The Office

Both weight loss and its associated improvements in cardiovascular and metabolic risk factors persisted for 6 years in most of the 418 severely obese adults who underwent Roux-en-Y gastric bypass surgery in a prospective study published in the Sept. 19 JAMA.

Despite some weight regain over time, surgery patients showed a mean weight loss of 28% at 6-year follow-up, as well as higher remission rates for diabetes, dyslipidemia, and hypertension, compared with the two control groups, said Ted D. Adams, Ph.D., of the department of internal medicine, University of Utah, Salt Lake City, and his associates.

© Sean Locke/iStockphoto.com

"Considering the 5%-9% weight loss at 1 year with only 2%-6% weight loss after 4 years of intensive lifestyle-based and medication-based therapy, the weight-loss maintenance of 28% ... in our Utah study is quite significant," they noted.

The study involved severely obese adults with a body mass index of 35 kg/m² or higher (mean BMI 45.9 kg/m²), of whom 82% were women and 96% were white. In addition to the patients who underwent either open or laparoscopic gastric bypass, there were 417 obese subjects in the first control group who were assessed for the surgery at the same time as the intervention group but did not have the surgery, and 321 obese subjects in the second control group who were randomly selected from a population-based sample of Utah residents.

Subjects in the control groups did not receive any weight-loss intervention as part of the study but were free to pursue it on their own. Over time, 101 of the subjects from both control groups chose to have bariatric surgery.

In the surgical group, mean weight loss was 35% at 2 years and 28% at 6 years, representing a 7% regain over time. By comparison, neither control group showed any significant weight loss or regain.

Diabetes remitted in 75% of the bypass group at 2 years, decreasing to 62% at 6 years. Despite the recurrence of diabetes in some patients, this long-term remission rate was dramatically better than the remission rates in the control groups (8% and 6%, respectively).

Similarly, the proportion of bypass patients who developed index diabetes during follow-up was markedly lower in the bypass group (2%) than in either control group (17% and 15%, respectively).

Remission of hypertension also was greater 6 years after bypass surgery (42%) than in the control groups (18% and 9%, respectively). Rates of high LDL cholesterol and triglycerides followed the same pattern, Dr. Adams and his colleagues wrote (JAMA 2012;308:1122-31).

Importantly, the weight loss and the concurrent improvement in cardiovascular and metabolic risk factors did not improve mortality. There were 29 deaths: 12 in the bypass group (3%); 14 in the first control group (3%); and 3 in the second control group (1%).

Notably, suicide was significantly more common in the bypass patients than in the control subjects. There were four suicides and three poisonings "of undetermined intention" overall, and six of these seven events occurred in bypass patients. The reason for this excess in the surgery group is unknown, but it is consistent with the finding that the mental component of the SF-36 fails to improve during follow-up, even though the physical component improves markedly among gastric bypass patients.

Other investigators have postulated that bariatric surgery precipitates profound changes "that may generate tension and pose special social, psychological, and lifestyle challenges. Preoperative and postoperative psychological assessment of social and emotional status related to post–bariatric surgical expectations and the potential risk of self-destructive behavior might be warranted," Dr. Adams and his associates said.

The rate of perioperative complications was 3% in the surgery group, and there were 38 hospitalizations for bypass-related indications.

This study was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Center for Research Resources. Dr. Adams’s associates reported ties to Vivus, Orexigen, GlaxoSmithKline, Health Outcome Solutions, and Ethicon Endo-Surgery.

Both weight loss and its associated improvements in cardiovascular and metabolic risk factors persisted for 6 years in most of the 418 severely obese adults who underwent Roux-en-Y gastric bypass surgery in a prospective study published in the Sept. 19 JAMA.

Despite some weight regain over time, surgery patients showed a mean weight loss of 28% at 6-year follow-up, as well as higher remission rates for diabetes, dyslipidemia, and hypertension, compared with the two control groups, said Ted D. Adams, Ph.D., of the department of internal medicine, University of Utah, Salt Lake City, and his associates.

© Sean Locke/iStockphoto.com

"Considering the 5%-9% weight loss at 1 year with only 2%-6% weight loss after 4 years of intensive lifestyle-based and medication-based therapy, the weight-loss maintenance of 28% ... in our Utah study is quite significant," they noted.

The study involved severely obese adults with a body mass index of 35 kg/m² or higher (mean BMI 45.9 kg/m²), of whom 82% were women and 96% were white. In addition to the patients who underwent either open or laparoscopic gastric bypass, there were 417 obese subjects in the first control group who were assessed for the surgery at the same time as the intervention group but did not have the surgery, and 321 obese subjects in the second control group who were randomly selected from a population-based sample of Utah residents.

Subjects in the control groups did not receive any weight-loss intervention as part of the study but were free to pursue it on their own. Over time, 101 of the subjects from both control groups chose to have bariatric surgery.

In the surgical group, mean weight loss was 35% at 2 years and 28% at 6 years, representing a 7% regain over time. By comparison, neither control group showed any significant weight loss or regain.

Diabetes remitted in 75% of the bypass group at 2 years, decreasing to 62% at 6 years. Despite the recurrence of diabetes in some patients, this long-term remission rate was dramatically better than the remission rates in the control groups (8% and 6%, respectively).

Similarly, the proportion of bypass patients who developed index diabetes during follow-up was markedly lower in the bypass group (2%) than in either control group (17% and 15%, respectively).

Remission of hypertension also was greater 6 years after bypass surgery (42%) than in the control groups (18% and 9%, respectively). Rates of high LDL cholesterol and triglycerides followed the same pattern, Dr. Adams and his colleagues wrote (JAMA 2012;308:1122-31).

Importantly, the weight loss and the concurrent improvement in cardiovascular and metabolic risk factors did not improve mortality. There were 29 deaths: 12 in the bypass group (3%); 14 in the first control group (3%); and 3 in the second control group (1%).

Notably, suicide was significantly more common in the bypass patients than in the control subjects. There were four suicides and three poisonings "of undetermined intention" overall, and six of these seven events occurred in bypass patients. The reason for this excess in the surgery group is unknown, but it is consistent with the finding that the mental component of the SF-36 fails to improve during follow-up, even though the physical component improves markedly among gastric bypass patients.

Other investigators have postulated that bariatric surgery precipitates profound changes "that may generate tension and pose special social, psychological, and lifestyle challenges. Preoperative and postoperative psychological assessment of social and emotional status related to post–bariatric surgical expectations and the potential risk of self-destructive behavior might be warranted," Dr. Adams and his associates said.

The rate of perioperative complications was 3% in the surgery group, and there were 38 hospitalizations for bypass-related indications.

This study was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Center for Research Resources. Dr. Adams’s associates reported ties to Vivus, Orexigen, GlaxoSmithKline, Health Outcome Solutions, and Ethicon Endo-Surgery.

Both weight loss and its associated improvements in cardiovascular and metabolic risk factors persisted for 6 years in most of the 418 severely obese adults who underwent Roux-en-Y gastric bypass surgery in a prospective study published in the Sept. 19 JAMA.

Despite some weight regain over time, surgery patients showed a mean weight loss of 28% at 6-year follow-up, as well as higher remission rates for diabetes, dyslipidemia, and hypertension, compared with the two control groups, said Ted D. Adams, Ph.D., of the department of internal medicine, University of Utah, Salt Lake City, and his associates.

© Sean Locke/iStockphoto.com

"Considering the 5%-9% weight loss at 1 year with only 2%-6% weight loss after 4 years of intensive lifestyle-based and medication-based therapy, the weight-loss maintenance of 28% ... in our Utah study is quite significant," they noted.

The study involved severely obese adults with a body mass index of 35 kg/m² or higher (mean BMI 45.9 kg/m²), of whom 82% were women and 96% were white. In addition to the patients who underwent either open or laparoscopic gastric bypass, there were 417 obese subjects in the first control group who were assessed for the surgery at the same time as the intervention group but did not have the surgery, and 321 obese subjects in the second control group who were randomly selected from a population-based sample of Utah residents.

Subjects in the control groups did not receive any weight-loss intervention as part of the study but were free to pursue it on their own. Over time, 101 of the subjects from both control groups chose to have bariatric surgery.

In the surgical group, mean weight loss was 35% at 2 years and 28% at 6 years, representing a 7% regain over time. By comparison, neither control group showed any significant weight loss or regain.

Diabetes remitted in 75% of the bypass group at 2 years, decreasing to 62% at 6 years. Despite the recurrence of diabetes in some patients, this long-term remission rate was dramatically better than the remission rates in the control groups (8% and 6%, respectively).

Similarly, the proportion of bypass patients who developed index diabetes during follow-up was markedly lower in the bypass group (2%) than in either control group (17% and 15%, respectively).

Remission of hypertension also was greater 6 years after bypass surgery (42%) than in the control groups (18% and 9%, respectively). Rates of high LDL cholesterol and triglycerides followed the same pattern, Dr. Adams and his colleagues wrote (JAMA 2012;308:1122-31).

Importantly, the weight loss and the concurrent improvement in cardiovascular and metabolic risk factors did not improve mortality. There were 29 deaths: 12 in the bypass group (3%); 14 in the first control group (3%); and 3 in the second control group (1%).

Notably, suicide was significantly more common in the bypass patients than in the control subjects. There were four suicides and three poisonings "of undetermined intention" overall, and six of these seven events occurred in bypass patients. The reason for this excess in the surgery group is unknown, but it is consistent with the finding that the mental component of the SF-36 fails to improve during follow-up, even though the physical component improves markedly among gastric bypass patients.

Other investigators have postulated that bariatric surgery precipitates profound changes "that may generate tension and pose special social, psychological, and lifestyle challenges. Preoperative and postoperative psychological assessment of social and emotional status related to post–bariatric surgical expectations and the potential risk of self-destructive behavior might be warranted," Dr. Adams and his associates said.

The rate of perioperative complications was 3% in the surgery group, and there were 38 hospitalizations for bypass-related indications.

This study was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Center for Research Resources. Dr. Adams’s associates reported ties to Vivus, Orexigen, GlaxoSmithKline, Health Outcome Solutions, and Ethicon Endo-Surgery.

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

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

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

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

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

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

My recent column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. "Isn’t it true," asked a colleague, "that most physicians tolerate marginal employees because it’s less painful than firing them?"

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. But sometimes it is unavoidable to preserve the efficiency and morale of yourself and your other employees.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as possible. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age. You cannot fire a woman because she is pregnant, or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting OSHA (Occupational Safety and Health Administration) violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims; or for exercising a legal right, such as voting or participating in a political demonstration.

And you cannot fire an alcohol abuser unless he or she is caught drinking at work; but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons, and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court.

As I’ve mentioned in the past, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since a wrongful termination lawsuit is always a possibility despite your best efforts to prevent it.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with, first thing on Monday morning. If you wait until Friday afternoon you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say; so for what it’s worth, here it is: "I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings."

There will, of course be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the story from you, not a distorted version through the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

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

My recent column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. "Isn’t it true," asked a colleague, "that most physicians tolerate marginal employees because it’s less painful than firing them?"

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. But sometimes it is unavoidable to preserve the efficiency and morale of yourself and your other employees.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as possible. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age. You cannot fire a woman because she is pregnant, or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting OSHA (Occupational Safety and Health Administration) violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims; or for exercising a legal right, such as voting or participating in a political demonstration.

And you cannot fire an alcohol abuser unless he or she is caught drinking at work; but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons, and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court.

As I’ve mentioned in the past, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since a wrongful termination lawsuit is always a possibility despite your best efforts to prevent it.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with, first thing on Monday morning. If you wait until Friday afternoon you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say; so for what it’s worth, here it is: "I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings."

There will, of course be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the story from you, not a distorted version through the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

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

My recent column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. "Isn’t it true," asked a colleague, "that most physicians tolerate marginal employees because it’s less painful than firing them?"

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. But sometimes it is unavoidable to preserve the efficiency and morale of yourself and your other employees.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as possible. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age. You cannot fire a woman because she is pregnant, or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting OSHA (Occupational Safety and Health Administration) violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims; or for exercising a legal right, such as voting or participating in a political demonstration.

And you cannot fire an alcohol abuser unless he or she is caught drinking at work; but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons, and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court.

As I’ve mentioned in the past, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since a wrongful termination lawsuit is always a possibility despite your best efforts to prevent it.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with, first thing on Monday morning. If you wait until Friday afternoon you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say; so for what it’s worth, here it is: "I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings."

There will, of course be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the story from you, not a distorted version through the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

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

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

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

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

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

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

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

As I write this, the government’s "new jobs" figures are at last turning a bit optimistic. This is consistent with the growing number of questions I’m receiving on a subject that hasn’t come up for awhile: hiring new employees. So although we probably haven’t seen the end of the Great Recession just yet, now might be a good time to review the basic rules in preparation for getting your office back to full speed.

Many of the personnel questions I receive concern the dreaded "marginal employee": the person who has done neither anything heinous enough to merit firing, nor anything special to merit continued employment. I always advise getting rid of such people, and then changing the hiring criteria that all too often result in poor hires.

Most bad hires come about because the employer does not have a clear vision of the kind of employee he or she wants. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate, from your initial screening of applicants through your assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.

So now – before a job vacancy occurs – is the time to reevaluate your entire hiring process. Take a hard look at your job descriptions, or start compiling them if you don’t have any. A good description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes (accurately and in detail) exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It is also sometimes tempting to hire the candidate that you have the "best feeling" about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.

Be alert for red flags in resumes: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of calling references; many applicants know that. Some old bosses will be reluctant to tell you anything substantive; I always ask, "Would you hire this person again?" You can interpret a lot from the answer – or lack of.

Interviews often get short shrift as well. Many doctors tend to do all the talking; as I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

But there are acceptable alternatives to some of those questions: You can ask if an applicant has ever gone by another name (for your background check), for example. You can ask if he or she is legally authorized to work in this country, and whether he or she will be physically able to perform the duties specified in the job description. Although past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. "The best executive," wrote Theodore Roosevelt, "is the one who has sense enough to pick good people to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it."

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

As I write this, the government’s "new jobs" figures are at last turning a bit optimistic. This is consistent with the growing number of questions I’m receiving on a subject that hasn’t come up for awhile: hiring new employees. So although we probably haven’t seen the end of the Great Recession just yet, now might be a good time to review the basic rules in preparation for getting your office back to full speed.

Many of the personnel questions I receive concern the dreaded "marginal employee": the person who has done neither anything heinous enough to merit firing, nor anything special to merit continued employment. I always advise getting rid of such people, and then changing the hiring criteria that all too often result in poor hires.

Most bad hires come about because the employer does not have a clear vision of the kind of employee he or she wants. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate, from your initial screening of applicants through your assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.

So now – before a job vacancy occurs – is the time to reevaluate your entire hiring process. Take a hard look at your job descriptions, or start compiling them if you don’t have any. A good description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes (accurately and in detail) exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It is also sometimes tempting to hire the candidate that you have the "best feeling" about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.

Be alert for red flags in resumes: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of calling references; many applicants know that. Some old bosses will be reluctant to tell you anything substantive; I always ask, "Would you hire this person again?" You can interpret a lot from the answer – or lack of.

Interviews often get short shrift as well. Many doctors tend to do all the talking; as I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

But there are acceptable alternatives to some of those questions: You can ask if an applicant has ever gone by another name (for your background check), for example. You can ask if he or she is legally authorized to work in this country, and whether he or she will be physically able to perform the duties specified in the job description. Although past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. "The best executive," wrote Theodore Roosevelt, "is the one who has sense enough to pick good people to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it."

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

As I write this, the government’s "new jobs" figures are at last turning a bit optimistic. This is consistent with the growing number of questions I’m receiving on a subject that hasn’t come up for awhile: hiring new employees. So although we probably haven’t seen the end of the Great Recession just yet, now might be a good time to review the basic rules in preparation for getting your office back to full speed.

Many of the personnel questions I receive concern the dreaded "marginal employee": the person who has done neither anything heinous enough to merit firing, nor anything special to merit continued employment. I always advise getting rid of such people, and then changing the hiring criteria that all too often result in poor hires.

Most bad hires come about because the employer does not have a clear vision of the kind of employee he or she wants. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate, from your initial screening of applicants through your assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.

So now – before a job vacancy occurs – is the time to reevaluate your entire hiring process. Take a hard look at your job descriptions, or start compiling them if you don’t have any. A good description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes (accurately and in detail) exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It is also sometimes tempting to hire the candidate that you have the "best feeling" about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.

Be alert for red flags in resumes: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of calling references; many applicants know that. Some old bosses will be reluctant to tell you anything substantive; I always ask, "Would you hire this person again?" You can interpret a lot from the answer – or lack of.

Interviews often get short shrift as well. Many doctors tend to do all the talking; as I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

But there are acceptable alternatives to some of those questions: You can ask if an applicant has ever gone by another name (for your background check), for example. You can ask if he or she is legally authorized to work in this country, and whether he or she will be physically able to perform the duties specified in the job description. Although past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. "The best executive," wrote Theodore Roosevelt, "is the one who has sense enough to pick good people to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it."

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

Visitors to my office often ask about the secret to maintaining "such a marvelous" 11-person staff. "You must pay them a fortune," they say.

Yes, they are compensated fairly; but that’s not why they stay. I know for a fact that many of them have turned down higher salaries at big clinics. Staff turnover is essentially nonexistent. (My most junior employee is going on 18 years.)

They remain, I believe, because I welcome their ideas; and I let them know on a regular basis that I notice and appreciate their efforts.

Soliciting employee input is a win-win; it builds loyalty and a sense of community, and you discover better ways to run your office.

I fancy myself an innovative guy, but I can’t think of everything myself. I don’t sit at the reception window; I don’t handle the phones; I don’t put patients in rooms. So, don’t let your staff keep good ideas to themselves. Your staff will only make the effort, however, if they understand that there is something in it for them, other than a token salary raise at year’s end.

The monthly office meeting is a great vehicle for brainstorming. I like my office manager to run them; or more precisely, we like to let them run themselves. We just moderate the discussion, identify problems, and solicit solutions. Usually the answer will come from the dialogue. In addition, we always leave time for airing of any proposals for general improvement of the office as a whole.

By encouraging my employees to propose solutions and suggest better methods and procedures, I demonstrate to them that they have a stake in the success of the office. And when a solution or a new suggestion is staff conceived, the staff has a stake in ensuring that it is implemented and that it works. This method also offers the opportunity to identify and work out minor problems before they become major ones.

Even in this digital age, an essential tool for me at office meetings is a good old-fashioned yellow legal pad, on which I note everything discussed. Each problem identified and each new idea offered is paired with proposed solutions and practical suggestions for implementation, and someone is assigned the responsibility of taking action. Not only does it guarantee that a problem will not continue and a good idea will not die, it also reassures staff that they are not just whistling in the dark when they point out a problem or propose a new office policy.

Some physicians hold meetings away from the office, perhaps at a local restaurant, going on the theory that staff will be more frank when outside of the office. Personally, I have never found my employees reluctant to express themselves in any setting, but if you have, consider that alternative.

Anytime someone comes up with a great idea, or calls attention to a significant issue, I make sure that the person hears – immediately and publicly – the praise that he or she deserves. That goes for all aspects of the office. Whenever I "catch someone doing something right," I note it, and praise that person.

Of course, it is also sometimes necessary to dole out constructive criticism; but as public as praise should be, criticism should be private. And the manner of the criticism is just as important as the setting. I prefer to point out the problem, ask what might have precipitated it, and suggest ways to correct it. After all, nobody is perfect. When you are understanding of your employees’ mistakes, they will be more understanding of yours.

The emphasis, however, is always on praise. When I leave at the end of the day I always thank the staff. If I can’t think of a specific thing to thank them for, I thank them for a good day. Employees thrive on praise, and will go out of their way to earn it.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email Dr. Eastern at [email protected].

Visitors to my office often ask about the secret to maintaining "such a marvelous" 11-person staff. "You must pay them a fortune," they say.

Yes, they are compensated fairly; but that’s not why they stay. I know for a fact that many of them have turned down higher salaries at big clinics. Staff turnover is essentially nonexistent. (My most junior employee is going on 18 years.)

They remain, I believe, because I welcome their ideas; and I let them know on a regular basis that I notice and appreciate their efforts.

Soliciting employee input is a win-win; it builds loyalty and a sense of community, and you discover better ways to run your office.

I fancy myself an innovative guy, but I can’t think of everything myself. I don’t sit at the reception window; I don’t handle the phones; I don’t put patients in rooms. So, don’t let your staff keep good ideas to themselves. Your staff will only make the effort, however, if they understand that there is something in it for them, other than a token salary raise at year’s end.

The monthly office meeting is a great vehicle for brainstorming. I like my office manager to run them; or more precisely, we like to let them run themselves. We just moderate the discussion, identify problems, and solicit solutions. Usually the answer will come from the dialogue. In addition, we always leave time for airing of any proposals for general improvement of the office as a whole.

By encouraging my employees to propose solutions and suggest better methods and procedures, I demonstrate to them that they have a stake in the success of the office. And when a solution or a new suggestion is staff conceived, the staff has a stake in ensuring that it is implemented and that it works. This method also offers the opportunity to identify and work out minor problems before they become major ones.

Even in this digital age, an essential tool for me at office meetings is a good old-fashioned yellow legal pad, on which I note everything discussed. Each problem identified and each new idea offered is paired with proposed solutions and practical suggestions for implementation, and someone is assigned the responsibility of taking action. Not only does it guarantee that a problem will not continue and a good idea will not die, it also reassures staff that they are not just whistling in the dark when they point out a problem or propose a new office policy.

Some physicians hold meetings away from the office, perhaps at a local restaurant, going on the theory that staff will be more frank when outside of the office. Personally, I have never found my employees reluctant to express themselves in any setting, but if you have, consider that alternative.

Anytime someone comes up with a great idea, or calls attention to a significant issue, I make sure that the person hears – immediately and publicly – the praise that he or she deserves. That goes for all aspects of the office. Whenever I "catch someone doing something right," I note it, and praise that person.

Of course, it is also sometimes necessary to dole out constructive criticism; but as public as praise should be, criticism should be private. And the manner of the criticism is just as important as the setting. I prefer to point out the problem, ask what might have precipitated it, and suggest ways to correct it. After all, nobody is perfect. When you are understanding of your employees’ mistakes, they will be more understanding of yours.

The emphasis, however, is always on praise. When I leave at the end of the day I always thank the staff. If I can’t think of a specific thing to thank them for, I thank them for a good day. Employees thrive on praise, and will go out of their way to earn it.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email Dr. Eastern at [email protected].

Visitors to my office often ask about the secret to maintaining "such a marvelous" 11-person staff. "You must pay them a fortune," they say.

Yes, they are compensated fairly; but that’s not why they stay. I know for a fact that many of them have turned down higher salaries at big clinics. Staff turnover is essentially nonexistent. (My most junior employee is going on 18 years.)

They remain, I believe, because I welcome their ideas; and I let them know on a regular basis that I notice and appreciate their efforts.

Soliciting employee input is a win-win; it builds loyalty and a sense of community, and you discover better ways to run your office.

I fancy myself an innovative guy, but I can’t think of everything myself. I don’t sit at the reception window; I don’t handle the phones; I don’t put patients in rooms. So, don’t let your staff keep good ideas to themselves. Your staff will only make the effort, however, if they understand that there is something in it for them, other than a token salary raise at year’s end.

The monthly office meeting is a great vehicle for brainstorming. I like my office manager to run them; or more precisely, we like to let them run themselves. We just moderate the discussion, identify problems, and solicit solutions. Usually the answer will come from the dialogue. In addition, we always leave time for airing of any proposals for general improvement of the office as a whole.

By encouraging my employees to propose solutions and suggest better methods and procedures, I demonstrate to them that they have a stake in the success of the office. And when a solution or a new suggestion is staff conceived, the staff has a stake in ensuring that it is implemented and that it works. This method also offers the opportunity to identify and work out minor problems before they become major ones.

Even in this digital age, an essential tool for me at office meetings is a good old-fashioned yellow legal pad, on which I note everything discussed. Each problem identified and each new idea offered is paired with proposed solutions and practical suggestions for implementation, and someone is assigned the responsibility of taking action. Not only does it guarantee that a problem will not continue and a good idea will not die, it also reassures staff that they are not just whistling in the dark when they point out a problem or propose a new office policy.

Some physicians hold meetings away from the office, perhaps at a local restaurant, going on the theory that staff will be more frank when outside of the office. Personally, I have never found my employees reluctant to express themselves in any setting, but if you have, consider that alternative.

Anytime someone comes up with a great idea, or calls attention to a significant issue, I make sure that the person hears – immediately and publicly – the praise that he or she deserves. That goes for all aspects of the office. Whenever I "catch someone doing something right," I note it, and praise that person.

Of course, it is also sometimes necessary to dole out constructive criticism; but as public as praise should be, criticism should be private. And the manner of the criticism is just as important as the setting. I prefer to point out the problem, ask what might have precipitated it, and suggest ways to correct it. After all, nobody is perfect. When you are understanding of your employees’ mistakes, they will be more understanding of yours.

The emphasis, however, is always on praise. When I leave at the end of the day I always thank the staff. If I can’t think of a specific thing to thank them for, I thank them for a good day. Employees thrive on praise, and will go out of their way to earn it.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email Dr. Eastern at [email protected].

My last few columns have covered various techniques for assuring that you are paid for what you do. However, despite your best efforts, there will always be a few deadbeats whom you will need to pursue. For the record, I’m speaking not about patients who fall on hard times and are unable to pay, but those who are able to pay and do not.

The worst kinds of deadbeats are the ones who rob you twice; they accept payments from insurance companies and then spend the money themselves. Such crooks must be pursued aggressively, with all the means at your disposal; but to reiterate the point I’ve tried to drive home recently, the best cure is prevention.

You already know that you should collect as many fees as possible at the time of service. For cosmetic procedures you should require a substantial deposit in advance, with the balance due at the time of service. When that is impossible, maximize the chances you will be paid by making sure all available payment mechanisms are in place.

In the last several columns (click here to access them), I described my credit-card-on-file system; patients who fail to pay their credit card bill are the credit card company’s problem, not yours. In cases in which you suspect fees might exceed credit card limits, you can arrange a realistic payment schedule in advance and have the patient fill out a credit application. You can find forms for this online at allbusiness.com, lawdog.com, and other sites.

In some cases, it may be worth the trouble to run a background check. There are easy and affordable ways to do this. Dunn & Bradstreet, for example, will furnish a report containing payment records and details of any lawsuits, liens, and other legal actions for as little as $30. The more financial information you have on file, the more leverage you have if a patient later balks at paying the balance.

Photo turner890/iStockphoto.com

For cosmetic work, always take before and after photos and have all patients sign a written consent giving permission for the procedure, assuming full financial responsibility, and acknowledging that no guarantees have been given or implied. This defuses the common deadbeat tactics of professing ignorance of personal financial obligation and/or dissatisfaction with results.

Despite all your precautions, a deadbeat will inevitably slip through on occasion; but even then, you have options for extracting payment. Collection agencies are the traditional first line of attack for most medical practices. Ideally, your agency should specialize in handling medical accounts, so it will know exactly how much pressure to exert to avoid charges of harassment. Delinquent accounts should be submitted earlier rather than later to maximize the chances of success; my manager never allows an account to age more than 90 days, and if circumstances dictate, she refers them sooner than that.

When collection agencies fail, think about small claims court. You’ll need to learn the rules for filing in your state, but most charge a nominal fee and place a limit of $5,000 or so on claims. No attorneys are involved. If your paperwork is in order, the court will nearly always rule in your favor, but it will not provide the means for actual collection. In other words, you’ll still have to persuade the deadbeat to pay up. However, in many states, a court order will give you the authority to attach a lien to property or garnish wages, which often provides enough leverage to force payment.

What about those double deadbeats who steal the insurance checks? First, check your third-party contract; sometimes, the insurance company or HMO will be compelled to pay you directly and then will go after the patient itself to get back its money. (They won’t volunteer this service, however – you’ll have to ask for it.)

If that’s not an option, consider reporting the misdirected payment to the Internal Revenue Service as income to the patient, by submitting a 1099-Miscellaneous Income form. Be sure to notify the deadbeat that you will be doing this. Sometimes, the threat of such action will convince the crook to pay up; but if not, at least you’ll have the satisfaction of knowing he or she will have to pay taxes on the money.

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

My last few columns have covered various techniques for assuring that you are paid for what you do. However, despite your best efforts, there will always be a few deadbeats whom you will need to pursue. For the record, I’m speaking not about patients who fall on hard times and are unable to pay, but those who are able to pay and do not.

The worst kinds of deadbeats are the ones who rob you twice; they accept payments from insurance companies and then spend the money themselves. Such crooks must be pursued aggressively, with all the means at your disposal; but to reiterate the point I’ve tried to drive home recently, the best cure is prevention.

You already know that you should collect as many fees as possible at the time of service. For cosmetic procedures you should require a substantial deposit in advance, with the balance due at the time of service. When that is impossible, maximize the chances you will be paid by making sure all available payment mechanisms are in place.

In the last several columns (click here to access them), I described my credit-card-on-file system; patients who fail to pay their credit card bill are the credit card company’s problem, not yours. In cases in which you suspect fees might exceed credit card limits, you can arrange a realistic payment schedule in advance and have the patient fill out a credit application. You can find forms for this online at allbusiness.com, lawdog.com, and other sites.

In some cases, it may be worth the trouble to run a background check. There are easy and affordable ways to do this. Dunn & Bradstreet, for example, will furnish a report containing payment records and details of any lawsuits, liens, and other legal actions for as little as $30. The more financial information you have on file, the more leverage you have if a patient later balks at paying the balance.

Photo turner890/iStockphoto.com

For cosmetic work, always take before and after photos and have all patients sign a written consent giving permission for the procedure, assuming full financial responsibility, and acknowledging that no guarantees have been given or implied. This defuses the common deadbeat tactics of professing ignorance of personal financial obligation and/or dissatisfaction with results.

Despite all your precautions, a deadbeat will inevitably slip through on occasion; but even then, you have options for extracting payment. Collection agencies are the traditional first line of attack for most medical practices. Ideally, your agency should specialize in handling medical accounts, so it will know exactly how much pressure to exert to avoid charges of harassment. Delinquent accounts should be submitted earlier rather than later to maximize the chances of success; my manager never allows an account to age more than 90 days, and if circumstances dictate, she refers them sooner than that.

When collection agencies fail, think about small claims court. You’ll need to learn the rules for filing in your state, but most charge a nominal fee and place a limit of $5,000 or so on claims. No attorneys are involved. If your paperwork is in order, the court will nearly always rule in your favor, but it will not provide the means for actual collection. In other words, you’ll still have to persuade the deadbeat to pay up. However, in many states, a court order will give you the authority to attach a lien to property or garnish wages, which often provides enough leverage to force payment.

What about those double deadbeats who steal the insurance checks? First, check your third-party contract; sometimes, the insurance company or HMO will be compelled to pay you directly and then will go after the patient itself to get back its money. (They won’t volunteer this service, however – you’ll have to ask for it.)

If that’s not an option, consider reporting the misdirected payment to the Internal Revenue Service as income to the patient, by submitting a 1099-Miscellaneous Income form. Be sure to notify the deadbeat that you will be doing this. Sometimes, the threat of such action will convince the crook to pay up; but if not, at least you’ll have the satisfaction of knowing he or she will have to pay taxes on the money.

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

My last few columns have covered various techniques for assuring that you are paid for what you do. However, despite your best efforts, there will always be a few deadbeats whom you will need to pursue. For the record, I’m speaking not about patients who fall on hard times and are unable to pay, but those who are able to pay and do not.

The worst kinds of deadbeats are the ones who rob you twice; they accept payments from insurance companies and then spend the money themselves. Such crooks must be pursued aggressively, with all the means at your disposal; but to reiterate the point I’ve tried to drive home recently, the best cure is prevention.

You already know that you should collect as many fees as possible at the time of service. For cosmetic procedures you should require a substantial deposit in advance, with the balance due at the time of service. When that is impossible, maximize the chances you will be paid by making sure all available payment mechanisms are in place.

In the last several columns (click here to access them), I described my credit-card-on-file system; patients who fail to pay their credit card bill are the credit card company’s problem, not yours. In cases in which you suspect fees might exceed credit card limits, you can arrange a realistic payment schedule in advance and have the patient fill out a credit application. You can find forms for this online at allbusiness.com, lawdog.com, and other sites.

In some cases, it may be worth the trouble to run a background check. There are easy and affordable ways to do this. Dunn & Bradstreet, for example, will furnish a report containing payment records and details of any lawsuits, liens, and other legal actions for as little as $30. The more financial information you have on file, the more leverage you have if a patient later balks at paying the balance.

Photo turner890/iStockphoto.com

For cosmetic work, always take before and after photos and have all patients sign a written consent giving permission for the procedure, assuming full financial responsibility, and acknowledging that no guarantees have been given or implied. This defuses the common deadbeat tactics of professing ignorance of personal financial obligation and/or dissatisfaction with results.

Despite all your precautions, a deadbeat will inevitably slip through on occasion; but even then, you have options for extracting payment. Collection agencies are the traditional first line of attack for most medical practices. Ideally, your agency should specialize in handling medical accounts, so it will know exactly how much pressure to exert to avoid charges of harassment. Delinquent accounts should be submitted earlier rather than later to maximize the chances of success; my manager never allows an account to age more than 90 days, and if circumstances dictate, she refers them sooner than that.

When collection agencies fail, think about small claims court. You’ll need to learn the rules for filing in your state, but most charge a nominal fee and place a limit of $5,000 or so on claims. No attorneys are involved. If your paperwork is in order, the court will nearly always rule in your favor, but it will not provide the means for actual collection. In other words, you’ll still have to persuade the deadbeat to pay up. However, in many states, a court order will give you the authority to attach a lien to property or garnish wages, which often provides enough leverage to force payment.

What about those double deadbeats who steal the insurance checks? First, check your third-party contract; sometimes, the insurance company or HMO will be compelled to pay you directly and then will go after the patient itself to get back its money. (They won’t volunteer this service, however – you’ll have to ask for it.)

If that’s not an option, consider reporting the misdirected payment to the Internal Revenue Service as income to the patient, by submitting a 1099-Miscellaneous Income form. Be sure to notify the deadbeat that you will be doing this. Sometimes, the threat of such action will convince the crook to pay up; but if not, at least you’ll have the satisfaction of knowing he or she will have to pay taxes on the money.

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