The Office

The latest anniversary of my birth is fast approaching; but fortunately, I have learned to celebrate these annual events rather than dread them. I now understand that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also found that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years and to determine whether any of them need updating.

Estate plans, in particular, need regular review and revision. Nothing important has changed in your life since you drafted your will, you say? Well, chances are the laws have changed; or, other factors may have rendered your plan obsolete without your even realizing it.

I am assuming, of course, that you have in fact drafted a will. If not, do it now. Things happen; if you die without one ("intestate," in lawyers’ lingo), your heirs will be at the mercy of attorneys, bureaucrats, state and federal laws, and greed. Quarrels will ensue; decisions will be made that are almost certainly at variance with what you would have wanted; and a substantial chunk of your estate, which could have gone to loved ones or to charity, will be lost to taxes and fees. If you don’t have a will, regardless of your age or current financial status, have one written at your earliest possible convenience.

That said, let’s consider some variables that mandate your constant vigilance:

• Laws change. Trust laws, in particular, have changed a great deal in recent years, and trust strategies have changed with them. New instruments like perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won\'t know without asking. State laws change, too, all the time.

Once a year my wife and I meet with our estate lawyer to learn about any new legislation that may have affected our plan. Last year, I learned that my irrevocable trust is no longer irrevocable; new laws now permit certain provisions to be modified.

Laws that don’t directly regulate wills and trusts can affect them as well. For instance, the ever-popular Health Insurance Portability and Accountability Act (HIPAA) affects your estate as well as your practice; under its provisions, your family cannot access your medical information or make treatment and life-support decisions without your specific permission. So if a Health Care Power of Attorney is not already part of your will, add it. And remember to modify it if your medical status, or your philosophy of life, change.

• Financial markets change. It’s not exactly a secret that asset values and interest rates are way different than they were even a few years ago. Real estate or securities bequests could now be significantly larger, or smaller. Your accountant and estate lawyer should take a look at your assets periodically and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if the value doesn’t. Let’s say you sell a business or property and reinvest the proceeds in something completely different; that will change how you leave that asset to your heirs, because a different set of tax laws will apply.

• Fiduciaries change. The executor of your estate and the trustee(s) of your trust(s) need periodic review. If your brother-in-law is your executor, and your sister divorces him, you may want to find a new executor. A once-vigorous trustee who is now old or sick should be replaced. Trustees are often financial institutions; if one of your corporate trustees goes belly up, or the employee you were working with retires or changes firms, you’ll need a replacement. Keep track of your fiduciaries and be prepared to make changes as needed.

• Personal circumstances change. Some changes – marriage, divorce, the death of an heir, or the birth of a new one – obviously require modifications to wills and trusts. But any significant alteration of your personal or financial circumstances probably merits at least a phone call to your financial planners. The need for changes, and your options should changes be necessary, are not always obvious.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is a clinical associate professor of dermatology at Seton Hall University School of Graduate Medical Education in South Orange, N.J. Dr. Eastern is a two-time past-president of the Dermatological Society of New Jersey and currently serves on its executive board. He holds teaching positions at a number of hospitals and has delivered more than 500 academic speaking presentations. He is the author of numerous articles and textbook chapters and is a long-time monthly columnist for Skin & Allergy News, a publication of IMNG Medical Media.

The latest anniversary of my birth is fast approaching; but fortunately, I have learned to celebrate these annual events rather than dread them. I now understand that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also found that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years and to determine whether any of them need updating.

Estate plans, in particular, need regular review and revision. Nothing important has changed in your life since you drafted your will, you say? Well, chances are the laws have changed; or, other factors may have rendered your plan obsolete without your even realizing it.

I am assuming, of course, that you have in fact drafted a will. If not, do it now. Things happen; if you die without one ("intestate," in lawyers’ lingo), your heirs will be at the mercy of attorneys, bureaucrats, state and federal laws, and greed. Quarrels will ensue; decisions will be made that are almost certainly at variance with what you would have wanted; and a substantial chunk of your estate, which could have gone to loved ones or to charity, will be lost to taxes and fees. If you don’t have a will, regardless of your age or current financial status, have one written at your earliest possible convenience.

That said, let’s consider some variables that mandate your constant vigilance:

• Laws change. Trust laws, in particular, have changed a great deal in recent years, and trust strategies have changed with them. New instruments like perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won\'t know without asking. State laws change, too, all the time.

Once a year my wife and I meet with our estate lawyer to learn about any new legislation that may have affected our plan. Last year, I learned that my irrevocable trust is no longer irrevocable; new laws now permit certain provisions to be modified.

Laws that don’t directly regulate wills and trusts can affect them as well. For instance, the ever-popular Health Insurance Portability and Accountability Act (HIPAA) affects your estate as well as your practice; under its provisions, your family cannot access your medical information or make treatment and life-support decisions without your specific permission. So if a Health Care Power of Attorney is not already part of your will, add it. And remember to modify it if your medical status, or your philosophy of life, change.

• Financial markets change. It’s not exactly a secret that asset values and interest rates are way different than they were even a few years ago. Real estate or securities bequests could now be significantly larger, or smaller. Your accountant and estate lawyer should take a look at your assets periodically and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if the value doesn’t. Let’s say you sell a business or property and reinvest the proceeds in something completely different; that will change how you leave that asset to your heirs, because a different set of tax laws will apply.

• Fiduciaries change. The executor of your estate and the trustee(s) of your trust(s) need periodic review. If your brother-in-law is your executor, and your sister divorces him, you may want to find a new executor. A once-vigorous trustee who is now old or sick should be replaced. Trustees are often financial institutions; if one of your corporate trustees goes belly up, or the employee you were working with retires or changes firms, you’ll need a replacement. Keep track of your fiduciaries and be prepared to make changes as needed.

• Personal circumstances change. Some changes – marriage, divorce, the death of an heir, or the birth of a new one – obviously require modifications to wills and trusts. But any significant alteration of your personal or financial circumstances probably merits at least a phone call to your financial planners. The need for changes, and your options should changes be necessary, are not always obvious.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is a clinical associate professor of dermatology at Seton Hall University School of Graduate Medical Education in South Orange, N.J. Dr. Eastern is a two-time past-president of the Dermatological Society of New Jersey and currently serves on its executive board. He holds teaching positions at a number of hospitals and has delivered more than 500 academic speaking presentations. He is the author of numerous articles and textbook chapters and is a long-time monthly columnist for Skin & Allergy News, a publication of IMNG Medical Media.

The latest anniversary of my birth is fast approaching; but fortunately, I have learned to celebrate these annual events rather than dread them. I now understand that life gets better as we get older, on all levels – except, perhaps, the physical.

But I have also found that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years and to determine whether any of them need updating.

Estate plans, in particular, need regular review and revision. Nothing important has changed in your life since you drafted your will, you say? Well, chances are the laws have changed; or, other factors may have rendered your plan obsolete without your even realizing it.

I am assuming, of course, that you have in fact drafted a will. If not, do it now. Things happen; if you die without one ("intestate," in lawyers’ lingo), your heirs will be at the mercy of attorneys, bureaucrats, state and federal laws, and greed. Quarrels will ensue; decisions will be made that are almost certainly at variance with what you would have wanted; and a substantial chunk of your estate, which could have gone to loved ones or to charity, will be lost to taxes and fees. If you don’t have a will, regardless of your age or current financial status, have one written at your earliest possible convenience.

That said, let’s consider some variables that mandate your constant vigilance:

• Laws change. Trust laws, in particular, have changed a great deal in recent years, and trust strategies have changed with them. New instruments like perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won\'t know without asking. State laws change, too, all the time.

Once a year my wife and I meet with our estate lawyer to learn about any new legislation that may have affected our plan. Last year, I learned that my irrevocable trust is no longer irrevocable; new laws now permit certain provisions to be modified.

Laws that don’t directly regulate wills and trusts can affect them as well. For instance, the ever-popular Health Insurance Portability and Accountability Act (HIPAA) affects your estate as well as your practice; under its provisions, your family cannot access your medical information or make treatment and life-support decisions without your specific permission. So if a Health Care Power of Attorney is not already part of your will, add it. And remember to modify it if your medical status, or your philosophy of life, change.

• Financial markets change. It’s not exactly a secret that asset values and interest rates are way different than they were even a few years ago. Real estate or securities bequests could now be significantly larger, or smaller. Your accountant and estate lawyer should take a look at your assets periodically and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if the value doesn’t. Let’s say you sell a business or property and reinvest the proceeds in something completely different; that will change how you leave that asset to your heirs, because a different set of tax laws will apply.

• Fiduciaries change. The executor of your estate and the trustee(s) of your trust(s) need periodic review. If your brother-in-law is your executor, and your sister divorces him, you may want to find a new executor. A once-vigorous trustee who is now old or sick should be replaced. Trustees are often financial institutions; if one of your corporate trustees goes belly up, or the employee you were working with retires or changes firms, you’ll need a replacement. Keep track of your fiduciaries and be prepared to make changes as needed.

• Personal circumstances change. Some changes – marriage, divorce, the death of an heir, or the birth of a new one – obviously require modifications to wills and trusts. But any significant alteration of your personal or financial circumstances probably merits at least a phone call to your financial planners. The need for changes, and your options should changes be necessary, are not always obvious.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is a clinical associate professor of dermatology at Seton Hall University School of Graduate Medical Education in South Orange, N.J. Dr. Eastern is a two-time past-president of the Dermatological Society of New Jersey and currently serves on its executive board. He holds teaching positions at a number of hospitals and has delivered more than 500 academic speaking presentations. He is the author of numerous articles and textbook chapters and is a long-time monthly columnist for Skin & Allergy News, a publication of IMNG Medical Media.

Tough economic times and the unpredictable consequences of health care reform are making a growing number of solo practitioners and small private groups very nervous. I’ve been receiving many inquiries about protective options, such as joining a multispecialty group, or merging two or more small practices into larger entities.

If becoming an employee of a large corporation does not appeal to you, a merger can offer significant advantages in stabilization of income and expenses; but careful planning – and a written agreement – is essential.

If you are considering this option, here are some things to think about.

• What is the compensation formula? Will everyone be paid only for what they do individually, or will revenue be shared equally? I favor a combination, so productivity is rewarded but your income doesn’t drop to zero when you take time off.

• Who will be in charge, and what percentage vote will be needed to approve important decisions? Typically, the majority rules; but you may wish to create a list of pivotal moves that will require unanimous approval, such as purchasing expensive equipment, borrowing money, or adding new partners.

• Will you keep your retirement plans separate, or combine them? If the latter, you will have to agree on the terms of the new plan, which can be the same as or different from any of the existing plans. You’ll probably need some legal guidance to ensure that assets from existing plans can be transferred into a new plan without tax issues.

If both practices are incorporated, there are two basic options for combining them. Corporation A can simply absorb corporation B; the latter ceases to exist, and corporation A, the so-called "surviving entity," assumes all assets and liabilities of both old corporations. Corporation B shareholders exchange shares of its stock for shares of corporation A, with adjustments for any inequalities in stock value.

The second option is to start a completely new corporation, which I’ll call corporation C. Corporations A and B dissolve, and distribute their equipment and charts to their shareholders, who then transfer the assets to corporation C.

Option 2 is popular, but I am not a fan. It is billed as an opportunity to start fresh, shielding everyone from exposure to malpractice suits and other liabilities, but the reality is, anyone looking to sue either old corporation will simply sue corporation C as the so-called "successor" corporation, on the grounds that it has assumed responsibility for its predecessors’ liabilities. You also will need new provider numbers, which may impede cash flow for months. Plus, the IRS treats corporate liquidations, even for merger purposes, as sales of assets, and taxes them.

In general, most experts that I’ve talked with favor the outright merger of corporations; it is tax neutral, and while it may theoretically be less satisfactory liability-wise, you can minimize risk by examining financial and legal records, and by identifying any glaring flaws in charting or coding. Your lawyers can add "hold harmless" clauses to the merger agreement, indemnifying each party against the others’ liabilities. This area, especially, is where you need experienced, competent legal advice.

Another common sticking point is known as "equalization." Ideally, each party brings an equal amount of assets to the table, but in the real world that is hardly ever the case. One party may contribute more equipment, for example, and the others are often asked to make up the difference ("equalize") with something else, usually cash.

An alternative is to agree that any inequalities will be compensated at the other end, in the form of buyout value; that is, physicians contributing more assets will receive larger buyouts when they leave or retire than those contributing less.

Non-compete provisions are always a difficult issue, mostly because they are so hard (and expensive) to enforce. An increasingly popular alternative is, once again, to deal with it at the other end, with a buyout penalty. An unhappy partner can leave, and compete, but at the cost of a substantially reduced buyout. This permits competition, but discourages it; and it compensates the remaining partners.

These are only some of the pivotal business and legal issues that must be settled in advance. A little planning and negotiation can prevent a lot of grief, regret, and legal expenses in the future.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Tough economic times and the unpredictable consequences of health care reform are making a growing number of solo practitioners and small private groups very nervous. I’ve been receiving many inquiries about protective options, such as joining a multispecialty group, or merging two or more small practices into larger entities.

If becoming an employee of a large corporation does not appeal to you, a merger can offer significant advantages in stabilization of income and expenses; but careful planning – and a written agreement – is essential.

If you are considering this option, here are some things to think about.

• What is the compensation formula? Will everyone be paid only for what they do individually, or will revenue be shared equally? I favor a combination, so productivity is rewarded but your income doesn’t drop to zero when you take time off.

• Who will be in charge, and what percentage vote will be needed to approve important decisions? Typically, the majority rules; but you may wish to create a list of pivotal moves that will require unanimous approval, such as purchasing expensive equipment, borrowing money, or adding new partners.

• Will you keep your retirement plans separate, or combine them? If the latter, you will have to agree on the terms of the new plan, which can be the same as or different from any of the existing plans. You’ll probably need some legal guidance to ensure that assets from existing plans can be transferred into a new plan without tax issues.

If both practices are incorporated, there are two basic options for combining them. Corporation A can simply absorb corporation B; the latter ceases to exist, and corporation A, the so-called "surviving entity," assumes all assets and liabilities of both old corporations. Corporation B shareholders exchange shares of its stock for shares of corporation A, with adjustments for any inequalities in stock value.

The second option is to start a completely new corporation, which I’ll call corporation C. Corporations A and B dissolve, and distribute their equipment and charts to their shareholders, who then transfer the assets to corporation C.

Option 2 is popular, but I am not a fan. It is billed as an opportunity to start fresh, shielding everyone from exposure to malpractice suits and other liabilities, but the reality is, anyone looking to sue either old corporation will simply sue corporation C as the so-called "successor" corporation, on the grounds that it has assumed responsibility for its predecessors’ liabilities. You also will need new provider numbers, which may impede cash flow for months. Plus, the IRS treats corporate liquidations, even for merger purposes, as sales of assets, and taxes them.

In general, most experts that I’ve talked with favor the outright merger of corporations; it is tax neutral, and while it may theoretically be less satisfactory liability-wise, you can minimize risk by examining financial and legal records, and by identifying any glaring flaws in charting or coding. Your lawyers can add "hold harmless" clauses to the merger agreement, indemnifying each party against the others’ liabilities. This area, especially, is where you need experienced, competent legal advice.

Another common sticking point is known as "equalization." Ideally, each party brings an equal amount of assets to the table, but in the real world that is hardly ever the case. One party may contribute more equipment, for example, and the others are often asked to make up the difference ("equalize") with something else, usually cash.

An alternative is to agree that any inequalities will be compensated at the other end, in the form of buyout value; that is, physicians contributing more assets will receive larger buyouts when they leave or retire than those contributing less.

Non-compete provisions are always a difficult issue, mostly because they are so hard (and expensive) to enforce. An increasingly popular alternative is, once again, to deal with it at the other end, with a buyout penalty. An unhappy partner can leave, and compete, but at the cost of a substantially reduced buyout. This permits competition, but discourages it; and it compensates the remaining partners.

These are only some of the pivotal business and legal issues that must be settled in advance. A little planning and negotiation can prevent a lot of grief, regret, and legal expenses in the future.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Tough economic times and the unpredictable consequences of health care reform are making a growing number of solo practitioners and small private groups very nervous. I’ve been receiving many inquiries about protective options, such as joining a multispecialty group, or merging two or more small practices into larger entities.

If becoming an employee of a large corporation does not appeal to you, a merger can offer significant advantages in stabilization of income and expenses; but careful planning – and a written agreement – is essential.

If you are considering this option, here are some things to think about.

• What is the compensation formula? Will everyone be paid only for what they do individually, or will revenue be shared equally? I favor a combination, so productivity is rewarded but your income doesn’t drop to zero when you take time off.

• Who will be in charge, and what percentage vote will be needed to approve important decisions? Typically, the majority rules; but you may wish to create a list of pivotal moves that will require unanimous approval, such as purchasing expensive equipment, borrowing money, or adding new partners.

• Will you keep your retirement plans separate, or combine them? If the latter, you will have to agree on the terms of the new plan, which can be the same as or different from any of the existing plans. You’ll probably need some legal guidance to ensure that assets from existing plans can be transferred into a new plan without tax issues.

If both practices are incorporated, there are two basic options for combining them. Corporation A can simply absorb corporation B; the latter ceases to exist, and corporation A, the so-called "surviving entity," assumes all assets and liabilities of both old corporations. Corporation B shareholders exchange shares of its stock for shares of corporation A, with adjustments for any inequalities in stock value.

The second option is to start a completely new corporation, which I’ll call corporation C. Corporations A and B dissolve, and distribute their equipment and charts to their shareholders, who then transfer the assets to corporation C.

Option 2 is popular, but I am not a fan. It is billed as an opportunity to start fresh, shielding everyone from exposure to malpractice suits and other liabilities, but the reality is, anyone looking to sue either old corporation will simply sue corporation C as the so-called "successor" corporation, on the grounds that it has assumed responsibility for its predecessors’ liabilities. You also will need new provider numbers, which may impede cash flow for months. Plus, the IRS treats corporate liquidations, even for merger purposes, as sales of assets, and taxes them.

In general, most experts that I’ve talked with favor the outright merger of corporations; it is tax neutral, and while it may theoretically be less satisfactory liability-wise, you can minimize risk by examining financial and legal records, and by identifying any glaring flaws in charting or coding. Your lawyers can add "hold harmless" clauses to the merger agreement, indemnifying each party against the others’ liabilities. This area, especially, is where you need experienced, competent legal advice.

Another common sticking point is known as "equalization." Ideally, each party brings an equal amount of assets to the table, but in the real world that is hardly ever the case. One party may contribute more equipment, for example, and the others are often asked to make up the difference ("equalize") with something else, usually cash.

An alternative is to agree that any inequalities will be compensated at the other end, in the form of buyout value; that is, physicians contributing more assets will receive larger buyouts when they leave or retire than those contributing less.

Non-compete provisions are always a difficult issue, mostly because they are so hard (and expensive) to enforce. An increasingly popular alternative is, once again, to deal with it at the other end, with a buyout penalty. An unhappy partner can leave, and compete, but at the cost of a substantially reduced buyout. This permits competition, but discourages it; and it compensates the remaining partners.

These are only some of the pivotal business and legal issues that must be settled in advance. A little planning and negotiation can prevent a lot of grief, regret, and legal expenses in the future.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

This month, yet another new bureaucracy unfolds: Under the Physician Payment Sunshine Act – part of the Affordable Care Act – manufacturers of drugs, devices, and biological and medical supplies covered by federal health care programs are now required to begin reporting financial interactions with physicians and teaching hospitals to the Centers for Medicare and Medicaid Services.

Ownership or investment interests in the manufacturers by physicians and their family members also must be disclosed. Most of the data will be published online by September 2014.

In addition to reporting the type of financial exchange and the dollar amount, manufacturers are required to report the reason for the interaction, including consulting, food, ownership or investment interest, direct compensation for speakers at education programs (whether or not they are accredited or certified), and research. There are exclusions, including drug samples intended for distribution to patients. Medical students and residents are excluded entirely. You will be allowed to review your data and seek corrections before it is published; and you will have an additional 2 years to pursue corrections.

Compensation for conducting clinical trials will be reported, but not posted on the website until the product receives Food and Drug Administration approval, or until 4 years after the payment, whichever is earlier. Payments for trials involving a new indication for an approved drug will be posted immediately.

So what will be the likely effects on research, industry-sponsored meetings, meals provided by drug reps, and the like? The short answer is that no one knows. Much will depend on how the information is reported, and how patients interpret the data that they see – if they take notice at all.

Sunshine laws are already in effect in six states – California, Colorado, Massachusetts, Minnesota, Vermont, and West Virginia – and the District of Columbia. (Maine repealed its law in 2011.) Observers disagree on their impact. Data from Maine and West Virginia showed no significant changes in prescribing patterns after the laws took effect, according to a 2012 article in Archives of Internal Medicine (now JAMA Internal Medicine).

Evidence indicates that physicians have already decreased their industry interaction on their own: About a quarter of all private practices now refuse to see pharmaceutical reps; most medical schools prohibit samples, gifts, and on-site meals, and many prohibit on-site interaction of any kind between reps and residents.

How the disclosure legislation translates into physician-patient interaction remains equally unclear. Do patients think less of doctors who accept the occasional industry-sponsored lunch for their employees? Do they think more of doctors who conduct industry-sponsored clinical research? There are no objective data, so far as I know.

My guess – based on no evidence but 30 years of experience – is that attorneys, activists, and the occasional reporter will data-mine the website, but few patients will ever bother to visit. Nevertheless, you should prepare now to ensure the accuracy of anything posted about you when the database launches next year. Mark your calendar; the data must be reported to the CMS by March 31 annually, so you will need to set aside time each April or May to review it. If you have many or complex industry relationships, you should probably contact each of the manufacturers in January or February and ask to see the data before they are submitted. Then review the information again once the CMS gets it, to be sure nothing was changed. Maintaining accurate financial records has always been important, but it will be even more so now, to effectively dispute any inconsistencies.

If you don’t see drug reps or give sponsored talks, don’t assume that you won’t be on the website. Check anyway; you might be indirectly involved in compensation that you were not aware of, or you may have been reported in error.

Pharmaceutical companies face stiff penalties if they do not comply with the Sunshine Act. Those that fail to report can be fined up to $150,000 annually, and those fines can rise to $1 million for those that intentionally fail to report. This means that the information will be disclosed. If you have any financial relationships with the pharmaceutical industry, you will need to anticipate the implications of the increased scrutiny that may (or may not) result.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

This month, yet another new bureaucracy unfolds: Under the Physician Payment Sunshine Act – part of the Affordable Care Act – manufacturers of drugs, devices, and biological and medical supplies covered by federal health care programs are now required to begin reporting financial interactions with physicians and teaching hospitals to the Centers for Medicare and Medicaid Services.

Ownership or investment interests in the manufacturers by physicians and their family members also must be disclosed. Most of the data will be published online by September 2014.

In addition to reporting the type of financial exchange and the dollar amount, manufacturers are required to report the reason for the interaction, including consulting, food, ownership or investment interest, direct compensation for speakers at education programs (whether or not they are accredited or certified), and research. There are exclusions, including drug samples intended for distribution to patients. Medical students and residents are excluded entirely. You will be allowed to review your data and seek corrections before it is published; and you will have an additional 2 years to pursue corrections.

Compensation for conducting clinical trials will be reported, but not posted on the website until the product receives Food and Drug Administration approval, or until 4 years after the payment, whichever is earlier. Payments for trials involving a new indication for an approved drug will be posted immediately.

So what will be the likely effects on research, industry-sponsored meetings, meals provided by drug reps, and the like? The short answer is that no one knows. Much will depend on how the information is reported, and how patients interpret the data that they see – if they take notice at all.

Sunshine laws are already in effect in six states – California, Colorado, Massachusetts, Minnesota, Vermont, and West Virginia – and the District of Columbia. (Maine repealed its law in 2011.) Observers disagree on their impact. Data from Maine and West Virginia showed no significant changes in prescribing patterns after the laws took effect, according to a 2012 article in Archives of Internal Medicine (now JAMA Internal Medicine).

Evidence indicates that physicians have already decreased their industry interaction on their own: About a quarter of all private practices now refuse to see pharmaceutical reps; most medical schools prohibit samples, gifts, and on-site meals, and many prohibit on-site interaction of any kind between reps and residents.

How the disclosure legislation translates into physician-patient interaction remains equally unclear. Do patients think less of doctors who accept the occasional industry-sponsored lunch for their employees? Do they think more of doctors who conduct industry-sponsored clinical research? There are no objective data, so far as I know.

My guess – based on no evidence but 30 years of experience – is that attorneys, activists, and the occasional reporter will data-mine the website, but few patients will ever bother to visit. Nevertheless, you should prepare now to ensure the accuracy of anything posted about you when the database launches next year. Mark your calendar; the data must be reported to the CMS by March 31 annually, so you will need to set aside time each April or May to review it. If you have many or complex industry relationships, you should probably contact each of the manufacturers in January or February and ask to see the data before they are submitted. Then review the information again once the CMS gets it, to be sure nothing was changed. Maintaining accurate financial records has always been important, but it will be even more so now, to effectively dispute any inconsistencies.

If you don’t see drug reps or give sponsored talks, don’t assume that you won’t be on the website. Check anyway; you might be indirectly involved in compensation that you were not aware of, or you may have been reported in error.

Pharmaceutical companies face stiff penalties if they do not comply with the Sunshine Act. Those that fail to report can be fined up to $150,000 annually, and those fines can rise to $1 million for those that intentionally fail to report. This means that the information will be disclosed. If you have any financial relationships with the pharmaceutical industry, you will need to anticipate the implications of the increased scrutiny that may (or may not) result.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

This month, yet another new bureaucracy unfolds: Under the Physician Payment Sunshine Act – part of the Affordable Care Act – manufacturers of drugs, devices, and biological and medical supplies covered by federal health care programs are now required to begin reporting financial interactions with physicians and teaching hospitals to the Centers for Medicare and Medicaid Services.

Ownership or investment interests in the manufacturers by physicians and their family members also must be disclosed. Most of the data will be published online by September 2014.

In addition to reporting the type of financial exchange and the dollar amount, manufacturers are required to report the reason for the interaction, including consulting, food, ownership or investment interest, direct compensation for speakers at education programs (whether or not they are accredited or certified), and research. There are exclusions, including drug samples intended for distribution to patients. Medical students and residents are excluded entirely. You will be allowed to review your data and seek corrections before it is published; and you will have an additional 2 years to pursue corrections.

Compensation for conducting clinical trials will be reported, but not posted on the website until the product receives Food and Drug Administration approval, or until 4 years after the payment, whichever is earlier. Payments for trials involving a new indication for an approved drug will be posted immediately.

So what will be the likely effects on research, industry-sponsored meetings, meals provided by drug reps, and the like? The short answer is that no one knows. Much will depend on how the information is reported, and how patients interpret the data that they see – if they take notice at all.

Sunshine laws are already in effect in six states – California, Colorado, Massachusetts, Minnesota, Vermont, and West Virginia – and the District of Columbia. (Maine repealed its law in 2011.) Observers disagree on their impact. Data from Maine and West Virginia showed no significant changes in prescribing patterns after the laws took effect, according to a 2012 article in Archives of Internal Medicine (now JAMA Internal Medicine).

Evidence indicates that physicians have already decreased their industry interaction on their own: About a quarter of all private practices now refuse to see pharmaceutical reps; most medical schools prohibit samples, gifts, and on-site meals, and many prohibit on-site interaction of any kind between reps and residents.

How the disclosure legislation translates into physician-patient interaction remains equally unclear. Do patients think less of doctors who accept the occasional industry-sponsored lunch for their employees? Do they think more of doctors who conduct industry-sponsored clinical research? There are no objective data, so far as I know.

My guess – based on no evidence but 30 years of experience – is that attorneys, activists, and the occasional reporter will data-mine the website, but few patients will ever bother to visit. Nevertheless, you should prepare now to ensure the accuracy of anything posted about you when the database launches next year. Mark your calendar; the data must be reported to the CMS by March 31 annually, so you will need to set aside time each April or May to review it. If you have many or complex industry relationships, you should probably contact each of the manufacturers in January or February and ask to see the data before they are submitted. Then review the information again once the CMS gets it, to be sure nothing was changed. Maintaining accurate financial records has always been important, but it will be even more so now, to effectively dispute any inconsistencies.

If you don’t see drug reps or give sponsored talks, don’t assume that you won’t be on the website. Check anyway; you might be indirectly involved in compensation that you were not aware of, or you may have been reported in error.

Pharmaceutical companies face stiff penalties if they do not comply with the Sunshine Act. Those that fail to report can be fined up to $150,000 annually, and those fines can rise to $1 million for those that intentionally fail to report. This means that the information will be disclosed. If you have any financial relationships with the pharmaceutical industry, you will need to anticipate the implications of the increased scrutiny that may (or may not) result.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

I’m hearing a lot of concern about the impending changes in the Health Insurance Portability and Accountability Act (HIPAA) – which is understandable, since the Department of Health and Human Services has presented them as "the most sweeping ... since [the Act] was first implemented."

But after a careful perusal of the new rules – all 150 three-column pages of them – I can say with a modest degree of confidence that for most physicians, compliance will not be as challenging as some (such as those trying to sell you compliance-related materials) have warned.

However, you can’t simply ignore the new regulations; definitions will be more complex, security breaches more liberally defined, and potential penalties will be stiffer. Herewith the salient points:

• Business associates. The criteria for identifying "business associates" (BAs) remain the same: nonemployees, performing "functions or activities" on behalf of the "covered entity" (your practice), that involve "creating, receiving, maintaining, or transmitting" personal health information (PHI).

Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services are BAs if they must have direct access to PHI to do their jobs.

Mail carriers, package-delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs, even though they might conceivably come in contact with PHI on occasion. You are required to use "reasonable diligence" in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.

Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement; just train them, as you do your employees. (I’ll have more on HIPAA and OSHA training in a future column.)

What is new is the additional onus placed on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract. You are expected to use "reasonable diligence" in monitoring the work of your BAs. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is ours. Let’s say that a contractor you hire to shred old medical records throws them into a trash bin instead; under the new rules, you must assume the worst-case scenario. Previously, you would only have to notify affected patients (and the government) if there was a "significant risk of financial or reputational harm," but now, any incident involving patient records is assumed to be a breach, and must be reported. Failure to do so could subject your practice, as well as the contractor, to significant fines – as high as $1 million in egregious cases.

• New patient rights. Patients will now be able to restrict the PHI shared with third-party insurers and health plans if they pay for the services themselves. They also have the right to request copies of their electronic health records, and you can bill the actual costs of responding to such a request. If you have EHR, now might be a good time to work out a system for doing this, because the response time has been decreased from 90 to 30 days – even less in some states.

• Marketing limitations. The new rule prohibits third-party-funded marketing to patients for products and services without their prior written authorization. You do not need prior authorization to market your own products and services, even when the communication is funded by a third party, but if there is any such funding, you will need to disclose it.

• Notice of privacy practices (NPP). You will need to revise your NPP to explain your relationships with BAs, and their status under the new rules. You will need to explain the breach notification process, too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.

• Get on it. The rules specify Sept. 23 as the effective date for the new regulations, although you have a year beyond that to revise your existing BA agreements. Extensions are possible, even likely.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

I’m hearing a lot of concern about the impending changes in the Health Insurance Portability and Accountability Act (HIPAA) – which is understandable, since the Department of Health and Human Services has presented them as "the most sweeping ... since [the Act] was first implemented."

But after a careful perusal of the new rules – all 150 three-column pages of them – I can say with a modest degree of confidence that for most physicians, compliance will not be as challenging as some (such as those trying to sell you compliance-related materials) have warned.

However, you can’t simply ignore the new regulations; definitions will be more complex, security breaches more liberally defined, and potential penalties will be stiffer. Herewith the salient points:

• Business associates. The criteria for identifying "business associates" (BAs) remain the same: nonemployees, performing "functions or activities" on behalf of the "covered entity" (your practice), that involve "creating, receiving, maintaining, or transmitting" personal health information (PHI).

Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services are BAs if they must have direct access to PHI to do their jobs.

Mail carriers, package-delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs, even though they might conceivably come in contact with PHI on occasion. You are required to use "reasonable diligence" in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.

Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement; just train them, as you do your employees. (I’ll have more on HIPAA and OSHA training in a future column.)

What is new is the additional onus placed on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract. You are expected to use "reasonable diligence" in monitoring the work of your BAs. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is ours. Let’s say that a contractor you hire to shred old medical records throws them into a trash bin instead; under the new rules, you must assume the worst-case scenario. Previously, you would only have to notify affected patients (and the government) if there was a "significant risk of financial or reputational harm," but now, any incident involving patient records is assumed to be a breach, and must be reported. Failure to do so could subject your practice, as well as the contractor, to significant fines – as high as $1 million in egregious cases.

• New patient rights. Patients will now be able to restrict the PHI shared with third-party insurers and health plans if they pay for the services themselves. They also have the right to request copies of their electronic health records, and you can bill the actual costs of responding to such a request. If you have EHR, now might be a good time to work out a system for doing this, because the response time has been decreased from 90 to 30 days – even less in some states.

• Marketing limitations. The new rule prohibits third-party-funded marketing to patients for products and services without their prior written authorization. You do not need prior authorization to market your own products and services, even when the communication is funded by a third party, but if there is any such funding, you will need to disclose it.

• Notice of privacy practices (NPP). You will need to revise your NPP to explain your relationships with BAs, and their status under the new rules. You will need to explain the breach notification process, too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.

• Get on it. The rules specify Sept. 23 as the effective date for the new regulations, although you have a year beyond that to revise your existing BA agreements. Extensions are possible, even likely.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

I’m hearing a lot of concern about the impending changes in the Health Insurance Portability and Accountability Act (HIPAA) – which is understandable, since the Department of Health and Human Services has presented them as "the most sweeping ... since [the Act] was first implemented."

But after a careful perusal of the new rules – all 150 three-column pages of them – I can say with a modest degree of confidence that for most physicians, compliance will not be as challenging as some (such as those trying to sell you compliance-related materials) have warned.

However, you can’t simply ignore the new regulations; definitions will be more complex, security breaches more liberally defined, and potential penalties will be stiffer. Herewith the salient points:

• Business associates. The criteria for identifying "business associates" (BAs) remain the same: nonemployees, performing "functions or activities" on behalf of the "covered entity" (your practice), that involve "creating, receiving, maintaining, or transmitting" personal health information (PHI).

Typical BAs include answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records. Practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services are BAs if they must have direct access to PHI to do their jobs.

Mail carriers, package-delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs, even though they might conceivably come in contact with PHI on occasion. You are required to use "reasonable diligence" in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.

Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement; just train them, as you do your employees. (I’ll have more on HIPAA and OSHA training in a future column.)

What is new is the additional onus placed on physicians for confidentiality breaches committed by their BAs. It’s not enough to simply have a BA contract. You are expected to use "reasonable diligence" in monitoring the work of your BAs. BAs and their subcontractors are directly responsible for their own actions, but the primary responsibility is ours. Let’s say that a contractor you hire to shred old medical records throws them into a trash bin instead; under the new rules, you must assume the worst-case scenario. Previously, you would only have to notify affected patients (and the government) if there was a "significant risk of financial or reputational harm," but now, any incident involving patient records is assumed to be a breach, and must be reported. Failure to do so could subject your practice, as well as the contractor, to significant fines – as high as $1 million in egregious cases.

• New patient rights. Patients will now be able to restrict the PHI shared with third-party insurers and health plans if they pay for the services themselves. They also have the right to request copies of their electronic health records, and you can bill the actual costs of responding to such a request. If you have EHR, now might be a good time to work out a system for doing this, because the response time has been decreased from 90 to 30 days – even less in some states.

• Marketing limitations. The new rule prohibits third-party-funded marketing to patients for products and services without their prior written authorization. You do not need prior authorization to market your own products and services, even when the communication is funded by a third party, but if there is any such funding, you will need to disclose it.

• Notice of privacy practices (NPP). You will need to revise your NPP to explain your relationships with BAs, and their status under the new rules. You will need to explain the breach notification process, too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.

• Get on it. The rules specify Sept. 23 as the effective date for the new regulations, although you have a year beyond that to revise your existing BA agreements. Extensions are possible, even likely.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both, but either way, the result is the same: You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple, three-part strategy:

• Discover which expectations went unmet and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

At this point, you may be asking, "Why should I care?" Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, but a dissatisfied one will frighten away 20 or more. Besides, if the complaint is significant and you don’t resolve it, the patient is likely to find someone who will; and chances are you won’t like their choice, or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time in advance to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: Listening to the complaint. Before you can resolve a problem, you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: "So, if I understand you correctly, you expected "X" to happen, but "Y" happened instead." If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation is to think more about protecting yourself than about making the patient happy, but that often leads to bigger problems. Don’t be defensive. Remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, cancelling a small fee for an angry patient can be very prudent, and in my opinion that looks exactly like what it is: an honest effort to rectify the situation. But in general, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything, but consider reserving a "private" chart area for such documentation (unless it is a bona fide clinical issue) so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, don’t take complaints personally – even when they are personal. It’s always worth remembering that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both, but either way, the result is the same: You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple, three-part strategy:

• Discover which expectations went unmet and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

At this point, you may be asking, "Why should I care?" Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, but a dissatisfied one will frighten away 20 or more. Besides, if the complaint is significant and you don’t resolve it, the patient is likely to find someone who will; and chances are you won’t like their choice, or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time in advance to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: Listening to the complaint. Before you can resolve a problem, you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: "So, if I understand you correctly, you expected "X" to happen, but "Y" happened instead." If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation is to think more about protecting yourself than about making the patient happy, but that often leads to bigger problems. Don’t be defensive. Remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, cancelling a small fee for an angry patient can be very prudent, and in my opinion that looks exactly like what it is: an honest effort to rectify the situation. But in general, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything, but consider reserving a "private" chart area for such documentation (unless it is a bona fide clinical issue) so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, don’t take complaints personally – even when they are personal. It’s always worth remembering that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both, but either way, the result is the same: You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple, three-part strategy:

• Discover which expectations went unmet and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

At this point, you may be asking, "Why should I care?" Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, but a dissatisfied one will frighten away 20 or more. Besides, if the complaint is significant and you don’t resolve it, the patient is likely to find someone who will; and chances are you won’t like their choice, or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time in advance to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: Listening to the complaint. Before you can resolve a problem, you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: "So, if I understand you correctly, you expected "X" to happen, but "Y" happened instead." If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation is to think more about protecting yourself than about making the patient happy, but that often leads to bigger problems. Don’t be defensive. Remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, cancelling a small fee for an angry patient can be very prudent, and in my opinion that looks exactly like what it is: an honest effort to rectify the situation. But in general, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything, but consider reserving a "private" chart area for such documentation (unless it is a bona fide clinical issue) so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, don’t take complaints personally – even when they are personal. It’s always worth remembering that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Much has been written of the widespread concern among America’s physicians over upcoming changes in our health care system. Dire predictions of impending doom have prompted many to consider early retirement.

I do not share such concerns, for what that is worth; but if you do, and you are serious about retiring sooner than planned, now would be a great time to take a close look at your financial situation.

Many doctors have a false sense of security about their money; most of us save too little. We either miscalculate or underestimate how much we’ll need to last through retirement.

We tend to live longer than we think we will, and as such we run the risk of outliving our savings. And we don’t face facts about long-term care. Not nearly enough of us have long-term care insurance, or the means to self-fund an extended long-term care situation.

Many people lack a clear idea of where their retirement income will come from, and even when they do, they don’t know how to manage their savings correctly. Doctors in particular are notorious for not understanding investments. Many attempt to manage their practice’s retirement plans with inadequate knowledge of how the investments within their plans work.

So how will you know if you can safely retire before Obamacare gets up to speed? Of course, as with everything else, it depends. But to arrive at any sort of reliable ballpark figure, you’ll need to know three things: (1) how much you realistically expect to spend annually after retirement; (2) how much principal you will need to generate that annual income; and (3) how far your present savings are from that target figure.

An oft-quoted rule of thumb is that in retirement you should plan to spend about 70% of what you are spending now. In my opinion, that’s nonsense. While a few significant expenses, such as disability and malpractice insurance premiums, will be eliminated, other expenses, such as travel, recreation, and medical care (including long-term care insurance, which no one should be without), will increase. My wife and I are assuming we will spend about the same in retirement as we spend now, and I suggest you do too.

Once you know how much money you will spend per year, you can calculate how much money – in interest- and dividend-producing assets – will be needed to generate that amount.

Ideally, you will want to spend only the interest and dividends; by leaving the principal untouched you will never run short, even if you retire at an unusually young age, or longevity runs in your family (or both). Most financial advisers use the 5% rule: You can safely assume a minimum average of 5% annual return on your nest egg. So if you want to spend $100,000 per year, you will need $2 million in assets; for $200,000, you’ll need $4 million.

This is where you may discover – if your present savings are a long way from your target figure – that early retirement is not a realistic option. Better, though, to make that unpleasant discovery now, rather than face the frightening prospect of running out of money at an advanced age. Don’t be tempted to close a wide gap in a hurry with high-return/high-risk investments, which often backfire, leaving you further than ever from retirement.

Of course, it goes without saying that debt can destroy the best-laid retirement plans. If you carry significant debt, pay it off as soon as possible, and certainly before you retire.

Even if you have no plans to retire in the immediate future, it is never too soon to think about retirement. Young physicians often defer contributing to their retirement plans because they want to save for a new house, or college for their children. But there are tangible tax benefits that you get now, because your contributions usually reduce your taxable income, and your investment grows tax-free until you take it out.

For long-term planning, the most foolproof strategy – seldom employed, because it’s boring – is to sock away a fixed amount per month (after your retirement plan has been funded) in a mutual fund. For example, $1,000 per month for 25 years with the market earning 10% overall comes to almost $2 million, with the power of compounded interest working for you.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Much has been written of the widespread concern among America’s physicians over upcoming changes in our health care system. Dire predictions of impending doom have prompted many to consider early retirement.

I do not share such concerns, for what that is worth; but if you do, and you are serious about retiring sooner than planned, now would be a great time to take a close look at your financial situation.

Many doctors have a false sense of security about their money; most of us save too little. We either miscalculate or underestimate how much we’ll need to last through retirement.

We tend to live longer than we think we will, and as such we run the risk of outliving our savings. And we don’t face facts about long-term care. Not nearly enough of us have long-term care insurance, or the means to self-fund an extended long-term care situation.

Many people lack a clear idea of where their retirement income will come from, and even when they do, they don’t know how to manage their savings correctly. Doctors in particular are notorious for not understanding investments. Many attempt to manage their practice’s retirement plans with inadequate knowledge of how the investments within their plans work.

So how will you know if you can safely retire before Obamacare gets up to speed? Of course, as with everything else, it depends. But to arrive at any sort of reliable ballpark figure, you’ll need to know three things: (1) how much you realistically expect to spend annually after retirement; (2) how much principal you will need to generate that annual income; and (3) how far your present savings are from that target figure.

An oft-quoted rule of thumb is that in retirement you should plan to spend about 70% of what you are spending now. In my opinion, that’s nonsense. While a few significant expenses, such as disability and malpractice insurance premiums, will be eliminated, other expenses, such as travel, recreation, and medical care (including long-term care insurance, which no one should be without), will increase. My wife and I are assuming we will spend about the same in retirement as we spend now, and I suggest you do too.

Once you know how much money you will spend per year, you can calculate how much money – in interest- and dividend-producing assets – will be needed to generate that amount.

Ideally, you will want to spend only the interest and dividends; by leaving the principal untouched you will never run short, even if you retire at an unusually young age, or longevity runs in your family (or both). Most financial advisers use the 5% rule: You can safely assume a minimum average of 5% annual return on your nest egg. So if you want to spend $100,000 per year, you will need $2 million in assets; for $200,000, you’ll need $4 million.

This is where you may discover – if your present savings are a long way from your target figure – that early retirement is not a realistic option. Better, though, to make that unpleasant discovery now, rather than face the frightening prospect of running out of money at an advanced age. Don’t be tempted to close a wide gap in a hurry with high-return/high-risk investments, which often backfire, leaving you further than ever from retirement.

Of course, it goes without saying that debt can destroy the best-laid retirement plans. If you carry significant debt, pay it off as soon as possible, and certainly before you retire.

Even if you have no plans to retire in the immediate future, it is never too soon to think about retirement. Young physicians often defer contributing to their retirement plans because they want to save for a new house, or college for their children. But there are tangible tax benefits that you get now, because your contributions usually reduce your taxable income, and your investment grows tax-free until you take it out.

For long-term planning, the most foolproof strategy – seldom employed, because it’s boring – is to sock away a fixed amount per month (after your retirement plan has been funded) in a mutual fund. For example, $1,000 per month for 25 years with the market earning 10% overall comes to almost $2 million, with the power of compounded interest working for you.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Much has been written of the widespread concern among America’s physicians over upcoming changes in our health care system. Dire predictions of impending doom have prompted many to consider early retirement.

I do not share such concerns, for what that is worth; but if you do, and you are serious about retiring sooner than planned, now would be a great time to take a close look at your financial situation.

Many doctors have a false sense of security about their money; most of us save too little. We either miscalculate or underestimate how much we’ll need to last through retirement.

We tend to live longer than we think we will, and as such we run the risk of outliving our savings. And we don’t face facts about long-term care. Not nearly enough of us have long-term care insurance, or the means to self-fund an extended long-term care situation.

Many people lack a clear idea of where their retirement income will come from, and even when they do, they don’t know how to manage their savings correctly. Doctors in particular are notorious for not understanding investments. Many attempt to manage their practice’s retirement plans with inadequate knowledge of how the investments within their plans work.

So how will you know if you can safely retire before Obamacare gets up to speed? Of course, as with everything else, it depends. But to arrive at any sort of reliable ballpark figure, you’ll need to know three things: (1) how much you realistically expect to spend annually after retirement; (2) how much principal you will need to generate that annual income; and (3) how far your present savings are from that target figure.

An oft-quoted rule of thumb is that in retirement you should plan to spend about 70% of what you are spending now. In my opinion, that’s nonsense. While a few significant expenses, such as disability and malpractice insurance premiums, will be eliminated, other expenses, such as travel, recreation, and medical care (including long-term care insurance, which no one should be without), will increase. My wife and I are assuming we will spend about the same in retirement as we spend now, and I suggest you do too.

Once you know how much money you will spend per year, you can calculate how much money – in interest- and dividend-producing assets – will be needed to generate that amount.

Ideally, you will want to spend only the interest and dividends; by leaving the principal untouched you will never run short, even if you retire at an unusually young age, or longevity runs in your family (or both). Most financial advisers use the 5% rule: You can safely assume a minimum average of 5% annual return on your nest egg. So if you want to spend $100,000 per year, you will need $2 million in assets; for $200,000, you’ll need $4 million.

This is where you may discover – if your present savings are a long way from your target figure – that early retirement is not a realistic option. Better, though, to make that unpleasant discovery now, rather than face the frightening prospect of running out of money at an advanced age. Don’t be tempted to close a wide gap in a hurry with high-return/high-risk investments, which often backfire, leaving you further than ever from retirement.

Of course, it goes without saying that debt can destroy the best-laid retirement plans. If you carry significant debt, pay it off as soon as possible, and certainly before you retire.

Even if you have no plans to retire in the immediate future, it is never too soon to think about retirement. Young physicians often defer contributing to their retirement plans because they want to save for a new house, or college for their children. But there are tangible tax benefits that you get now, because your contributions usually reduce your taxable income, and your investment grows tax-free until you take it out.

For long-term planning, the most foolproof strategy – seldom employed, because it’s boring – is to sock away a fixed amount per month (after your retirement plan has been funded) in a mutual fund. For example, $1,000 per month for 25 years with the market earning 10% overall comes to almost $2 million, with the power of compounded interest working for you.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Every medical office, even the smallest, should have a time clock, and there are two very good reasons why. The obvious one is for stamping employee time cards. This is essential, even if all your employees are paid weekly or semiweekly rather than by the hour.

In most states, any employee who works more than 40 hours in any given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they had worked hundreds of hours of unpaid overtime. This may be completely untrue, but labor boards almost invariably side with employees in such disputes – unless the employer can produce time records to disprove the claim. A time clock is cheap insurance against such headaches.

For hourly wage employees, time records are even more important, obviously because you only want to pay them for the hours they work. If you are paying your part-timers for the number of hours they should be working, without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time or to stay the entire length of their shift, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can’t count on being paid for the extra time.

Time clocks also work to the advantage of your employees, since they will be paid for all the time they work. In fact, if any employees object to being asked to punch in every day, point out that they will be assured of payment for fractional time worked past their usual hours – time which until now may have gone unpaid.

The second – possibly more important – reason to have a time clock is to punch in your patients. A time clock is a great tool in the endless struggle to run your practice on time.

As each patient arrives, have your receptionist time-stamp the "encounter form" that goes back with the patient’s chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are – and you’ll have an answer for the curmudgeon who walked in 15 minutes ago, but insists he’s been sitting there for 2 hours.

Time/attendance systems range from simple and cheap to complex and expensive. Many of the newer mechanical clocks will automatically calculate time between punches and total work time, and these can be configured for weekly, biweekly, semimonthly or monthly pay periods. Some will automatically deduct meal breaks from the totals. However, remember that you can only exclude meal breaks from compensable time when an employee is completely relieved of work duties for at least 1 uninterrupted half-hour.

If you have a problem with "buddy punching" (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic timing systems, both web-based and in-house, which can be deployed across a local computer network. These systems will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third party payroll services.

One popular Web-based system is Count Me In, which has the fingerprint option, and also allows you to restrict clocking in or out to those IP addresses that you authorize. The system prevents employees from punching in from home, or a vacation house, or a distant casino. Other examples of cloud-based systems: Time Card Manager, Time Force, and Time America. PHP Timeclock is a free, open-source download – though setting it up on your server will require some technical expertise.

As always, I have no financial interest in any product or service discussed in this column. Whether you go the mechanical or electronic route, make sure that the system you choose has security measures in place to prevent anyone from altering the displayed time at will. You need to be reasonably certain that your time stamps have not been fudged.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Every medical office, even the smallest, should have a time clock, and there are two very good reasons why. The obvious one is for stamping employee time cards. This is essential, even if all your employees are paid weekly or semiweekly rather than by the hour.

In most states, any employee who works more than 40 hours in any given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they had worked hundreds of hours of unpaid overtime. This may be completely untrue, but labor boards almost invariably side with employees in such disputes – unless the employer can produce time records to disprove the claim. A time clock is cheap insurance against such headaches.

For hourly wage employees, time records are even more important, obviously because you only want to pay them for the hours they work. If you are paying your part-timers for the number of hours they should be working, without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time or to stay the entire length of their shift, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can’t count on being paid for the extra time.

Time clocks also work to the advantage of your employees, since they will be paid for all the time they work. In fact, if any employees object to being asked to punch in every day, point out that they will be assured of payment for fractional time worked past their usual hours – time which until now may have gone unpaid.

The second – possibly more important – reason to have a time clock is to punch in your patients. A time clock is a great tool in the endless struggle to run your practice on time.

As each patient arrives, have your receptionist time-stamp the "encounter form" that goes back with the patient’s chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are – and you’ll have an answer for the curmudgeon who walked in 15 minutes ago, but insists he’s been sitting there for 2 hours.

Time/attendance systems range from simple and cheap to complex and expensive. Many of the newer mechanical clocks will automatically calculate time between punches and total work time, and these can be configured for weekly, biweekly, semimonthly or monthly pay periods. Some will automatically deduct meal breaks from the totals. However, remember that you can only exclude meal breaks from compensable time when an employee is completely relieved of work duties for at least 1 uninterrupted half-hour.

If you have a problem with "buddy punching" (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic timing systems, both web-based and in-house, which can be deployed across a local computer network. These systems will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third party payroll services.

One popular Web-based system is Count Me In, which has the fingerprint option, and also allows you to restrict clocking in or out to those IP addresses that you authorize. The system prevents employees from punching in from home, or a vacation house, or a distant casino. Other examples of cloud-based systems: Time Card Manager, Time Force, and Time America. PHP Timeclock is a free, open-source download – though setting it up on your server will require some technical expertise.

As always, I have no financial interest in any product or service discussed in this column. Whether you go the mechanical or electronic route, make sure that the system you choose has security measures in place to prevent anyone from altering the displayed time at will. You need to be reasonably certain that your time stamps have not been fudged.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Every medical office, even the smallest, should have a time clock, and there are two very good reasons why. The obvious one is for stamping employee time cards. This is essential, even if all your employees are paid weekly or semiweekly rather than by the hour.

In most states, any employee who works more than 40 hours in any given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they had worked hundreds of hours of unpaid overtime. This may be completely untrue, but labor boards almost invariably side with employees in such disputes – unless the employer can produce time records to disprove the claim. A time clock is cheap insurance against such headaches.

For hourly wage employees, time records are even more important, obviously because you only want to pay them for the hours they work. If you are paying your part-timers for the number of hours they should be working, without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time or to stay the entire length of their shift, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can’t count on being paid for the extra time.

Time clocks also work to the advantage of your employees, since they will be paid for all the time they work. In fact, if any employees object to being asked to punch in every day, point out that they will be assured of payment for fractional time worked past their usual hours – time which until now may have gone unpaid.

The second – possibly more important – reason to have a time clock is to punch in your patients. A time clock is a great tool in the endless struggle to run your practice on time.

As each patient arrives, have your receptionist time-stamp the "encounter form" that goes back with the patient’s chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are – and you’ll have an answer for the curmudgeon who walked in 15 minutes ago, but insists he’s been sitting there for 2 hours.

Time/attendance systems range from simple and cheap to complex and expensive. Many of the newer mechanical clocks will automatically calculate time between punches and total work time, and these can be configured for weekly, biweekly, semimonthly or monthly pay periods. Some will automatically deduct meal breaks from the totals. However, remember that you can only exclude meal breaks from compensable time when an employee is completely relieved of work duties for at least 1 uninterrupted half-hour.

If you have a problem with "buddy punching" (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic timing systems, both web-based and in-house, which can be deployed across a local computer network. These systems will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third party payroll services.

One popular Web-based system is Count Me In, which has the fingerprint option, and also allows you to restrict clocking in or out to those IP addresses that you authorize. The system prevents employees from punching in from home, or a vacation house, or a distant casino. Other examples of cloud-based systems: Time Card Manager, Time Force, and Time America. PHP Timeclock is a free, open-source download – though setting it up on your server will require some technical expertise.

As always, I have no financial interest in any product or service discussed in this column. Whether you go the mechanical or electronic route, make sure that the system you choose has security measures in place to prevent anyone from altering the displayed time at will. You need to be reasonably certain that your time stamps have not been fudged.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

The holiday season has come and gone with alarming speed; and now, ’tis the season for resolutions, turning over a new leaf, promising – yet again – to break all those bad habits once and for all.

I can’t presume to know what your professional bad habits are, but I do know the ones I get asked about the most. The following "top ten list" might provide some inspiration for assembling a list of your own:

1. Start on time. So many doctors complain of running behind. Guess what? Your patients complain about that too. Waiting is the most common patient complaint, and you can’t hope to run on time if you don’t start on time. No single change will improve your efficiency more than this.

2. Organize your Internet time. I confess, this one is on my own list most years. E-mail needs to be answered, and your office’s Twitter feed and Facebook page need updating; but do it before or after office hours. It’s just too easy to start clicking that mouse, and suddenly you’re half an hour behind.

3. Permit fewer interruptions. Phone calls and pharmaceutical reps seem to be the big interrupters in most offices. Make some rules, and stick to them. I’ll stop to take an emergency call, or one from an immediate family member; all others get routed to the nurses or are returned at lunch or after hours. Reps make appointments, like everybody else – and only if they have something new to talk about.

4. Organize samples. See my column on this subject. We strip all the space-wasting packaging off our samples and store them, alphabetically, in cardboard "parts" bins, available in many industrial catalogs. Besides always knowing what you have, you’ll always know what you’re out of; and your staff will waste far less time tracking samples down. Also, a bin system makes logging samples in and out much easier, should that become a requirement – as the FDA keeps promising.

5. Clear your "horizontal file cabinet." That’s the mess on your desk, all the paperwork you never seem to get to (probably because you’re tweeting or answering e-mail). Set aside an hour or two and get it all done. You’ll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don’t start a new mess.

6. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.

7. Make sure your long-range financial planning is on track. This is another task physicians tend to "set and forget," but the Great Recession was an eye-opener for many of us. Once a year, sit down with your accountant and planner, and make sure your investments are well diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, and retirement accounts – are in the best shape possible. Now would be a good time.

8. Pay down your debt. Debt can destroy the best-laid retirement plans; many learned this the hard way when the "bubble" burst. If you carry significant debt, set up a plan to pay it off as soon as you can.

9. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, "I wish I had spent more time in the office." This is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, "Life is what happens to you while you’re busy making other plans."

10. Look at yourself. A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. Take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding the things that need changing . . . ask your spouse. He or she will be happy to outline them for you, in great detail.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. T

The holiday season has come and gone with alarming speed; and now, ’tis the season for resolutions, turning over a new leaf, promising – yet again – to break all those bad habits once and for all.

I can’t presume to know what your professional bad habits are, but I do know the ones I get asked about the most. The following "top ten list" might provide some inspiration for assembling a list of your own:

1. Start on time. So many doctors complain of running behind. Guess what? Your patients complain about that too. Waiting is the most common patient complaint, and you can’t hope to run on time if you don’t start on time. No single change will improve your efficiency more than this.

2. Organize your Internet time. I confess, this one is on my own list most years. E-mail needs to be answered, and your office’s Twitter feed and Facebook page need updating; but do it before or after office hours. It’s just too easy to start clicking that mouse, and suddenly you’re half an hour behind.

3. Permit fewer interruptions. Phone calls and pharmaceutical reps seem to be the big interrupters in most offices. Make some rules, and stick to them. I’ll stop to take an emergency call, or one from an immediate family member; all others get routed to the nurses or are returned at lunch or after hours. Reps make appointments, like everybody else – and only if they have something new to talk about.

4. Organize samples. See my column on this subject. We strip all the space-wasting packaging off our samples and store them, alphabetically, in cardboard "parts" bins, available in many industrial catalogs. Besides always knowing what you have, you’ll always know what you’re out of; and your staff will waste far less time tracking samples down. Also, a bin system makes logging samples in and out much easier, should that become a requirement – as the FDA keeps promising.

5. Clear your "horizontal file cabinet." That’s the mess on your desk, all the paperwork you never seem to get to (probably because you’re tweeting or answering e-mail). Set aside an hour or two and get it all done. You’ll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don’t start a new mess.

6. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.

7. Make sure your long-range financial planning is on track. This is another task physicians tend to "set and forget," but the Great Recession was an eye-opener for many of us. Once a year, sit down with your accountant and planner, and make sure your investments are well diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, and retirement accounts – are in the best shape possible. Now would be a good time.

8. Pay down your debt. Debt can destroy the best-laid retirement plans; many learned this the hard way when the "bubble" burst. If you carry significant debt, set up a plan to pay it off as soon as you can.

9. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, "I wish I had spent more time in the office." This is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, "Life is what happens to you while you’re busy making other plans."

10. Look at yourself. A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. Take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding the things that need changing . . . ask your spouse. He or she will be happy to outline them for you, in great detail.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. T

The holiday season has come and gone with alarming speed; and now, ’tis the season for resolutions, turning over a new leaf, promising – yet again – to break all those bad habits once and for all.

I can’t presume to know what your professional bad habits are, but I do know the ones I get asked about the most. The following "top ten list" might provide some inspiration for assembling a list of your own:

1. Start on time. So many doctors complain of running behind. Guess what? Your patients complain about that too. Waiting is the most common patient complaint, and you can’t hope to run on time if you don’t start on time. No single change will improve your efficiency more than this.

2. Organize your Internet time. I confess, this one is on my own list most years. E-mail needs to be answered, and your office’s Twitter feed and Facebook page need updating; but do it before or after office hours. It’s just too easy to start clicking that mouse, and suddenly you’re half an hour behind.

3. Permit fewer interruptions. Phone calls and pharmaceutical reps seem to be the big interrupters in most offices. Make some rules, and stick to them. I’ll stop to take an emergency call, or one from an immediate family member; all others get routed to the nurses or are returned at lunch or after hours. Reps make appointments, like everybody else – and only if they have something new to talk about.

4. Organize samples. See my column on this subject. We strip all the space-wasting packaging off our samples and store them, alphabetically, in cardboard "parts" bins, available in many industrial catalogs. Besides always knowing what you have, you’ll always know what you’re out of; and your staff will waste far less time tracking samples down. Also, a bin system makes logging samples in and out much easier, should that become a requirement – as the FDA keeps promising.

5. Clear your "horizontal file cabinet." That’s the mess on your desk, all the paperwork you never seem to get to (probably because you’re tweeting or answering e-mail). Set aside an hour or two and get it all done. You’ll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don’t start a new mess.

6. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.

7. Make sure your long-range financial planning is on track. This is another task physicians tend to "set and forget," but the Great Recession was an eye-opener for many of us. Once a year, sit down with your accountant and planner, and make sure your investments are well diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, and retirement accounts – are in the best shape possible. Now would be a good time.

8. Pay down your debt. Debt can destroy the best-laid retirement plans; many learned this the hard way when the "bubble" burst. If you carry significant debt, set up a plan to pay it off as soon as you can.

9. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, "I wish I had spent more time in the office." This is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, "Life is what happens to you while you’re busy making other plans."

10. Look at yourself. A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. Take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding the things that need changing . . . ask your spouse. He or she will be happy to outline them for you, in great detail.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. T

As I’ve been writing for several years, holiday bonuses have increasingly become a thing of the past in the business world. Most companies have replaced them with various types of structured, incentive-based reward systems.

Yet an informal poll of dermatologists around the country on the RxDerm-L listserv reveals that a substantial percentage of private practitioners continue to offer their employees no-strings-attached holiday bonuses. This is somewhat understandable in the sense that, once employees come to expect a particular benefit, it is difficult to take it away. Given the uncertainties of the fluctuating economy, though, and the impending changes in the status of health care in this country, many practices may have to follow the national trend and begin tying their awards programs to performance.

Holiday bonuses have been falling out of favor in the business world because companies face increased pressure to reduce costs and so have become more focused on growth and performance. Since this is also increasingly true in the world of private practice, it makes sense for medical practices to heed this trend.

Instead of giving arbitrary, across-the-board bonuses, you may want to find ways to appropriately reward your highest-performing employees. This can be done by reserving more bonus budgets (called "variable compensation" in business lingo, as opposed to guaranteed, salaried compensation) for bonuses that are based on performance and must be re-earned each year.

First, however, you must decide what targets and goals you wish your employees to achieve during the year. Specific performance goals will vary by the type of practice: Cosmetic practices might set financial goals, such as a profit and revenue targets, while offices primarily practicing medical dermatology might measure performance according to output and quality of work.

Whatever changes you decide to make, be sure to share them with your staff from the outset. Employees must be aware of what they need to accomplish to earn a performance-based bonus.

Commonly cited guidelines for effectively rewarding employees include the following:

• Reward your employees in ways that they find rewarding. (This does not necessarily mean cash.) The reward should be matched to the achievement, so bigger achievements earn bigger rewards.

• 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. A reward coming weeks or months later – say, during the holiday season – has little or no effect as a performance incentive.

So how do you know what rewards your employees will find rewarding? Ask them! In my office, their ideas have been surprisingly creative – and 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, so I obtained 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 hotly contested in the office.

One of the strongest motivators is the confidence that you, the boss, have taken the time to notice a job well done and praise it publicly, in a timely manner.

Time off is another powerful motivator: Who (including you) doesn’t appreciate a bit more free time?

This is not to say, of course, that you cannot also give your employees a gift at holiday time – as long as you (and they) understand that it is a one-time gift, with no guarantees or expectations of annual repetition. Such gifts usually consist of either cash (or gift certificates/cards) or a non-cash gift such as a fruit basket or baked goods.

Keep in mind that bonuses and gifts nearly always qualify as a tax write-off for employers, but they may or may not count as taxable income for employees. As a general rule, cash bonuses tend to be taxable while non-cash awards are not, but check your state’s applicable laws to be sure.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail him at our editorial offices at [email protected].

As I’ve been writing for several years, holiday bonuses have increasingly become a thing of the past in the business world. Most companies have replaced them with various types of structured, incentive-based reward systems.

Yet an informal poll of dermatologists around the country on the RxDerm-L listserv reveals that a substantial percentage of private practitioners continue to offer their employees no-strings-attached holiday bonuses. This is somewhat understandable in the sense that, once employees come to expect a particular benefit, it is difficult to take it away. Given the uncertainties of the fluctuating economy, though, and the impending changes in the status of health care in this country, many practices may have to follow the national trend and begin tying their awards programs to performance.

Holiday bonuses have been falling out of favor in the business world because companies face increased pressure to reduce costs and so have become more focused on growth and performance. Since this is also increasingly true in the world of private practice, it makes sense for medical practices to heed this trend.

Instead of giving arbitrary, across-the-board bonuses, you may want to find ways to appropriately reward your highest-performing employees. This can be done by reserving more bonus budgets (called "variable compensation" in business lingo, as opposed to guaranteed, salaried compensation) for bonuses that are based on performance and must be re-earned each year.

First, however, you must decide what targets and goals you wish your employees to achieve during the year. Specific performance goals will vary by the type of practice: Cosmetic practices might set financial goals, such as a profit and revenue targets, while offices primarily practicing medical dermatology might measure performance according to output and quality of work.

Whatever changes you decide to make, be sure to share them with your staff from the outset. Employees must be aware of what they need to accomplish to earn a performance-based bonus.

Commonly cited guidelines for effectively rewarding employees include the following:

• Reward your employees in ways that they find rewarding. (This does not necessarily mean cash.) The reward should be matched to the achievement, so bigger achievements earn bigger rewards.

• 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. A reward coming weeks or months later – say, during the holiday season – has little or no effect as a performance incentive.

So how do you know what rewards your employees will find rewarding? Ask them! In my office, their ideas have been surprisingly creative – and 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, so I obtained 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 hotly contested in the office.

One of the strongest motivators is the confidence that you, the boss, have taken the time to notice a job well done and praise it publicly, in a timely manner.

Time off is another powerful motivator: Who (including you) doesn’t appreciate a bit more free time?

This is not to say, of course, that you cannot also give your employees a gift at holiday time – as long as you (and they) understand that it is a one-time gift, with no guarantees or expectations of annual repetition. Such gifts usually consist of either cash (or gift certificates/cards) or a non-cash gift such as a fruit basket or baked goods.

Keep in mind that bonuses and gifts nearly always qualify as a tax write-off for employers, but they may or may not count as taxable income for employees. As a general rule, cash bonuses tend to be taxable while non-cash awards are not, but check your state’s applicable laws to be sure.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail him at our editorial offices at [email protected].

As I’ve been writing for several years, holiday bonuses have increasingly become a thing of the past in the business world. Most companies have replaced them with various types of structured, incentive-based reward systems.

Yet an informal poll of dermatologists around the country on the RxDerm-L listserv reveals that a substantial percentage of private practitioners continue to offer their employees no-strings-attached holiday bonuses. This is somewhat understandable in the sense that, once employees come to expect a particular benefit, it is difficult to take it away. Given the uncertainties of the fluctuating economy, though, and the impending changes in the status of health care in this country, many practices may have to follow the national trend and begin tying their awards programs to performance.

Holiday bonuses have been falling out of favor in the business world because companies face increased pressure to reduce costs and so have become more focused on growth and performance. Since this is also increasingly true in the world of private practice, it makes sense for medical practices to heed this trend.

Instead of giving arbitrary, across-the-board bonuses, you may want to find ways to appropriately reward your highest-performing employees. This can be done by reserving more bonus budgets (called "variable compensation" in business lingo, as opposed to guaranteed, salaried compensation) for bonuses that are based on performance and must be re-earned each year.

First, however, you must decide what targets and goals you wish your employees to achieve during the year. Specific performance goals will vary by the type of practice: Cosmetic practices might set financial goals, such as a profit and revenue targets, while offices primarily practicing medical dermatology might measure performance according to output and quality of work.

Whatever changes you decide to make, be sure to share them with your staff from the outset. Employees must be aware of what they need to accomplish to earn a performance-based bonus.

Commonly cited guidelines for effectively rewarding employees include the following:

• Reward your employees in ways that they find rewarding. (This does not necessarily mean cash.) The reward should be matched to the achievement, so bigger achievements earn bigger rewards.

• 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. A reward coming weeks or months later – say, during the holiday season – has little or no effect as a performance incentive.

So how do you know what rewards your employees will find rewarding? Ask them! In my office, their ideas have been surprisingly creative – and 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, so I obtained 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 hotly contested in the office.

One of the strongest motivators is the confidence that you, the boss, have taken the time to notice a job well done and praise it publicly, in a timely manner.

Time off is another powerful motivator: Who (including you) doesn’t appreciate a bit more free time?

This is not to say, of course, that you cannot also give your employees a gift at holiday time – as long as you (and they) understand that it is a one-time gift, with no guarantees or expectations of annual repetition. Such gifts usually consist of either cash (or gift certificates/cards) or a non-cash gift such as a fruit basket or baked goods.

Keep in mind that bonuses and gifts nearly always qualify as a tax write-off for employers, but they may or may not count as taxable income for employees. As a general rule, cash bonuses tend to be taxable while non-cash awards are not, but check your state’s applicable laws to be sure.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail him at our editorial offices at [email protected].

Did you notice that your practice was slower than normal last February? In fact, if you plot your patient census over a few years, you will probably discover that it dips every February. And you will discover other slow periods, like December, and busy months during other parts of the year.

Seasonal fluctuations are a reality in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January and February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are on vacation. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change through advertising or by sending out an e-mail blast, but, unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep-pockets game requiring long, expensive campaigns that are only practical for a large, nationwide corporation.

Take soup, for example. For many years, canned soup was purchased and consumed almost exclusively during the winter months because it was universally perceived as a cold-weather product. After years of pervasive advertising extolling its nutritional virtues (remember Campbell’s slogan "Soup is good food"?), the soup industry succeeded in convincing the public to buy their product year round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean that there is nothing we can do about our practices’ seasonal variations? Not at all, but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

Plotting seasonality is easy: You can make a graph using Microsoft Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2-3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively, you can plot patient visits per month. I do both.

Once you know your seasonality, review your options, which could mean modifying your own habits when necessary. If you typically take a vacation in August, for example, you many want to reconsider if August is one of your busiest months. Consider vacationing during predictable slow periods instead.

Although I have said that you can’t change most seasonal behavior, it is possible to "retrain" some of your long-time, loyal patients to come in during slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November, encouraging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive: Why not advertise during slow periods to fill the empty slots? Because you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

Then, try to flatten your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, which would be the seasonal peaks. Once in your practice, some of them can then be shifted into slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail Dr. Eastern at our editorial offices at [email protected].

Did you notice that your practice was slower than normal last February? In fact, if you plot your patient census over a few years, you will probably discover that it dips every February. And you will discover other slow periods, like December, and busy months during other parts of the year.

Seasonal fluctuations are a reality in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January and February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are on vacation. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change through advertising or by sending out an e-mail blast, but, unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep-pockets game requiring long, expensive campaigns that are only practical for a large, nationwide corporation.

Take soup, for example. For many years, canned soup was purchased and consumed almost exclusively during the winter months because it was universally perceived as a cold-weather product. After years of pervasive advertising extolling its nutritional virtues (remember Campbell’s slogan "Soup is good food"?), the soup industry succeeded in convincing the public to buy their product year round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean that there is nothing we can do about our practices’ seasonal variations? Not at all, but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

Plotting seasonality is easy: You can make a graph using Microsoft Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2-3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively, you can plot patient visits per month. I do both.

Once you know your seasonality, review your options, which could mean modifying your own habits when necessary. If you typically take a vacation in August, for example, you many want to reconsider if August is one of your busiest months. Consider vacationing during predictable slow periods instead.

Although I have said that you can’t change most seasonal behavior, it is possible to "retrain" some of your long-time, loyal patients to come in during slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November, encouraging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive: Why not advertise during slow periods to fill the empty slots? Because you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

Then, try to flatten your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, which would be the seasonal peaks. Once in your practice, some of them can then be shifted into slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail Dr. Eastern at our editorial offices at [email protected].

Did you notice that your practice was slower than normal last February? In fact, if you plot your patient census over a few years, you will probably discover that it dips every February. And you will discover other slow periods, like December, and busy months during other parts of the year.

Seasonal fluctuations are a reality in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January and February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are on vacation. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change through advertising or by sending out an e-mail blast, but, unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep-pockets game requiring long, expensive campaigns that are only practical for a large, nationwide corporation.

Take soup, for example. For many years, canned soup was purchased and consumed almost exclusively during the winter months because it was universally perceived as a cold-weather product. After years of pervasive advertising extolling its nutritional virtues (remember Campbell’s slogan "Soup is good food"?), the soup industry succeeded in convincing the public to buy their product year round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean that there is nothing we can do about our practices’ seasonal variations? Not at all, but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

Plotting seasonality is easy: You can make a graph using Microsoft Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2-3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively, you can plot patient visits per month. I do both.

Once you know your seasonality, review your options, which could mean modifying your own habits when necessary. If you typically take a vacation in August, for example, you many want to reconsider if August is one of your busiest months. Consider vacationing during predictable slow periods instead.

Although I have said that you can’t change most seasonal behavior, it is possible to "retrain" some of your long-time, loyal patients to come in during slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November, encouraging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive: Why not advertise during slow periods to fill the empty slots? Because you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

Then, try to flatten your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, which would be the seasonal peaks. Once in your practice, some of them can then be shifted into slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail Dr. Eastern at our editorial offices at [email protected].