you are referring out substantial quantities of subspecialty services, such as laser or cosmetic work or Mohs surgery, you might want to recruit an associate who is specially trained in those services to keep those patients in-house.

Before you begin recruiting, however, make sure that all of the current physicians are in agreement that another physician is necessary.

It is worth considering the possibility that your practice needs something other than a new physician. If physicians are doing administrative tasks when they could be practicing medicine, consider hiring a practice administrator to manage your business and finances.

You may want to consider bringing in a nurse practitioner or physician assistant to do acne follow-ups and other routine duties, freeing physician time for more specialized procedures. (If you missed the column I wrote last year addressing this subject in detail, go to www.skinandallergynews.com

If indeed it is a new physician that you believe your practice needs, consider all of the costs related to hiring and supporting him or her for at least the first year. (Once again, check out the online archives for a previous column addressing this subject in more detail.)

You must also remember to include the costs of additional support personnel; additional examination or procedure rooms; a larger reception area; and the associated mortgage or leasehold improvement costs, overhead expenses, payroll taxes, and lawyer fees.

If the new physician provides services that are new to your practice, you will most likely need new equipment. This means that you must factor quotes from suppliers into your calculations.

Then, there is always the question of just how these additional costs will be met. No matter how large their current backlog, many dermatologists worry that their practices won't have enough additional patients to support a new doctor.

You can remove much of the guesswork by estimating how many additional patients your practice will need to break even. Do that by dividing your previous year's total revenues by the total number of patient visits to determine average revenue per visit. Then divide the total estimated cost of hiring a new physician by your revenue per visit. This is the approximate number of additional visits that must be generated for the new associate's costs to be covered.

The calculations will, of course, become more complex if the new physician will be doing only Mohs or cosmetic procedures, but you get the idea.

How much you pay a new associate will depend heavily on your location and individual circumstances. Find out what nearby practices are paying their recruits, and ask applicants themselves how much they expect to be paid.

The ultimate determination may require the services of an experienced practice consultant who is familiar with your practice area.

Many candidates will also expect incentive compensation for exceeding their revenue-generation goals.

You should also consider rewarding other performance achievements, including relationship building, teamwork, practice promotion, and attraction of new referrers.

Remember to factor in the fringe benefits that your practice provides. Most compensation packages include such standard benefits as paid time off, health insurance, society dues, hospital staff fees, CME costs, subscriptions, retirement plan contributions (when eligible), and malpractice insurance.

Lastly, you may also want to consider covering the physician's moving expenses, especially if it would help close the deal.

The questions don't stop when it comes to the mechanics of hiring new associates. Several readers have written to ask when to add new employees and how much to pay them.

Generally, it shouldn't be too difficult to determine if you need a new associate. Just look at your appointment book. How many slots are open? How long does a new patient have to wait for an appointment? Practice experts differ on rules of thumb, but in my opinion, if it takes 3 weeks or longer for a new patient to get an appointment, you are almost certainly losing patients and referrals to your competitors.

Another red flag may come from your referrers. If you are beginning to hear complaints that you are not as available as you once were, or that your reports are not prepared in as timely a manner, it is important to address these concerns before your referrers begin sending their patients elsewhere.

Young associates also ensure that your practice will continue to thrive. Your long-time referrers will eventually retire, and the young newcomers who replace them will naturally tend to refer to specialists closer to their age, leaving your practice to stagnate if younger physicians are not a part of it.

Additionally, expanding your practice may enable you to negotiate better terms in your managed care contracts by offering more hours and services.

If you are referring out substantial quantities of subspecialty services, such as laser or cosmetic work or Mohs surgery, you might want to recruit an associate who is specially trained in those services to keep those patients in-house.

Before you begin recruiting, however, make sure that all of the current physicians are in agreement that another physician is necessary.

It is worth considering the possibility that your practice needs something other than a new physician. If physicians are doing administrative tasks when they could be practicing medicine, consider hiring a practice administrator to manage your business and finances.

You may want to consider bringing in a nurse practitioner or physician assistant to do acne follow-ups and other routine duties, freeing physician time for more specialized procedures. (If you missed the column I wrote last year addressing this subject in detail, go to www.skinandallergynews.com

If indeed it is a new physician that you believe your practice needs, consider all of the costs related to hiring and supporting him or her for at least the first year. (Once again, check out the online archives for a previous column addressing this subject in more detail.)

You must also remember to include the costs of additional support personnel; additional examination or procedure rooms; a larger reception area; and the associated mortgage or leasehold improvement costs, overhead expenses, payroll taxes, and lawyer fees.

If the new physician provides services that are new to your practice, you will most likely need new equipment. This means that you must factor quotes from suppliers into your calculations.

Then, there is always the question of just how these additional costs will be met. No matter how large their current backlog, many dermatologists worry that their practices won't have enough additional patients to support a new doctor.

You can remove much of the guesswork by estimating how many additional patients your practice will need to break even. Do that by dividing your previous year's total revenues by the total number of patient visits to determine average revenue per visit. Then divide the total estimated cost of hiring a new physician by your revenue per visit. This is the approximate number of additional visits that must be generated for the new associate's costs to be covered.

The calculations will, of course, become more complex if the new physician will be doing only Mohs or cosmetic procedures, but you get the idea.

How much you pay a new associate will depend heavily on your location and individual circumstances. Find out what nearby practices are paying their recruits, and ask applicants themselves how much they expect to be paid.

The ultimate determination may require the services of an experienced practice consultant who is familiar with your practice area.

Many candidates will also expect incentive compensation for exceeding their revenue-generation goals.

You should also consider rewarding other performance achievements, including relationship building, teamwork, practice promotion, and attraction of new referrers.

Remember to factor in the fringe benefits that your practice provides. Most compensation packages include such standard benefits as paid time off, health insurance, society dues, hospital staff fees, CME costs, subscriptions, retirement plan contributions (when eligible), and malpractice insurance.

Lastly, you may also want to consider covering the physician's moving expenses, especially if it would help close the deal.

Vacuum extraction for shoulder dystocia

A 28-year-old woman in labor presented at the hospital. While delivering her child, the ObGyn encountered shoulder dystocia and proceeded to use vacuum extraction. Diagnosed with Erb’s palsy, the child has undergone physical and occupational therapy and is now doing well.

Patient’s claim The ObGyn did not manage the shoulder dystocia properly. Vacuum extraction, which was not needed, was performed by an inexperienced assisting physician after shoulder dystocia had occurred. Asymmetry of the child’s chest, as well as arm length discrepancy, will increase as the child grows.

Doctor’s defense Vacuum extraction was used to alleviate stress on the infant, who had mitral valve prolapse. The assisting physician was directly observed and supervised by the ObGyn, who was performing the McRoberts maneuver.

Verdict New York defense verdict.

Monochorionic monoamniotic twin dies

A 29-year-old woman pregnant with monochorionic, monoamniotic twins was admitted to the hospital when she went into premature labor. Despite her request for delivery, the ObGyn decided to delay delivery and administered terbutaline. Five days later, the twins were delivered: one healthy, the other stillborn.

Patient’s claim Delivery should have occurred earlier, before the one fetus had died.

Doctor’s defense Unpredictable and un-preventable complications of the pregnancy caused the stillbirth.

Verdict $487,000 Indiana verdict. An appeal was pending.

For more on twin gestations, see the cover article by Victoria Belogolovkin, MD, and Joanne Stone, MD.

Oversized head went unnoticed despite US

A woman in her 17th week of pregnancy underwent ultrasonography (US) with radiologist A to check for a fetal heartbeat and to confirm both the presence of the fetus in the uterus and a single pregnancy. She also underwent a blood test for Down’s syndrome, Trisomy 18, and neural tube defects. All tests were normal. At her next appointment, radiologist B used US to verify the sex of the fetus. The remainder of her pregnancy passed without incident. The child was delivered by cesarean section and had a grossly enlarged head and other congenital defects. An MRI 2 days later showed the right hemisphere of the brain to be huge with a severely abnormal structure. The child had multiple brain surgeries but continues to suffer from intractable seizures. He is severely retarded and has been diagnosed with Proteus syndrome, also known as Elephant Man syndrome.

Patient’s claim Instead of limited US on 2 occasions (which led her to believe the fetus was normal), a full US should have been done. This would have allowed the brain abnormalities to be diagnosed while there was still time for a legal abortion. During the second US, Dr. B noted that the baby had a big head. The sonogram taken by Dr. A showed the early stages of disease, and if Dr. B had taken one during the second US, the dramatic difference in head size would have been evident. She denied that she requested the second US to verify the sex.

Doctor’s defense Dr. A claimed he tells all patients that US does not look for fetal anatomical abnormalities and that they can be referred to a perinatologist for that information. Dr. B claimed the second US was only to verify the sex. Both denied liability, claiming that the child’s disorder is very rare and a full US was not needed. Also, a diagnosis might not have been made, and it was un-likely the fetus would have been aborted.

Verdict California defense verdict.

Small bowel is injured in repeat C-section

A 25-year-old woman underwent a second cesarean section performed by the same OB who had handled her first cesarean section 3 years earlier. During the second procedure, the small bowel was perforated, requiring emergency intraoperative corrective surgery.

Patient’s claim She lost 3 inches of her small bowel and suffers severe intermittent diarrhea, pain, and a partial bowel obstruction.

Doctor’s defense The woman’s problems predated the cesarean section. She was not under a doctor’s care or taking medication, and she had not been hospitalized since the corrective surgery. Bowel perforation, a known risk, was complicated by a bowel loop adherent to the abdominal rectus muscle. Also, the woman was not a candidate for vaginal delivery because of her history: colostomy, blood transfusions, digestive problems, and failure to progress in the first pregnancy.

Verdict New York defense verdict.

Why a hysterectomy and not another D&C?

A 72-year-old woman with a uterine polyp presented at the hospital for a dilation and curettage (D&C) procedure. Because of her stenotic cervix, which was abnormally constructed, the physician discontinued the surgery after trying unsuccessfully to dilate the cervix. The patient later underwent abdominal hysterectomy and developed incontinence and constant pelvic pain.

Patient’s claim The hysterectomy was unnecessary and lacked informed consent. The physician said she had cancer and would die without the hysterectomy, but cancer was not found. A repeat D&C was warranted.

Doctor’s defense He stopped the original surgery because he didn’t want to perforate the bowel; he never told the patient she had cancer; and a simple hysterectomy cannot cause incontinence.

Verdict New York defense verdict.

FP, not OB, delivers severely injured child

A woman hospitalized at 38 weeks’ gestation—with high blood pressure and at risk for toxemia—was diagnosed with pregnancy-induced hypertension (PIH). Fetal monitoring showed the fetus to be stable. The woman was given magnesium sulfate for the PIH, misoprostol and oxytocin to induce and augment labor, and an epidural. After decelerations were noted the following evening, amnioinfusion was ordered. Scalp stimulation 3 hours later yielded no response. Oxygen saturation of the fetus was normal. Oxytocin was increased, and the infant was delivered several hours later, but required 10 minutes of resuscitation before it began breathing. The diagnosis was severe hypoxic–ischemic encephalopathy, and the child requires a ventilator and tube feeding.

Patient’s claim The family practice physician should have transferred care to an obstetrician, and a cesarean section should have been performed.

Doctor’s defense Not reported.

Verdict Mediated California settlement: $3.4 million from the hospital, $100,000 from the obstetrical group, and $1.5 million from an unidentified defendant.

Vacuum extraction for shoulder dystocia

A 28-year-old woman in labor presented at the hospital. While delivering her child, the ObGyn encountered shoulder dystocia and proceeded to use vacuum extraction. Diagnosed with Erb’s palsy, the child has undergone physical and occupational therapy and is now doing well.

Patient’s claim The ObGyn did not manage the shoulder dystocia properly. Vacuum extraction, which was not needed, was performed by an inexperienced assisting physician after shoulder dystocia had occurred. Asymmetry of the child’s chest, as well as arm length discrepancy, will increase as the child grows.

Doctor’s defense Vacuum extraction was used to alleviate stress on the infant, who had mitral valve prolapse. The assisting physician was directly observed and supervised by the ObGyn, who was performing the McRoberts maneuver.

Verdict New York defense verdict.

Monochorionic monoamniotic twin dies

A 29-year-old woman pregnant with monochorionic, monoamniotic twins was admitted to the hospital when she went into premature labor. Despite her request for delivery, the ObGyn decided to delay delivery and administered terbutaline. Five days later, the twins were delivered: one healthy, the other stillborn.

Patient’s claim Delivery should have occurred earlier, before the one fetus had died.

Doctor’s defense Unpredictable and un-preventable complications of the pregnancy caused the stillbirth.

Verdict $487,000 Indiana verdict. An appeal was pending.

For more on twin gestations, see the cover article by Victoria Belogolovkin, MD, and Joanne Stone, MD.

Oversized head went unnoticed despite US

A woman in her 17th week of pregnancy underwent ultrasonography (US) with radiologist A to check for a fetal heartbeat and to confirm both the presence of the fetus in the uterus and a single pregnancy. She also underwent a blood test for Down’s syndrome, Trisomy 18, and neural tube defects. All tests were normal. At her next appointment, radiologist B used US to verify the sex of the fetus. The remainder of her pregnancy passed without incident. The child was delivered by cesarean section and had a grossly enlarged head and other congenital defects. An MRI 2 days later showed the right hemisphere of the brain to be huge with a severely abnormal structure. The child had multiple brain surgeries but continues to suffer from intractable seizures. He is severely retarded and has been diagnosed with Proteus syndrome, also known as Elephant Man syndrome.

Patient’s claim Instead of limited US on 2 occasions (which led her to believe the fetus was normal), a full US should have been done. This would have allowed the brain abnormalities to be diagnosed while there was still time for a legal abortion. During the second US, Dr. B noted that the baby had a big head. The sonogram taken by Dr. A showed the early stages of disease, and if Dr. B had taken one during the second US, the dramatic difference in head size would have been evident. She denied that she requested the second US to verify the sex.

Doctor’s defense Dr. A claimed he tells all patients that US does not look for fetal anatomical abnormalities and that they can be referred to a perinatologist for that information. Dr. B claimed the second US was only to verify the sex. Both denied liability, claiming that the child’s disorder is very rare and a full US was not needed. Also, a diagnosis might not have been made, and it was un-likely the fetus would have been aborted.

Verdict California defense verdict.

Small bowel is injured in repeat C-section

A 25-year-old woman underwent a second cesarean section performed by the same OB who had handled her first cesarean section 3 years earlier. During the second procedure, the small bowel was perforated, requiring emergency intraoperative corrective surgery.

Patient’s claim She lost 3 inches of her small bowel and suffers severe intermittent diarrhea, pain, and a partial bowel obstruction.

Doctor’s defense The woman’s problems predated the cesarean section. She was not under a doctor’s care or taking medication, and she had not been hospitalized since the corrective surgery. Bowel perforation, a known risk, was complicated by a bowel loop adherent to the abdominal rectus muscle. Also, the woman was not a candidate for vaginal delivery because of her history: colostomy, blood transfusions, digestive problems, and failure to progress in the first pregnancy.

Verdict New York defense verdict.

Why a hysterectomy and not another D&C?

A 72-year-old woman with a uterine polyp presented at the hospital for a dilation and curettage (D&C) procedure. Because of her stenotic cervix, which was abnormally constructed, the physician discontinued the surgery after trying unsuccessfully to dilate the cervix. The patient later underwent abdominal hysterectomy and developed incontinence and constant pelvic pain.

Patient’s claim The hysterectomy was unnecessary and lacked informed consent. The physician said she had cancer and would die without the hysterectomy, but cancer was not found. A repeat D&C was warranted.

Doctor’s defense He stopped the original surgery because he didn’t want to perforate the bowel; he never told the patient she had cancer; and a simple hysterectomy cannot cause incontinence.

Verdict New York defense verdict.

FP, not OB, delivers severely injured child

A woman hospitalized at 38 weeks’ gestation—with high blood pressure and at risk for toxemia—was diagnosed with pregnancy-induced hypertension (PIH). Fetal monitoring showed the fetus to be stable. The woman was given magnesium sulfate for the PIH, misoprostol and oxytocin to induce and augment labor, and an epidural. After decelerations were noted the following evening, amnioinfusion was ordered. Scalp stimulation 3 hours later yielded no response. Oxygen saturation of the fetus was normal. Oxytocin was increased, and the infant was delivered several hours later, but required 10 minutes of resuscitation before it began breathing. The diagnosis was severe hypoxic–ischemic encephalopathy, and the child requires a ventilator and tube feeding.

Patient’s claim The family practice physician should have transferred care to an obstetrician, and a cesarean section should have been performed.

Doctor’s defense Not reported.

Verdict Mediated California settlement: $3.4 million from the hospital, $100,000 from the obstetrical group, and $1.5 million from an unidentified defendant.

Vacuum extraction for shoulder dystocia

A 28-year-old woman in labor presented at the hospital. While delivering her child, the ObGyn encountered shoulder dystocia and proceeded to use vacuum extraction. Diagnosed with Erb’s palsy, the child has undergone physical and occupational therapy and is now doing well.

Patient’s claim The ObGyn did not manage the shoulder dystocia properly. Vacuum extraction, which was not needed, was performed by an inexperienced assisting physician after shoulder dystocia had occurred. Asymmetry of the child’s chest, as well as arm length discrepancy, will increase as the child grows.

Doctor’s defense Vacuum extraction was used to alleviate stress on the infant, who had mitral valve prolapse. The assisting physician was directly observed and supervised by the ObGyn, who was performing the McRoberts maneuver.

Verdict New York defense verdict.

Monochorionic monoamniotic twin dies

A 29-year-old woman pregnant with monochorionic, monoamniotic twins was admitted to the hospital when she went into premature labor. Despite her request for delivery, the ObGyn decided to delay delivery and administered terbutaline. Five days later, the twins were delivered: one healthy, the other stillborn.

Patient’s claim Delivery should have occurred earlier, before the one fetus had died.

Doctor’s defense Unpredictable and un-preventable complications of the pregnancy caused the stillbirth.

Verdict $487,000 Indiana verdict. An appeal was pending.

For more on twin gestations, see the cover article by Victoria Belogolovkin, MD, and Joanne Stone, MD.

Oversized head went unnoticed despite US

A woman in her 17th week of pregnancy underwent ultrasonography (US) with radiologist A to check for a fetal heartbeat and to confirm both the presence of the fetus in the uterus and a single pregnancy. She also underwent a blood test for Down’s syndrome, Trisomy 18, and neural tube defects. All tests were normal. At her next appointment, radiologist B used US to verify the sex of the fetus. The remainder of her pregnancy passed without incident. The child was delivered by cesarean section and had a grossly enlarged head and other congenital defects. An MRI 2 days later showed the right hemisphere of the brain to be huge with a severely abnormal structure. The child had multiple brain surgeries but continues to suffer from intractable seizures. He is severely retarded and has been diagnosed with Proteus syndrome, also known as Elephant Man syndrome.

Patient’s claim Instead of limited US on 2 occasions (which led her to believe the fetus was normal), a full US should have been done. This would have allowed the brain abnormalities to be diagnosed while there was still time for a legal abortion. During the second US, Dr. B noted that the baby had a big head. The sonogram taken by Dr. A showed the early stages of disease, and if Dr. B had taken one during the second US, the dramatic difference in head size would have been evident. She denied that she requested the second US to verify the sex.

Doctor’s defense Dr. A claimed he tells all patients that US does not look for fetal anatomical abnormalities and that they can be referred to a perinatologist for that information. Dr. B claimed the second US was only to verify the sex. Both denied liability, claiming that the child’s disorder is very rare and a full US was not needed. Also, a diagnosis might not have been made, and it was un-likely the fetus would have been aborted.

Verdict California defense verdict.

Small bowel is injured in repeat C-section

A 25-year-old woman underwent a second cesarean section performed by the same OB who had handled her first cesarean section 3 years earlier. During the second procedure, the small bowel was perforated, requiring emergency intraoperative corrective surgery.

Patient’s claim She lost 3 inches of her small bowel and suffers severe intermittent diarrhea, pain, and a partial bowel obstruction.

Doctor’s defense The woman’s problems predated the cesarean section. She was not under a doctor’s care or taking medication, and she had not been hospitalized since the corrective surgery. Bowel perforation, a known risk, was complicated by a bowel loop adherent to the abdominal rectus muscle. Also, the woman was not a candidate for vaginal delivery because of her history: colostomy, blood transfusions, digestive problems, and failure to progress in the first pregnancy.

Verdict New York defense verdict.

Why a hysterectomy and not another D&C?

A 72-year-old woman with a uterine polyp presented at the hospital for a dilation and curettage (D&C) procedure. Because of her stenotic cervix, which was abnormally constructed, the physician discontinued the surgery after trying unsuccessfully to dilate the cervix. The patient later underwent abdominal hysterectomy and developed incontinence and constant pelvic pain.

Patient’s claim The hysterectomy was unnecessary and lacked informed consent. The physician said she had cancer and would die without the hysterectomy, but cancer was not found. A repeat D&C was warranted.

Doctor’s defense He stopped the original surgery because he didn’t want to perforate the bowel; he never told the patient she had cancer; and a simple hysterectomy cannot cause incontinence.

Verdict New York defense verdict.

FP, not OB, delivers severely injured child

A woman hospitalized at 38 weeks’ gestation—with high blood pressure and at risk for toxemia—was diagnosed with pregnancy-induced hypertension (PIH). Fetal monitoring showed the fetus to be stable. The woman was given magnesium sulfate for the PIH, misoprostol and oxytocin to induce and augment labor, and an epidural. After decelerations were noted the following evening, amnioinfusion was ordered. Scalp stimulation 3 hours later yielded no response. Oxygen saturation of the fetus was normal. Oxytocin was increased, and the infant was delivered several hours later, but required 10 minutes of resuscitation before it began breathing. The diagnosis was severe hypoxic–ischemic encephalopathy, and the child requires a ventilator and tube feeding.

Patient’s claim The family practice physician should have transferred care to an obstetrician, and a cesarean section should have been performed.

Doctor’s defense Not reported.

Verdict Mediated California settlement: $3.4 million from the hospital, $100,000 from the obstetrical group, and $1.5 million from an unidentified defendant.

M.K., age 29 years, presents at term and in labor to the state-of-the-art hospital where you practice. During labor, transient slowing of the fetal heart rate (FHR) is detected, and you perform an urgent cesarean section, with successful delivery of the infant. Cord blood shows no evidence of acidosis, and the Apgar score is 8 at 1 minute and 9 at 5 minutes.

Two years later, after the child is diagnosed with ataxic cerebral palsy (CP), the parents file a $10 million lawsuit that names you as defendant.

Could you have done something to avoid litigation?

Absolutely! But the best preventive strategy has nothing to do with the science of medicine.

Because of the near certainty of being sued—usually, without merit—over the course of one’s career, an ObGyn has little choice but to practice defensive medicine. Until true tort reform is passed, we believe that physicians should rely on contract law to avoid lawsuits such as the one described above. The best defense begins at the patient’s first appointment, when she should be asked to sign a basic agreement. This article describes how such a strategy can greatly bolster your case should a lawsuit eventually be filed.

Avoiding the “death knell”

Until recently, a diagnosis of CP coupled with a lawsuit sounded the proverbial death knell for an obstetrician. The high stakes, long statute of limitations, and availability of “experts” willing to testify about standard-of-care violations all but guaranteed an early settlement. No obstetrician could risk presenting his or her case to a jury likely to be sympathetic to the plaintiff. The settlement of such cases was usually substantial—in the high 6 or low 7 figures—and the physician’s name was subsequently entered into the National Practitioner Data Bank. These settlements fueled high professional liability premiums, which remain extreme across the country.

Causes of CP are now more clearly understood

In 2003, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics published a report, “Neonatal encephalopathy and cerebral palsy: Defining the pathogenesis and pathophysiology” (NEACP),¹ that challenged a number of long-held assumptions—among them the belief that electronic FHR monitoring can highlight fetal distress in time to prevent intrapartum fetal asphyxia and lower the number of cases of CP. (For the findings of this report, see “Tracing the origin of a case of CP.”) Sadly, electronic fetal monitoring has had no impact on the rate of CP, despite a dramatic increase in cesarean deliveries. A study by Nelson et al² found that nonreassuring FHR patterns had a 99% false-positive rate for predicting CP.

The overall conclusion of the NEACP report: Most cases of CP are not the result of intrapartum events.

Unreliable testimony propels many cases

The NEACP report is an important, peer-reviewed document, and although it could be labeled as self-serving, it does provide a road map for documenting, with evidence, how intrapartum events can indeed cause CP.

It can be argued that CP lawsuits unsupported by any of the NEACP criteria do not belong in court.

Frivolous cases often proceed with frivolous expert testimony, which can be defined as testimony that a majority or respectable minority in the field would not utter. Put a different way, if the expert is the only person holding a particular view, that unique opinion probably does not define the standard of care.

What can physicians do?

There are remedies available to physicians worried about frivolous lawsuits. The most effective strategy, we believe, is to be proactive: Have the patient sign a contract well before delivery in which she agrees not to sue indiscriminately in certain circumstances. Such a contract can include language requiring the patient to follow reasonable procedural guidelines if she does decide to sue.

If handled correctly, contract law can protect physicians. A reasonable contract does not ask the patient to forego all legal remedies; it does leave her with recourse in the event of negligence. Having a patient sign a blanket release would be considered an “abuse of power,” and the courts would probably dismiss such an agreement.

An enforceable contract has to withstand legal challenges. The contracts used by Medical Justice Services, the organization we established to protect physicians from frivolous lawsuits, define the expectations regarding resolution of concerns. For example, the patient agrees that the physician cannot be sued for a frivolous reason. It does not bar litigation for any reason—just for a frivolous reason. Should a legitimate dispute arise, both the patient and physician agree to use experts who are members of, and follow the code of ethics of, the physician’s professional specialty society—in this case, ACOG. The goal is to ensure that experts are reputable and accountable.

Breach of contract should also be defined in the document. For example, in obstetric and gynecologic cases, a conclusion by the ACOG ethics committee that court testimony is “frivolous” might be listed in the contract as a determinant of breach. Definitions and rules of procedure are often embedded in contracts.

Will such a contract hold up?

An unenforceable contract is described as “unconscionable.” In a recent legal case,³ the court determined: “To be unconscionable, ‘the contract must be such as no sensible man not under delusion, duress, or in distress would make, and such as no honest and fair man would accept.’”

The 2 provisions of the Medical Justice agreement—the promise not to bring a frivolous lawsuit and the mutual promise to use an expert in the same specialty who follows the code of ethics of his or her specialty society—would probably not be considered unconscionable. The first promise is already the law in every state and is reflected in numerous statutes; when addressed in a contract, such a statute is easier to enforce. The second promise focuses on the procedures for advancing a legitimate case.

As a reputable treatise on contract law points out, “There is a growing tendency for courts to uphold the right of parties to prescribe certain rules of evidence should a lawsuit arise out of the bargain between them, so long as it does not unduly interfere with the inherent power and right of the court to consider relevant evidence.”⁴ Therefore, those who sign contracts have some latitude to determine, in advance, how procedures might vary from general courtroom standards.

It is well established that patients and physicians can contract to use arbitration. Arbitration asks the plaintiff to forego her right to trial by jury in the presence of a judge. Imposing reasonable conditions for the use of expert witnesses is clearly less restrictive than requiring arbitration.

In 2 recent cases,^2,5 the courts relied on several factors to determine that the contracts in question were not unconscionable:

• Contractual provisions weren’t hidden but were instead highlighted, and the contract was otherwise easy to read and understand
  
• The patient had the opportunity to read the contract fully and ask questions
  
• There was no effect on the physician’s duty to provide reasonable care
  
• The contract did not limit the liability of the provider to the patient.
  

What if the infant becomes the plaintiff?

An important question in obstetric-related lawsuits is whether the child is bound by the terms of a contract signed by the mother. Falling back on the arbitration analogy, there are ways to hold individuals who haven’t physically signed the contract—including a minor child and any attorney the patient hires—to the terms it spells out. A child can be bound by the mother in an agreement to arbitrate entered into during the prenatal period. In one case, a court interpreted the arbitration clause to apply to any claim arising from services under the agreement, even though the plaintiff had not been born when the agreement was signed.⁶ This case is of particular interest to ObGyns because it established a precedent that limits the right of children to sue even though they themselves never signed the agreement.

In another case,⁷ a spouse who did not sign the contract filed a lawsuit for loss of consortium due to a physician’s negligence. The court found that all claims arising from the alleged malpractice must be arbitrated when a patient signs a contract agreeing to arbitrate claims of negligence. Similarly, heirs in a wrongful death action were found to be bound by the decedent’s agreement to arbitrate when the contract required that claims by the “member’s heir or personal representative” be arbitrated.⁸

Can a contract be enforced retroactively?

ObGyns often have long-term relationships with patients. Or they may wish to implement the provisions described above after 1 or several prenatal visits. Is it possible to design a new contract to address past actions?

Maybe.

In California, there is a precedent for retroactive activation of an arbitration agreement. In 1993, the California Court of Appeals upheld an arbitration agreement that was defined for both future and retroactive treatment.⁹

Will a patient sign such a contract?

The short answer is “Yes.” Patients sign contracts all the time. They agree to pay their bill. They agree that records can be sent to referring physicians. They agree that they have made an informed decision about their care.

Medical Justice Services has a long track record of promoting such contracts as part of the physician–patient relationship. We have found that most patients are comfortable signing a contract that limits their right to sue to cases with clear merit and requires them to use reputable and accountable experts if there is a legitimate dispute. In this way, patients who deserve a remedy have full access to the courts.

Bringing up the topic of a contract before care is initiated is no more likely to create tension than a traditional informed consent discussion would. Most patients believe themselves to be reasonable and cannot imagine filing a lawsuit for an illegitimate reason.

By deterring unjustified litigation, the widespread use of contracts can help stabilize professional liability premiums, minimize the cost of health care, and preserve access to health care. In cerebral palsy litigation, where the stakes are high, 1 of the better ways to control the legal outcome is by means of a contract, especially when there is minimal or no evidence of NEACP criteria.

M.K., age 29 years, presents at term and in labor to the state-of-the-art hospital where you practice. During labor, transient slowing of the fetal heart rate (FHR) is detected, and you perform an urgent cesarean section, with successful delivery of the infant. Cord blood shows no evidence of acidosis, and the Apgar score is 8 at 1 minute and 9 at 5 minutes.

Two years later, after the child is diagnosed with ataxic cerebral palsy (CP), the parents file a $10 million lawsuit that names you as defendant.

Could you have done something to avoid litigation?

Absolutely! But the best preventive strategy has nothing to do with the science of medicine.

Because of the near certainty of being sued—usually, without merit—over the course of one’s career, an ObGyn has little choice but to practice defensive medicine. Until true tort reform is passed, we believe that physicians should rely on contract law to avoid lawsuits such as the one described above. The best defense begins at the patient’s first appointment, when she should be asked to sign a basic agreement. This article describes how such a strategy can greatly bolster your case should a lawsuit eventually be filed.

Avoiding the “death knell”

Until recently, a diagnosis of CP coupled with a lawsuit sounded the proverbial death knell for an obstetrician. The high stakes, long statute of limitations, and availability of “experts” willing to testify about standard-of-care violations all but guaranteed an early settlement. No obstetrician could risk presenting his or her case to a jury likely to be sympathetic to the plaintiff. The settlement of such cases was usually substantial—in the high 6 or low 7 figures—and the physician’s name was subsequently entered into the National Practitioner Data Bank. These settlements fueled high professional liability premiums, which remain extreme across the country.

Causes of CP are now more clearly understood

In 2003, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics published a report, “Neonatal encephalopathy and cerebral palsy: Defining the pathogenesis and pathophysiology” (NEACP),¹ that challenged a number of long-held assumptions—among them the belief that electronic FHR monitoring can highlight fetal distress in time to prevent intrapartum fetal asphyxia and lower the number of cases of CP. (For the findings of this report, see “Tracing the origin of a case of CP.”) Sadly, electronic fetal monitoring has had no impact on the rate of CP, despite a dramatic increase in cesarean deliveries. A study by Nelson et al² found that nonreassuring FHR patterns had a 99% false-positive rate for predicting CP.

The overall conclusion of the NEACP report: Most cases of CP are not the result of intrapartum events.

Unreliable testimony propels many cases

The NEACP report is an important, peer-reviewed document, and although it could be labeled as self-serving, it does provide a road map for documenting, with evidence, how intrapartum events can indeed cause CP.

It can be argued that CP lawsuits unsupported by any of the NEACP criteria do not belong in court.

Frivolous cases often proceed with frivolous expert testimony, which can be defined as testimony that a majority or respectable minority in the field would not utter. Put a different way, if the expert is the only person holding a particular view, that unique opinion probably does not define the standard of care.

What can physicians do?

There are remedies available to physicians worried about frivolous lawsuits. The most effective strategy, we believe, is to be proactive: Have the patient sign a contract well before delivery in which she agrees not to sue indiscriminately in certain circumstances. Such a contract can include language requiring the patient to follow reasonable procedural guidelines if she does decide to sue.

If handled correctly, contract law can protect physicians. A reasonable contract does not ask the patient to forego all legal remedies; it does leave her with recourse in the event of negligence. Having a patient sign a blanket release would be considered an “abuse of power,” and the courts would probably dismiss such an agreement.

An enforceable contract has to withstand legal challenges. The contracts used by Medical Justice Services, the organization we established to protect physicians from frivolous lawsuits, define the expectations regarding resolution of concerns. For example, the patient agrees that the physician cannot be sued for a frivolous reason. It does not bar litigation for any reason—just for a frivolous reason. Should a legitimate dispute arise, both the patient and physician agree to use experts who are members of, and follow the code of ethics of, the physician’s professional specialty society—in this case, ACOG. The goal is to ensure that experts are reputable and accountable.

Breach of contract should also be defined in the document. For example, in obstetric and gynecologic cases, a conclusion by the ACOG ethics committee that court testimony is “frivolous” might be listed in the contract as a determinant of breach. Definitions and rules of procedure are often embedded in contracts.

Will such a contract hold up?

An unenforceable contract is described as “unconscionable.” In a recent legal case,³ the court determined: “To be unconscionable, ‘the contract must be such as no sensible man not under delusion, duress, or in distress would make, and such as no honest and fair man would accept.’”

The 2 provisions of the Medical Justice agreement—the promise not to bring a frivolous lawsuit and the mutual promise to use an expert in the same specialty who follows the code of ethics of his or her specialty society—would probably not be considered unconscionable. The first promise is already the law in every state and is reflected in numerous statutes; when addressed in a contract, such a statute is easier to enforce. The second promise focuses on the procedures for advancing a legitimate case.

As a reputable treatise on contract law points out, “There is a growing tendency for courts to uphold the right of parties to prescribe certain rules of evidence should a lawsuit arise out of the bargain between them, so long as it does not unduly interfere with the inherent power and right of the court to consider relevant evidence.”⁴ Therefore, those who sign contracts have some latitude to determine, in advance, how procedures might vary from general courtroom standards.

It is well established that patients and physicians can contract to use arbitration. Arbitration asks the plaintiff to forego her right to trial by jury in the presence of a judge. Imposing reasonable conditions for the use of expert witnesses is clearly less restrictive than requiring arbitration.

In 2 recent cases,^2,5 the courts relied on several factors to determine that the contracts in question were not unconscionable:

• Contractual provisions weren’t hidden but were instead highlighted, and the contract was otherwise easy to read and understand
  
• The patient had the opportunity to read the contract fully and ask questions
  
• There was no effect on the physician’s duty to provide reasonable care
  
• The contract did not limit the liability of the provider to the patient.
  

What if the infant becomes the plaintiff?

An important question in obstetric-related lawsuits is whether the child is bound by the terms of a contract signed by the mother. Falling back on the arbitration analogy, there are ways to hold individuals who haven’t physically signed the contract—including a minor child and any attorney the patient hires—to the terms it spells out. A child can be bound by the mother in an agreement to arbitrate entered into during the prenatal period. In one case, a court interpreted the arbitration clause to apply to any claim arising from services under the agreement, even though the plaintiff had not been born when the agreement was signed.⁶ This case is of particular interest to ObGyns because it established a precedent that limits the right of children to sue even though they themselves never signed the agreement.

In another case,⁷ a spouse who did not sign the contract filed a lawsuit for loss of consortium due to a physician’s negligence. The court found that all claims arising from the alleged malpractice must be arbitrated when a patient signs a contract agreeing to arbitrate claims of negligence. Similarly, heirs in a wrongful death action were found to be bound by the decedent’s agreement to arbitrate when the contract required that claims by the “member’s heir or personal representative” be arbitrated.⁸

Can a contract be enforced retroactively?

ObGyns often have long-term relationships with patients. Or they may wish to implement the provisions described above after 1 or several prenatal visits. Is it possible to design a new contract to address past actions?

Maybe.

In California, there is a precedent for retroactive activation of an arbitration agreement. In 1993, the California Court of Appeals upheld an arbitration agreement that was defined for both future and retroactive treatment.⁹

Will a patient sign such a contract?

The short answer is “Yes.” Patients sign contracts all the time. They agree to pay their bill. They agree that records can be sent to referring physicians. They agree that they have made an informed decision about their care.

Medical Justice Services has a long track record of promoting such contracts as part of the physician–patient relationship. We have found that most patients are comfortable signing a contract that limits their right to sue to cases with clear merit and requires them to use reputable and accountable experts if there is a legitimate dispute. In this way, patients who deserve a remedy have full access to the courts.

Bringing up the topic of a contract before care is initiated is no more likely to create tension than a traditional informed consent discussion would. Most patients believe themselves to be reasonable and cannot imagine filing a lawsuit for an illegitimate reason.

By deterring unjustified litigation, the widespread use of contracts can help stabilize professional liability premiums, minimize the cost of health care, and preserve access to health care. In cerebral palsy litigation, where the stakes are high, 1 of the better ways to control the legal outcome is by means of a contract, especially when there is minimal or no evidence of NEACP criteria.

M.K., age 29 years, presents at term and in labor to the state-of-the-art hospital where you practice. During labor, transient slowing of the fetal heart rate (FHR) is detected, and you perform an urgent cesarean section, with successful delivery of the infant. Cord blood shows no evidence of acidosis, and the Apgar score is 8 at 1 minute and 9 at 5 minutes.

Two years later, after the child is diagnosed with ataxic cerebral palsy (CP), the parents file a $10 million lawsuit that names you as defendant.

Could you have done something to avoid litigation?

Absolutely! But the best preventive strategy has nothing to do with the science of medicine.

Because of the near certainty of being sued—usually, without merit—over the course of one’s career, an ObGyn has little choice but to practice defensive medicine. Until true tort reform is passed, we believe that physicians should rely on contract law to avoid lawsuits such as the one described above. The best defense begins at the patient’s first appointment, when she should be asked to sign a basic agreement. This article describes how such a strategy can greatly bolster your case should a lawsuit eventually be filed.

Avoiding the “death knell”

Until recently, a diagnosis of CP coupled with a lawsuit sounded the proverbial death knell for an obstetrician. The high stakes, long statute of limitations, and availability of “experts” willing to testify about standard-of-care violations all but guaranteed an early settlement. No obstetrician could risk presenting his or her case to a jury likely to be sympathetic to the plaintiff. The settlement of such cases was usually substantial—in the high 6 or low 7 figures—and the physician’s name was subsequently entered into the National Practitioner Data Bank. These settlements fueled high professional liability premiums, which remain extreme across the country.

Causes of CP are now more clearly understood

In 2003, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics published a report, “Neonatal encephalopathy and cerebral palsy: Defining the pathogenesis and pathophysiology” (NEACP),¹ that challenged a number of long-held assumptions—among them the belief that electronic FHR monitoring can highlight fetal distress in time to prevent intrapartum fetal asphyxia and lower the number of cases of CP. (For the findings of this report, see “Tracing the origin of a case of CP.”) Sadly, electronic fetal monitoring has had no impact on the rate of CP, despite a dramatic increase in cesarean deliveries. A study by Nelson et al² found that nonreassuring FHR patterns had a 99% false-positive rate for predicting CP.

The overall conclusion of the NEACP report: Most cases of CP are not the result of intrapartum events.

Unreliable testimony propels many cases

The NEACP report is an important, peer-reviewed document, and although it could be labeled as self-serving, it does provide a road map for documenting, with evidence, how intrapartum events can indeed cause CP.

It can be argued that CP lawsuits unsupported by any of the NEACP criteria do not belong in court.

Frivolous cases often proceed with frivolous expert testimony, which can be defined as testimony that a majority or respectable minority in the field would not utter. Put a different way, if the expert is the only person holding a particular view, that unique opinion probably does not define the standard of care.

What can physicians do?

There are remedies available to physicians worried about frivolous lawsuits. The most effective strategy, we believe, is to be proactive: Have the patient sign a contract well before delivery in which she agrees not to sue indiscriminately in certain circumstances. Such a contract can include language requiring the patient to follow reasonable procedural guidelines if she does decide to sue.

If handled correctly, contract law can protect physicians. A reasonable contract does not ask the patient to forego all legal remedies; it does leave her with recourse in the event of negligence. Having a patient sign a blanket release would be considered an “abuse of power,” and the courts would probably dismiss such an agreement.

An enforceable contract has to withstand legal challenges. The contracts used by Medical Justice Services, the organization we established to protect physicians from frivolous lawsuits, define the expectations regarding resolution of concerns. For example, the patient agrees that the physician cannot be sued for a frivolous reason. It does not bar litigation for any reason—just for a frivolous reason. Should a legitimate dispute arise, both the patient and physician agree to use experts who are members of, and follow the code of ethics of, the physician’s professional specialty society—in this case, ACOG. The goal is to ensure that experts are reputable and accountable.

Breach of contract should also be defined in the document. For example, in obstetric and gynecologic cases, a conclusion by the ACOG ethics committee that court testimony is “frivolous” might be listed in the contract as a determinant of breach. Definitions and rules of procedure are often embedded in contracts.

Will such a contract hold up?

An unenforceable contract is described as “unconscionable.” In a recent legal case,³ the court determined: “To be unconscionable, ‘the contract must be such as no sensible man not under delusion, duress, or in distress would make, and such as no honest and fair man would accept.’”

The 2 provisions of the Medical Justice agreement—the promise not to bring a frivolous lawsuit and the mutual promise to use an expert in the same specialty who follows the code of ethics of his or her specialty society—would probably not be considered unconscionable. The first promise is already the law in every state and is reflected in numerous statutes; when addressed in a contract, such a statute is easier to enforce. The second promise focuses on the procedures for advancing a legitimate case.

As a reputable treatise on contract law points out, “There is a growing tendency for courts to uphold the right of parties to prescribe certain rules of evidence should a lawsuit arise out of the bargain between them, so long as it does not unduly interfere with the inherent power and right of the court to consider relevant evidence.”⁴ Therefore, those who sign contracts have some latitude to determine, in advance, how procedures might vary from general courtroom standards.

It is well established that patients and physicians can contract to use arbitration. Arbitration asks the plaintiff to forego her right to trial by jury in the presence of a judge. Imposing reasonable conditions for the use of expert witnesses is clearly less restrictive than requiring arbitration.

In 2 recent cases,^2,5 the courts relied on several factors to determine that the contracts in question were not unconscionable:

• Contractual provisions weren’t hidden but were instead highlighted, and the contract was otherwise easy to read and understand
  
• The patient had the opportunity to read the contract fully and ask questions
  
• There was no effect on the physician’s duty to provide reasonable care
  
• The contract did not limit the liability of the provider to the patient.
  

What if the infant becomes the plaintiff?

An important question in obstetric-related lawsuits is whether the child is bound by the terms of a contract signed by the mother. Falling back on the arbitration analogy, there are ways to hold individuals who haven’t physically signed the contract—including a minor child and any attorney the patient hires—to the terms it spells out. A child can be bound by the mother in an agreement to arbitrate entered into during the prenatal period. In one case, a court interpreted the arbitration clause to apply to any claim arising from services under the agreement, even though the plaintiff had not been born when the agreement was signed.⁶ This case is of particular interest to ObGyns because it established a precedent that limits the right of children to sue even though they themselves never signed the agreement.

In another case,⁷ a spouse who did not sign the contract filed a lawsuit for loss of consortium due to a physician’s negligence. The court found that all claims arising from the alleged malpractice must be arbitrated when a patient signs a contract agreeing to arbitrate claims of negligence. Similarly, heirs in a wrongful death action were found to be bound by the decedent’s agreement to arbitrate when the contract required that claims by the “member’s heir or personal representative” be arbitrated.⁸

Can a contract be enforced retroactively?

ObGyns often have long-term relationships with patients. Or they may wish to implement the provisions described above after 1 or several prenatal visits. Is it possible to design a new contract to address past actions?

Maybe.

In California, there is a precedent for retroactive activation of an arbitration agreement. In 1993, the California Court of Appeals upheld an arbitration agreement that was defined for both future and retroactive treatment.⁹

Will a patient sign such a contract?

The short answer is “Yes.” Patients sign contracts all the time. They agree to pay their bill. They agree that records can be sent to referring physicians. They agree that they have made an informed decision about their care.

Medical Justice Services has a long track record of promoting such contracts as part of the physician–patient relationship. We have found that most patients are comfortable signing a contract that limits their right to sue to cases with clear merit and requires them to use reputable and accountable experts if there is a legitimate dispute. In this way, patients who deserve a remedy have full access to the courts.

Bringing up the topic of a contract before care is initiated is no more likely to create tension than a traditional informed consent discussion would. Most patients believe themselves to be reasonable and cannot imagine filing a lawsuit for an illegitimate reason.

By deterring unjustified litigation, the widespread use of contracts can help stabilize professional liability premiums, minimize the cost of health care, and preserve access to health care. In cerebral palsy litigation, where the stakes are high, 1 of the better ways to control the legal outcome is by means of a contract, especially when there is minimal or no evidence of NEACP criteria.

Questions keep coming in on the broad and complex subject of hiring employees. (If you missed any of the several columns I've written about hiring and firing, go to www.skinandallergynews.com

Several readers have asked about candidate interviews. As I've written before, the importance of thorough interviewing cannot be overemphasized.

The tendency of many physicians is to conduct superficial interviews—or even skip them entirely—and then hire the candidate they have the “best feeling” about. This probably leads to more bad hires than any other hiring mistake. And hiring the wrong person can be one of the most expensive mistakes you can make.

As every physician knows, hunches are no substitute for hard data. You need to be well prepared before conducting interviews. Know the job description and hiring criteria, carefully review resumes (highlighting items you would like to ask about), check references, and conduct thorough but efficient interviews.

Be alert for resume red flags: significant time gaps between jobs; positions at companies that are no longer in business or that are otherwise impossible to verify; job titles that don't make sense, given the applicant's history and qualifications. The interview can resolve such quandaries, or confirm them.

Conduct your interviews in a comfortable location and allocate a reasonable amount of time. I need about 30 minutes: 5 for getting acquainted, 15 to ask the questions I have prepared, and 5–10 for the candidate to ask me questions.

I always have an identical list of questions to ask all candidates, which gives me a level basis of comparison of candidates' answers; however, I also tailor questions for each individual, based on what I have discovered in resumes and other reference materials.

There are, of course, certain questions which by law cannot be asked, such as those related to gender, race, creed, religion, or national origin, but there are acceptable alternatives to many forbidden questions.

For example, you cannot ask an applicant's age or date of birth, but you can ask if he or she is over 18 years old. You cannot ask about specific disabilities, but it is legal to ask if the applicant is physically capable of performing the job's essential duties.

You cannot inquire about marital status, maiden name, or how many children an applicant has or who cares for them, but it is permissible to ask if the applicant has ever gone by another name (for employment history and background check). And while you can't ask if he or she is a U.S. citizen, you can ask if the applicant is legally authorized to work in the United States.

Rather than ask about past drug or alcohol addictions, you can ask about current addictions, but only to illegal drugs. Questions about arrest records are forbidden, but you may ask if the applicant has ever been convicted if the question is accompanied by a statement that an affirmative answer will not necessarily disqualify him or her from employment.

Other than those sorts of obligatory, specific questions, I try to be as nonspecific and open-ended in my questioning as possible. In the first edition of “Human Resources Kit for Dummies” (John Wiley & Sons, 1999), Max Messmer suggests some excellent general questions:

▸ What do you know about our practice and why do you want to work here?

▸ What interests you about this job and what skills and strengths can you bring to it?

▸ What would you describe as your greatest strengths as an employee? What are your greatest weaknesses?

▸ Who was your best boss ever and why? Who was your worst boss, and looking back, what could you have done to make the relationship better?

▸ How do you think that best boss would describe you? What about the worst boss?

▸ What do you think was your single greatest achievement on the job? What was your worst failure?

▸ Where do you see yourself and your career in 3 years?

▸ Can you tell me about an important decision you made and how you arrived at it?

▸ How do you handle conflict? Can you give me an example of how you handled workplace conflict in the past?

The idea is to avoid leading questions, which tend to elicit exactly the answers you want to hear, which lead, in turn, to snap judgments.

Conversely, the questions a candidate asks can be very helpful in making your decision. Candidates who go beyond the basic salary/benefits questions, who show evidence they have done their research about your practice, can offer important insights into their values, goals, and aspirations as well as their analytical abilities and true desire to work for you.

Questions keep coming in on the broad and complex subject of hiring employees. (If you missed any of the several columns I've written about hiring and firing, go to www.skinandallergynews.com

Several readers have asked about candidate interviews. As I've written before, the importance of thorough interviewing cannot be overemphasized.

The tendency of many physicians is to conduct superficial interviews—or even skip them entirely—and then hire the candidate they have the “best feeling” about. This probably leads to more bad hires than any other hiring mistake. And hiring the wrong person can be one of the most expensive mistakes you can make.

As every physician knows, hunches are no substitute for hard data. You need to be well prepared before conducting interviews. Know the job description and hiring criteria, carefully review resumes (highlighting items you would like to ask about), check references, and conduct thorough but efficient interviews.

Be alert for resume red flags: significant time gaps between jobs; positions at companies that are no longer in business or that are otherwise impossible to verify; job titles that don't make sense, given the applicant's history and qualifications. The interview can resolve such quandaries, or confirm them.

Conduct your interviews in a comfortable location and allocate a reasonable amount of time. I need about 30 minutes: 5 for getting acquainted, 15 to ask the questions I have prepared, and 5–10 for the candidate to ask me questions.

I always have an identical list of questions to ask all candidates, which gives me a level basis of comparison of candidates' answers; however, I also tailor questions for each individual, based on what I have discovered in resumes and other reference materials.

There are, of course, certain questions which by law cannot be asked, such as those related to gender, race, creed, religion, or national origin, but there are acceptable alternatives to many forbidden questions.

For example, you cannot ask an applicant's age or date of birth, but you can ask if he or she is over 18 years old. You cannot ask about specific disabilities, but it is legal to ask if the applicant is physically capable of performing the job's essential duties.

You cannot inquire about marital status, maiden name, or how many children an applicant has or who cares for them, but it is permissible to ask if the applicant has ever gone by another name (for employment history and background check). And while you can't ask if he or she is a U.S. citizen, you can ask if the applicant is legally authorized to work in the United States.

Rather than ask about past drug or alcohol addictions, you can ask about current addictions, but only to illegal drugs. Questions about arrest records are forbidden, but you may ask if the applicant has ever been convicted if the question is accompanied by a statement that an affirmative answer will not necessarily disqualify him or her from employment.

Other than those sorts of obligatory, specific questions, I try to be as nonspecific and open-ended in my questioning as possible. In the first edition of “Human Resources Kit for Dummies” (John Wiley & Sons, 1999), Max Messmer suggests some excellent general questions:

▸ What do you know about our practice and why do you want to work here?

▸ What interests you about this job and what skills and strengths can you bring to it?

▸ What would you describe as your greatest strengths as an employee? What are your greatest weaknesses?

▸ Who was your best boss ever and why? Who was your worst boss, and looking back, what could you have done to make the relationship better?

▸ How do you think that best boss would describe you? What about the worst boss?

▸ What do you think was your single greatest achievement on the job? What was your worst failure?

▸ Where do you see yourself and your career in 3 years?

▸ Can you tell me about an important decision you made and how you arrived at it?

▸ How do you handle conflict? Can you give me an example of how you handled workplace conflict in the past?

The idea is to avoid leading questions, which tend to elicit exactly the answers you want to hear, which lead, in turn, to snap judgments.

Conversely, the questions a candidate asks can be very helpful in making your decision. Candidates who go beyond the basic salary/benefits questions, who show evidence they have done their research about your practice, can offer important insights into their values, goals, and aspirations as well as their analytical abilities and true desire to work for you.

Questions keep coming in on the broad and complex subject of hiring employees. (If you missed any of the several columns I've written about hiring and firing, go to www.skinandallergynews.com

Several readers have asked about candidate interviews. As I've written before, the importance of thorough interviewing cannot be overemphasized.

The tendency of many physicians is to conduct superficial interviews—or even skip them entirely—and then hire the candidate they have the “best feeling” about. This probably leads to more bad hires than any other hiring mistake. And hiring the wrong person can be one of the most expensive mistakes you can make.

As every physician knows, hunches are no substitute for hard data. You need to be well prepared before conducting interviews. Know the job description and hiring criteria, carefully review resumes (highlighting items you would like to ask about), check references, and conduct thorough but efficient interviews.

Be alert for resume red flags: significant time gaps between jobs; positions at companies that are no longer in business or that are otherwise impossible to verify; job titles that don't make sense, given the applicant's history and qualifications. The interview can resolve such quandaries, or confirm them.

Conduct your interviews in a comfortable location and allocate a reasonable amount of time. I need about 30 minutes: 5 for getting acquainted, 15 to ask the questions I have prepared, and 5–10 for the candidate to ask me questions.

I always have an identical list of questions to ask all candidates, which gives me a level basis of comparison of candidates' answers; however, I also tailor questions for each individual, based on what I have discovered in resumes and other reference materials.

There are, of course, certain questions which by law cannot be asked, such as those related to gender, race, creed, religion, or national origin, but there are acceptable alternatives to many forbidden questions.

For example, you cannot ask an applicant's age or date of birth, but you can ask if he or she is over 18 years old. You cannot ask about specific disabilities, but it is legal to ask if the applicant is physically capable of performing the job's essential duties.

You cannot inquire about marital status, maiden name, or how many children an applicant has or who cares for them, but it is permissible to ask if the applicant has ever gone by another name (for employment history and background check). And while you can't ask if he or she is a U.S. citizen, you can ask if the applicant is legally authorized to work in the United States.

Rather than ask about past drug or alcohol addictions, you can ask about current addictions, but only to illegal drugs. Questions about arrest records are forbidden, but you may ask if the applicant has ever been convicted if the question is accompanied by a statement that an affirmative answer will not necessarily disqualify him or her from employment.

Other than those sorts of obligatory, specific questions, I try to be as nonspecific and open-ended in my questioning as possible. In the first edition of “Human Resources Kit for Dummies” (John Wiley & Sons, 1999), Max Messmer suggests some excellent general questions:

▸ What do you know about our practice and why do you want to work here?

▸ What interests you about this job and what skills and strengths can you bring to it?

▸ What would you describe as your greatest strengths as an employee? What are your greatest weaknesses?

▸ Who was your best boss ever and why? Who was your worst boss, and looking back, what could you have done to make the relationship better?

▸ How do you think that best boss would describe you? What about the worst boss?

▸ What do you think was your single greatest achievement on the job? What was your worst failure?

▸ Where do you see yourself and your career in 3 years?

▸ Can you tell me about an important decision you made and how you arrived at it?

▸ How do you handle conflict? Can you give me an example of how you handled workplace conflict in the past?

The idea is to avoid leading questions, which tend to elicit exactly the answers you want to hear, which lead, in turn, to snap judgments.

Conversely, the questions a candidate asks can be very helpful in making your decision. Candidates who go beyond the basic salary/benefits questions, who show evidence they have done their research about your practice, can offer important insights into their values, goals, and aspirations as well as their analytical abilities and true desire to work for you.