Perspective -- Delegation

It’s interesting that the more things change, the more they stay the same. The most easily correctable problem I see in private offices today is the same one I saw 30 years ago: underdelegation. (A newer and more alarming problem is overdelegation, but we’ll get to that later.)

Private practitioners famously spend inordinate amounts of time embroiled in minutiae. After all, they are continually hearing the same mantra from know-it-alls like me: The physician is the captain of the vessel, and ultimate responsibility for everyone’s screw-ups rests with you; ergo, as captain, you must run a tight ship.

There is a big difference, however, between maintaining control of your practice’s inner workings and micromanaging the day-to-day details. One never sees a ship’s captain swabbing the decks, cooking the meals, or fixing the engine, and you shouldn’t be billing, purchasing, or arguing with pharmacists when there are patients to see.

Most doctors do delegate, of course, but many don’t do it enough. Try this experiment: For a week, write down everything you do around the office, especially the menial stuff. Then, over the weekend, look at your list. You’ll probably be surprised at how much time you waste on chores that could be delegated.

Handing off tasks can be hard – especially if you have the “nobody does it as well as I do” disease. My rule of thumb: Everything requiring a physician’s license should be done by physicians; everything else should be done by employees or contractors.

I know what you’re thinking: This is going to cost me, and the results won’t be up to my standards. Your overhead may increase while employees learn new duties. You may also need to raise salaries to compensate for the increased workload, or even hire a new person or two. Simple arithmetic, though, will show that in the long run a new employee working at a fraction of your hourly rate will do the job cheaper than you can. Granted, you cannot expect them to immediately do it as well as you do, but with time, proper training, and a bit of patience, employees will nearly always meet, and even exceed, your expectations.

Be alert, however, for something I call reverse delegation. It’s not at all unusual for an employee, faced with a new assignment, to pepper the boss with questions, complaints, and fears about doing it properly. It’s easy, at this point, to yield to the pressure and simply do the job yourself. You have taken the bait: Your subordinate has delegated the task back to you!

If you employ nurse practitioners or physician assistants, reassess your options with them as well. Consider additional aspects of examination, diagnosis, testing, and treatment of routine patients that they could be doing, which will in turn free up more of your time for new patients and complex cases.

Remember, though, that state laws vary on who can delegate what to whom. Consult your attorney and local medical association if there is any question about what your state permits, particularly with regard to NPs and PAs.

And that brings us to the disturbing trend of overdelegation. Last year, the Department of Health and Human Services’ Office of Inspector General (a government office you never want to hear from) looked at services billed under Medicare’s “incident-to” rule to determine whether nonphysician billings were appropriate. When suspicious data were identified – for example, when billed services for a single day exceeded 24 hours – the suspect practice was investigated.

The OIG’s report concluded that 21% of services not performed personally by physicians in their selective sample were performed by unqualified nonphysicians.

Offices were found in which Mohs was being delegated to unqualified staff, including, in some cases, untrained medical assistants. The report was based on a relatively small sample, so it is not clear how prevalent such practices are, but, clearly, any prevalence is too high, and you will not fare well with the OIG if you are caught.

Delegating doesn’t mean handing off a task and forgetting about it. Always maintain an open flow of communication with your employees. A good boss does not micromanage, but does remain in the loop.

Dr. Joseph S. Eastern writes the column, “Managing Your Dermatology Practice,” which regularly appears in Skin & Allergy News, an Elsevier publication. 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].

It’s interesting that the more things change, the more they stay the same. The most easily correctable problem I see in private offices today is the same one I saw 30 years ago: underdelegation. (A newer and more alarming problem is overdelegation, but we’ll get to that later.)

Private practitioners famously spend inordinate amounts of time embroiled in minutiae. After all, they are continually hearing the same mantra from know-it-alls like me: The physician is the captain of the vessel, and ultimate responsibility for everyone’s screw-ups rests with you; ergo, as captain, you must run a tight ship.

There is a big difference, however, between maintaining control of your practice’s inner workings and micromanaging the day-to-day details. One never sees a ship’s captain swabbing the decks, cooking the meals, or fixing the engine, and you shouldn’t be billing, purchasing, or arguing with pharmacists when there are patients to see.

Most doctors do delegate, of course, but many don’t do it enough. Try this experiment: For a week, write down everything you do around the office, especially the menial stuff. Then, over the weekend, look at your list. You’ll probably be surprised at how much time you waste on chores that could be delegated.

Handing off tasks can be hard – especially if you have the “nobody does it as well as I do” disease. My rule of thumb: Everything requiring a physician’s license should be done by physicians; everything else should be done by employees or contractors.

I know what you’re thinking: This is going to cost me, and the results won’t be up to my standards. Your overhead may increase while employees learn new duties. You may also need to raise salaries to compensate for the increased workload, or even hire a new person or two. Simple arithmetic, though, will show that in the long run a new employee working at a fraction of your hourly rate will do the job cheaper than you can. Granted, you cannot expect them to immediately do it as well as you do, but with time, proper training, and a bit of patience, employees will nearly always meet, and even exceed, your expectations.

Be alert, however, for something I call reverse delegation. It’s not at all unusual for an employee, faced with a new assignment, to pepper the boss with questions, complaints, and fears about doing it properly. It’s easy, at this point, to yield to the pressure and simply do the job yourself. You have taken the bait: Your subordinate has delegated the task back to you!

If you employ nurse practitioners or physician assistants, reassess your options with them as well. Consider additional aspects of examination, diagnosis, testing, and treatment of routine patients that they could be doing, which will in turn free up more of your time for new patients and complex cases.

Remember, though, that state laws vary on who can delegate what to whom. Consult your attorney and local medical association if there is any question about what your state permits, particularly with regard to NPs and PAs.

And that brings us to the disturbing trend of overdelegation. Last year, the Department of Health and Human Services’ Office of Inspector General (a government office you never want to hear from) looked at services billed under Medicare’s “incident-to” rule to determine whether nonphysician billings were appropriate. When suspicious data were identified – for example, when billed services for a single day exceeded 24 hours – the suspect practice was investigated.

The OIG’s report concluded that 21% of services not performed personally by physicians in their selective sample were performed by unqualified nonphysicians.

Offices were found in which Mohs was being delegated to unqualified staff, including, in some cases, untrained medical assistants. The report was based on a relatively small sample, so it is not clear how prevalent such practices are, but, clearly, any prevalence is too high, and you will not fare well with the OIG if you are caught.

Delegating doesn’t mean handing off a task and forgetting about it. Always maintain an open flow of communication with your employees. A good boss does not micromanage, but does remain in the loop.

Dr. Joseph S. Eastern writes the column, “Managing Your Dermatology Practice,” which regularly appears in Skin & Allergy News, an Elsevier publication. 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].

It’s interesting that the more things change, the more they stay the same. The most easily correctable problem I see in private offices today is the same one I saw 30 years ago: underdelegation. (A newer and more alarming problem is overdelegation, but we’ll get to that later.)

Private practitioners famously spend inordinate amounts of time embroiled in minutiae. After all, they are continually hearing the same mantra from know-it-alls like me: The physician is the captain of the vessel, and ultimate responsibility for everyone’s screw-ups rests with you; ergo, as captain, you must run a tight ship.

There is a big difference, however, between maintaining control of your practice’s inner workings and micromanaging the day-to-day details. One never sees a ship’s captain swabbing the decks, cooking the meals, or fixing the engine, and you shouldn’t be billing, purchasing, or arguing with pharmacists when there are patients to see.

Most doctors do delegate, of course, but many don’t do it enough. Try this experiment: For a week, write down everything you do around the office, especially the menial stuff. Then, over the weekend, look at your list. You’ll probably be surprised at how much time you waste on chores that could be delegated.

Handing off tasks can be hard – especially if you have the “nobody does it as well as I do” disease. My rule of thumb: Everything requiring a physician’s license should be done by physicians; everything else should be done by employees or contractors.

I know what you’re thinking: This is going to cost me, and the results won’t be up to my standards. Your overhead may increase while employees learn new duties. You may also need to raise salaries to compensate for the increased workload, or even hire a new person or two. Simple arithmetic, though, will show that in the long run a new employee working at a fraction of your hourly rate will do the job cheaper than you can. Granted, you cannot expect them to immediately do it as well as you do, but with time, proper training, and a bit of patience, employees will nearly always meet, and even exceed, your expectations.

Be alert, however, for something I call reverse delegation. It’s not at all unusual for an employee, faced with a new assignment, to pepper the boss with questions, complaints, and fears about doing it properly. It’s easy, at this point, to yield to the pressure and simply do the job yourself. You have taken the bait: Your subordinate has delegated the task back to you!

If you employ nurse practitioners or physician assistants, reassess your options with them as well. Consider additional aspects of examination, diagnosis, testing, and treatment of routine patients that they could be doing, which will in turn free up more of your time for new patients and complex cases.

Remember, though, that state laws vary on who can delegate what to whom. Consult your attorney and local medical association if there is any question about what your state permits, particularly with regard to NPs and PAs.

And that brings us to the disturbing trend of overdelegation. Last year, the Department of Health and Human Services’ Office of Inspector General (a government office you never want to hear from) looked at services billed under Medicare’s “incident-to” rule to determine whether nonphysician billings were appropriate. When suspicious data were identified – for example, when billed services for a single day exceeded 24 hours – the suspect practice was investigated.

The OIG’s report concluded that 21% of services not performed personally by physicians in their selective sample were performed by unqualified nonphysicians.

Offices were found in which Mohs was being delegated to unqualified staff, including, in some cases, untrained medical assistants. The report was based on a relatively small sample, so it is not clear how prevalent such practices are, but, clearly, any prevalence is too high, and you will not fare well with the OIG if you are caught.

Delegating doesn’t mean handing off a task and forgetting about it. Always maintain an open flow of communication with your employees. A good boss does not micromanage, but does remain in the loop.

Dr. Joseph S. Eastern writes the column, “Managing Your Dermatology Practice,” which regularly appears in Skin & Allergy News, an Elsevier publication. 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].