Managing Your Practice

The obstacles faced by healthcare providers and patients in rural areas are vastly different than those in urban areas. Rural Americans face a unique combination of factors that create disparities in healthcare not found in urban areas:

• Only about 10% of physicians practice in rural America despite the fact that nearly one-fourth of the population lives in these areas.
• Rural residents tend to be poorer. On the average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty line. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty.
• Hypertension is higher in rural than urban areas (101.3 per 1,000 individuals in MSAs and 128.8 per 1,000 individuals in non-MSAs).
• 20% of nonmetropolitan counties lack mental health services, compared with 5% of metropolitan counties.
• Medicare payments to rural hospitals and physicians are dramatically less than those to their urban counterparts for equivalent services. And more than 470 rural hospitals have closed in the past 25 years.
• Medicare patients with acute myocardial infarction (AMI) who were treated in rural hospitals were less likely than those treated in urban hospitals to receive recommended treatments and had significantly higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals.
• Rural residents have greater transportation difficulties reaching healthcare providers, often traveling great distances to reach a doctor or hospital.

Source: www.ruralhealthweb.org

The obstacles faced by healthcare providers and patients in rural areas are vastly different than those in urban areas. Rural Americans face a unique combination of factors that create disparities in healthcare not found in urban areas:

• Only about 10% of physicians practice in rural America despite the fact that nearly one-fourth of the population lives in these areas.
• Rural residents tend to be poorer. On the average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty line. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty.
• Hypertension is higher in rural than urban areas (101.3 per 1,000 individuals in MSAs and 128.8 per 1,000 individuals in non-MSAs).
• 20% of nonmetropolitan counties lack mental health services, compared with 5% of metropolitan counties.
• Medicare payments to rural hospitals and physicians are dramatically less than those to their urban counterparts for equivalent services. And more than 470 rural hospitals have closed in the past 25 years.
• Medicare patients with acute myocardial infarction (AMI) who were treated in rural hospitals were less likely than those treated in urban hospitals to receive recommended treatments and had significantly higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals.
• Rural residents have greater transportation difficulties reaching healthcare providers, often traveling great distances to reach a doctor or hospital.

Source: www.ruralhealthweb.org

The obstacles faced by healthcare providers and patients in rural areas are vastly different than those in urban areas. Rural Americans face a unique combination of factors that create disparities in healthcare not found in urban areas:

• Only about 10% of physicians practice in rural America despite the fact that nearly one-fourth of the population lives in these areas.
• Rural residents tend to be poorer. On the average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty line. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty.
• Hypertension is higher in rural than urban areas (101.3 per 1,000 individuals in MSAs and 128.8 per 1,000 individuals in non-MSAs).
• 20% of nonmetropolitan counties lack mental health services, compared with 5% of metropolitan counties.
• Medicare payments to rural hospitals and physicians are dramatically less than those to their urban counterparts for equivalent services. And more than 470 rural hospitals have closed in the past 25 years.
• Medicare patients with acute myocardial infarction (AMI) who were treated in rural hospitals were less likely than those treated in urban hospitals to receive recommended treatments and had significantly higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals.
• Rural residents have greater transportation difficulties reaching healthcare providers, often traveling great distances to reach a doctor or hospital.

Source: www.ruralhealthweb.org

SHM immediate past president Joseph Ming Wah Li, MD, SFHM, practices hospital medicine at Beth Israel Deaconess Medical Center in Boston, but Oklahoma is where he grew up, went to medical school, and performed rural rotations. Some parts of hospitalist practice are the same at big and small hospitals, urban and rural settings, he says.

“Recruitment of high-quality physicians is always a challenge,” Dr. Li says. “That’s where SHM can help.”

SHM’s Career Center, official publications, and the SHM annual meeting are excellent avenues for recruitment, Dr. Li says. SHM also offers online practice-management tools and a variety of collaborative resources—SQUINT, a searchable repository of innovative QI methods and systems, and an electronic QI toolkit known as eQUIPS—to help rural hospitalists.

Based in Kansas City, the National Rural Health Association (www.ruralhealthweb.org) provides additional resources for small, rural hospitals. The NRHA is working with the Office of the National Coordinator for Health IT and 62 Regional Extension Centers to help rural providers with EHR adoption and implementation, guiding them to meet meaningful-use standards.

“NRHA is a member organization with multiple constituencies,” says Brock Slabach, senior vice president for member services. “If anybody in hospital medicine works in a rural community and wants to connect with an organization like ours, we don’t have a lot of hospitalist members, but we would welcome them.”

SHM immediate past president Joseph Ming Wah Li, MD, SFHM, practices hospital medicine at Beth Israel Deaconess Medical Center in Boston, but Oklahoma is where he grew up, went to medical school, and performed rural rotations. Some parts of hospitalist practice are the same at big and small hospitals, urban and rural settings, he says.

“Recruitment of high-quality physicians is always a challenge,” Dr. Li says. “That’s where SHM can help.”

SHM’s Career Center, official publications, and the SHM annual meeting are excellent avenues for recruitment, Dr. Li says. SHM also offers online practice-management tools and a variety of collaborative resources—SQUINT, a searchable repository of innovative QI methods and systems, and an electronic QI toolkit known as eQUIPS—to help rural hospitalists.

Based in Kansas City, the National Rural Health Association (www.ruralhealthweb.org) provides additional resources for small, rural hospitals. The NRHA is working with the Office of the National Coordinator for Health IT and 62 Regional Extension Centers to help rural providers with EHR adoption and implementation, guiding them to meet meaningful-use standards.

“NRHA is a member organization with multiple constituencies,” says Brock Slabach, senior vice president for member services. “If anybody in hospital medicine works in a rural community and wants to connect with an organization like ours, we don’t have a lot of hospitalist members, but we would welcome them.”

SHM immediate past president Joseph Ming Wah Li, MD, SFHM, practices hospital medicine at Beth Israel Deaconess Medical Center in Boston, but Oklahoma is where he grew up, went to medical school, and performed rural rotations. Some parts of hospitalist practice are the same at big and small hospitals, urban and rural settings, he says.

“Recruitment of high-quality physicians is always a challenge,” Dr. Li says. “That’s where SHM can help.”

SHM’s Career Center, official publications, and the SHM annual meeting are excellent avenues for recruitment, Dr. Li says. SHM also offers online practice-management tools and a variety of collaborative resources—SQUINT, a searchable repository of innovative QI methods and systems, and an electronic QI toolkit known as eQUIPS—to help rural hospitalists.

Based in Kansas City, the National Rural Health Association (www.ruralhealthweb.org) provides additional resources for small, rural hospitals. The NRHA is working with the Office of the National Coordinator for Health IT and 62 Regional Extension Centers to help rural providers with EHR adoption and implementation, guiding them to meet meaningful-use standards.

“NRHA is a member organization with multiple constituencies,” says Brock Slabach, senior vice president for member services. “If anybody in hospital medicine works in a rural community and wants to connect with an organization like ours, we don’t have a lot of hospitalist members, but we would welcome them.”

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

 

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

 

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

 

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

Where do rural hospitals look if they are having trouble attracting hospitalists to their communities—and keeping them there? One target should be graduates of international medical schools. Brian Bossard, MD, FACP, FHM, director of Inpatient Physician Associates in Lincoln, Neb., estimates that he has recruited 40 physicians to HM practice at the three hospitals his group serves, and at least a dozen of them were international medical graduates (IMGs).

Dr. Bossard works closely with a specialized immigration attorney, Elahe Najfabadi of the Offices of Carl Shusterman in Los Angeles. “There are lots of barriers to address to negotiate positive outcomes,” Dr. Bossard says. “You need an attorney you can rely on thoroughly.”

There are basically two categories of visas for IMGs: H-1B visas, which are capped nationally but allow doctors the flexibility to move around, and J-1 visas, which allow clinicians to remain in the U.S. while completing their medical studies. J-1 visas expire after two years, but physicians often are granted waivers and remain in the U.S.

According to Najfabadi, each state is allowed 30 physician J-1 visa waivers annually. Physicians must work in underserved areas, including rural communities, and those physicians must stay in the job for three years.

When it comes to the J-1 waiver program, timelines, deadlines, requirements for employers, and other regulations vary by state.

“In one state, we’ve had cases where the state wants verification of the doctor’s approved immigration status before issuing the medical license,” Najfabadi says.

The Immigration and Naturalization Service requires a valid license or a letter from the state that the physician is eligible in order to grant an H-1B permit. Najfabadi encourages potential rural employers of IMGs to learn the rules in their state, and to take advantage of such resources such as the IMG Task Force (http://www.imgtaskforce.org/).

“What I have found is that we get exceedingly high-quality physicians to provide care in rural communities,” Dr. Bossard says. “I love working with them.”

Larry Beresford is a freelance writer in Oakland, Calif.

 

 

Where do rural hospitals look if they are having trouble attracting hospitalists to their communities—and keeping them there? One target should be graduates of international medical schools. Brian Bossard, MD, FACP, FHM, director of Inpatient Physician Associates in Lincoln, Neb., estimates that he has recruited 40 physicians to HM practice at the three hospitals his group serves, and at least a dozen of them were international medical graduates (IMGs).

Dr. Bossard works closely with a specialized immigration attorney, Elahe Najfabadi of the Offices of Carl Shusterman in Los Angeles. “There are lots of barriers to address to negotiate positive outcomes,” Dr. Bossard says. “You need an attorney you can rely on thoroughly.”

There are basically two categories of visas for IMGs: H-1B visas, which are capped nationally but allow doctors the flexibility to move around, and J-1 visas, which allow clinicians to remain in the U.S. while completing their medical studies. J-1 visas expire after two years, but physicians often are granted waivers and remain in the U.S.

According to Najfabadi, each state is allowed 30 physician J-1 visa waivers annually. Physicians must work in underserved areas, including rural communities, and those physicians must stay in the job for three years.

When it comes to the J-1 waiver program, timelines, deadlines, requirements for employers, and other regulations vary by state.

“In one state, we’ve had cases where the state wants verification of the doctor’s approved immigration status before issuing the medical license,” Najfabadi says.

The Immigration and Naturalization Service requires a valid license or a letter from the state that the physician is eligible in order to grant an H-1B permit. Najfabadi encourages potential rural employers of IMGs to learn the rules in their state, and to take advantage of such resources such as the IMG Task Force (http://www.imgtaskforce.org/).

“What I have found is that we get exceedingly high-quality physicians to provide care in rural communities,” Dr. Bossard says. “I love working with them.”

Larry Beresford is a freelance writer in Oakland, Calif.

 

 

Where do rural hospitals look if they are having trouble attracting hospitalists to their communities—and keeping them there? One target should be graduates of international medical schools. Brian Bossard, MD, FACP, FHM, director of Inpatient Physician Associates in Lincoln, Neb., estimates that he has recruited 40 physicians to HM practice at the three hospitals his group serves, and at least a dozen of them were international medical graduates (IMGs).

Dr. Bossard works closely with a specialized immigration attorney, Elahe Najfabadi of the Offices of Carl Shusterman in Los Angeles. “There are lots of barriers to address to negotiate positive outcomes,” Dr. Bossard says. “You need an attorney you can rely on thoroughly.”

There are basically two categories of visas for IMGs: H-1B visas, which are capped nationally but allow doctors the flexibility to move around, and J-1 visas, which allow clinicians to remain in the U.S. while completing their medical studies. J-1 visas expire after two years, but physicians often are granted waivers and remain in the U.S.

According to Najfabadi, each state is allowed 30 physician J-1 visa waivers annually. Physicians must work in underserved areas, including rural communities, and those physicians must stay in the job for three years.

When it comes to the J-1 waiver program, timelines, deadlines, requirements for employers, and other regulations vary by state.

“In one state, we’ve had cases where the state wants verification of the doctor’s approved immigration status before issuing the medical license,” Najfabadi says.

The Immigration and Naturalization Service requires a valid license or a letter from the state that the physician is eligible in order to grant an H-1B permit. Najfabadi encourages potential rural employers of IMGs to learn the rules in their state, and to take advantage of such resources such as the IMG Task Force (http://www.imgtaskforce.org/).

“What I have found is that we get exceedingly high-quality physicians to provide care in rural communities,” Dr. Bossard says. “I love working with them.”

Larry Beresford is a freelance writer in Oakland, Calif.

 

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

Click here to listen to Dr. Johns

Click here to listen to Dr. Johns

Click here to listen to Dr. Johns

Click here to listen to the state officials

Click here to listen to the state officials

Click here to listen to the state officials

Woman told “Biopsy isn’t urgent”

TWO MONTHS AFTER HER INITIAL VISIT, a 58-year-old woman returned to the gynecologist with vaginal bleeding. In March 2004, ultrasonography (US) showed slight thickening of the endometrial lining and a “pin dot” described as being a prepolyp. Vaginal bleeding was determined to be due to thinning of the vaginal wall with menopause.

The patient reported daily vaginal bleeding when she saw the gynecologist in January 2005. A new, large, rounded, solid mass within the endometrial cavity consistent with a large endometrial polyp was seen on US. The radiologist recommended hysteroscopic biopsy with excision, but the gynecologist told the patient it was not urgent.

In March 2005, hysteroscopy confirmed carcinosarcoma of the uterus. The patient underwent a hysterectomy followed by pelvic radiation and brachytherapy.

Eight months later, metastasis was found in the lungs; she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to react when the patient first reported vaginal bleeding. An earlier diagnosis could have prevented her death.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT An $820,000 Massachusetts settlement was reached.

US report misses fetal abnormalities

A PREGNANT WOMAN UNDERWENT US. The preliminary report indicated echogenic cardiac focus and unilateral pyelectasis. Twenty-five days later, the mother underwent a level II US. A radiologist wrote that fetal anatomy was normal in both reports. The mother had two additional sonograms, with no reported abnormality.

The baby was born with aplasia and hypoplasia with both arms absent below a short humerus, an absent left leg, and a shortened right leg with a remnant foot and three small toes.

PARENTS’ CLAIM The radiologist’s US reports failed to accurately describe the fetal anatomy, depriving the parents of the chance to terminate the pregnancy.

DEFENDANTS’ DEFENSE Proper treatment was given.

VERDICT A $4.5 million Florida verdict was returned. Fault was assigned to the radiologist (85%) and the level II technologist (15%).

Forceps delivery injures mother’s pelvic floor

DURING A TRIAL OF LABOR, a 34-year-old woman experienced deep transverse arrest and lack of progress due to pelvic restriction. The ObGyn proceeded to deliver the baby vaginally using forceps, which caused pelvic floor injuries to the mother.

Several months later, she underwent corrective repair surgery for pelvic floor prolapse. She has continuing vaginal and rectal pain and dysfunction.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as pelvic restriction was found. The injuries reduce the woman’s chances of having another child.

PHYSICIAN’S DEFENSE A trial of labor was proper. The patient’s continuing fertility problems are related to chronic yeast infections and prescription birth control.

VERDICT A $1,716,469 Illinois verdict was returned, which included $484,000 to the patient’s husband for loss of consortium.

7 CASES OF INJURED BOWEL

1 Woman dies from bowel injury

DURING A SLING PROCEDURE for vaginal prolapse, a 50-year-old woman required a transfusion. The next day, she was nauseated and constipated. A day later, she went to the ED with shortness of breath and chest and abdominal pain. Her symptoms persisted for 8 days before an injury to her transverse colon was found during exploratory surgery. She suffered massive organ failure caused by sepsis and died 3 weeks after the initial surgery.

ESTATE’S CLAIM The gynecologist should have investigated why she needed a transfusion during surgery. He should have reacted earlier to her postsurgical complaints.

PHYSICIAN’S DEFENSE Bowel injury is a known risk of the procedure. The patient suffered multiple strokes after being readmitted to the hospital.

VERDICT A $2.4 million South Carolina verdict was returned.

2 Colostomy, coma after hysterectomy

DUE TO FIBROID TUMORS and pelvic pain, a 39-year-old woman’s ObGyn suggested laparoscopic-assisted vaginal hysterectomy. A third-year resident performed most of the procedure. The ObGyn’s associate covered postsurgical care.

When the patient reported increasing pain and rectal bleeding, an exploratory laparotomy was performed 3 days after surgery. Bowel and ureter injuries were repaired and a permanent colostomy was created. The patient developed septic shock with multiple organ failure, and was placed in a chemically induced coma for 3 weeks, after which she had to relearn to walk, talk, and care for herself.

 

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery. He failed to obtain consent for the resident’s participation. The associate failed to respond to her declining postoperative condition in a timely manner.

DEFENDANTS’ DEFENSE Surgery was properly performed and postoperative care was appropriate. The bowel injury was a thermal or pressure necrosis that occurred 3 days after surgery. Two different consent forms signed by the patient included notification that a resident might assist; the resident was introduced to the patient prior to surgery. The patient’s injury claims were exaggerated; her future medical bills would be limited to colostomy supplies.

VERDICT A $1,926,069 Texas verdict was returned.

3 Were physicians qualified on robot?

A 48-YEAR-OLD WOMAN UNDERWENT robotic-assisted total hysterectomy and oophorectomy for uterine fibroids and cysts. During surgery, the physicians realized that the sigmoid colon had been perforated. A general surgeon repaired the injury with a loop ileostomy, which was successfully reversed 3 months later. The patient continues to have constipation, with occasional bleeding, pain, and burning.

PATIENT’S CLAIM The risks of robotic surgery were never fully explained to her. Failure to properly visualize her internal organs led to the injury; the extent of damage exceeded what is considered “acceptable risk” of the procedure. The physicians had little experience and training in robotic surgery.

PHYSICIANS’ DEFENSE The case was settled before trial.

VERDICT A $350,000 Massachusetts settlement was reached.

4 Adhesions limit view of bowel

A 76-YEAR-OLD WOMAN UNDERWENT surgical removal of an ovarian cyst. The ObGyn attempted a laparoscopic procedure but converted to laparotomy when extensive adhesions were encountered. The next morning, the patient discovered that her navel was discharging fecal matter. Exploratory surgery determined that the bowel had been perforated. She required additional surgery and had a long recovery.

PATIENT’S CLAIM The ObGyn was negligent in failing to diagnose and treat bowel perforation in a timely manner. An intraoperative bowel inspection should have occurred due to the likelihood of a bowel injury related to the adhesions.

PHYSICIAN’S DEFENSE Adhesions restricted inspection of every area.

VERDICT A $225,000 New York settlement was reached.

5 Skydiver’s ongoing postop pain

AFTER REPORTING DYSMENORRHEA and menometrorrhagia, a 34-year-old woman underwent dilatation and curettage, thermal endometrial ablation, and diagnostic laparoscopy. A day later, she reported increasing pain. The ObGyn’s examination revealed minimal abdominal distension, sluggish bowel sounds, and some guarding, with no rebound tenderness or acute distress. US showed a 3-cm pocket of fluid in the abdomen. Two hours later, an exam revealed a soft abdomen and normal bowel sounds. She was sent home with instructions to return the next day or, if her condition worsened, to go to the ED.

Her husband called the next day to report she was feeling better. The patient woke the following morning with massive distension, worse pain, and severe shortness of breath. At the ED, a CT scan revealed a large amount of abdominal fluid. During emergency laparotomy, an injury was found in the jejunum, necessitating a 3-inch resection.

PATIENT’S CLAIM The ObGyn was negligent in not treating her postoperative symptoms in a more proactive manner. Adhesions developed from peritonitis, leading to chronic abdominal pain. Several operations were required.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of the procedure. There was no indication during surgery or at the office visit that the jejunum was injured. Adhesions were not the cause of the patient’s ongoing pain; very few adhesions were found during subsequent operations. The woman was an avid skydiver who had completed 200 jumps since her initial surgery.

VERDICT An Illinois defense verdict was returned.

6 Bowel injury at laparoscopy

WHEN THE GYNECOLOGIST recognized a bowel injury during laparoscopic salpingectomy, he called a general surgeon, who repaired three areas of bowel. The patient was released 2 days after surgery. She called the gynecologist 2 days later to report fever and vaginal bleeding. She was told to come to the office, but she cancelled when the fever subsided. The next day, she went to the ED, where sepsis was diagnosed. She was flown to another hospital for surgery. A 1-cm small-bowel perforation was found in an area of earlier repair because a suture had been disrupted. A temporary colostomy was reversed 3 months later.

PATIENT’S CLAIM The gynecologist was negligent in performing laparoscopic salpingectomy. The patient should not have been discharged because her white blood cell count and heart rate were elevated.

DEFENDANTS’ DEFENSE Performance of a laparoscopic procedure was proper. Discharge was reasonable, as there was only a potential for complications with no evident problems.

 

VERDICT An Missouri defense verdict was returned.

7 Was treatment of abscess delayed?

A 49-YEAR-OLD WOMAN with menorrhagia underwent cryoablation. Two weeks later, she went to the ED with pain and constipation. Following CT scans and US, she was found to have a tubo-ovarian abscess. After an enema and subsequent bowel movement, her pain improved. She was discharged with instructions to follow-up with her gynecologist. Six days later, the gynecologist prescribed triple antibiotics, analgesics, and weekly visits for the abscess. Two weeks later, she reported unbearable pain and was sent to the ED. She was found to have a microperforation of the sigmoid colon and multiple gynecologic pathologies, including myomata, right serous cystadenoma, and left tubo-ovarian complex suggestive of endometriosis. Hysterectomy and colostomy were performed; the colostomy was reversed several months later.

PATIENT’S CLAIM She should have been hospitalized when the abscess was found so that the infection could be treated properly. She alleged lack of informed consent for the cryoablation.

PHYSICIAN’S DEFENSE Hospitalization was unnecessary; the patient had initially improved, and the outcome would not have changed with intravenous antibiotics. The patient was fully informed of the risks of the procedure.

VERDICT A Pennsylvania defense verdict was returned.

Woman told “Biopsy isn’t urgent”

TWO MONTHS AFTER HER INITIAL VISIT, a 58-year-old woman returned to the gynecologist with vaginal bleeding. In March 2004, ultrasonography (US) showed slight thickening of the endometrial lining and a “pin dot” described as being a prepolyp. Vaginal bleeding was determined to be due to thinning of the vaginal wall with menopause.

The patient reported daily vaginal bleeding when she saw the gynecologist in January 2005. A new, large, rounded, solid mass within the endometrial cavity consistent with a large endometrial polyp was seen on US. The radiologist recommended hysteroscopic biopsy with excision, but the gynecologist told the patient it was not urgent.

In March 2005, hysteroscopy confirmed carcinosarcoma of the uterus. The patient underwent a hysterectomy followed by pelvic radiation and brachytherapy.

Eight months later, metastasis was found in the lungs; she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to react when the patient first reported vaginal bleeding. An earlier diagnosis could have prevented her death.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT An $820,000 Massachusetts settlement was reached.

US report misses fetal abnormalities

A PREGNANT WOMAN UNDERWENT US. The preliminary report indicated echogenic cardiac focus and unilateral pyelectasis. Twenty-five days later, the mother underwent a level II US. A radiologist wrote that fetal anatomy was normal in both reports. The mother had two additional sonograms, with no reported abnormality.

The baby was born with aplasia and hypoplasia with both arms absent below a short humerus, an absent left leg, and a shortened right leg with a remnant foot and three small toes.

PARENTS’ CLAIM The radiologist’s US reports failed to accurately describe the fetal anatomy, depriving the parents of the chance to terminate the pregnancy.

DEFENDANTS’ DEFENSE Proper treatment was given.

VERDICT A $4.5 million Florida verdict was returned. Fault was assigned to the radiologist (85%) and the level II technologist (15%).

Forceps delivery injures mother’s pelvic floor

DURING A TRIAL OF LABOR, a 34-year-old woman experienced deep transverse arrest and lack of progress due to pelvic restriction. The ObGyn proceeded to deliver the baby vaginally using forceps, which caused pelvic floor injuries to the mother.

Several months later, she underwent corrective repair surgery for pelvic floor prolapse. She has continuing vaginal and rectal pain and dysfunction.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as pelvic restriction was found. The injuries reduce the woman’s chances of having another child.

PHYSICIAN’S DEFENSE A trial of labor was proper. The patient’s continuing fertility problems are related to chronic yeast infections and prescription birth control.

VERDICT A $1,716,469 Illinois verdict was returned, which included $484,000 to the patient’s husband for loss of consortium.

7 CASES OF INJURED BOWEL

1 Woman dies from bowel injury

DURING A SLING PROCEDURE for vaginal prolapse, a 50-year-old woman required a transfusion. The next day, she was nauseated and constipated. A day later, she went to the ED with shortness of breath and chest and abdominal pain. Her symptoms persisted for 8 days before an injury to her transverse colon was found during exploratory surgery. She suffered massive organ failure caused by sepsis and died 3 weeks after the initial surgery.

ESTATE’S CLAIM The gynecologist should have investigated why she needed a transfusion during surgery. He should have reacted earlier to her postsurgical complaints.

PHYSICIAN’S DEFENSE Bowel injury is a known risk of the procedure. The patient suffered multiple strokes after being readmitted to the hospital.

VERDICT A $2.4 million South Carolina verdict was returned.

2 Colostomy, coma after hysterectomy

DUE TO FIBROID TUMORS and pelvic pain, a 39-year-old woman’s ObGyn suggested laparoscopic-assisted vaginal hysterectomy. A third-year resident performed most of the procedure. The ObGyn’s associate covered postsurgical care.

When the patient reported increasing pain and rectal bleeding, an exploratory laparotomy was performed 3 days after surgery. Bowel and ureter injuries were repaired and a permanent colostomy was created. The patient developed septic shock with multiple organ failure, and was placed in a chemically induced coma for 3 weeks, after which she had to relearn to walk, talk, and care for herself.

 

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery. He failed to obtain consent for the resident’s participation. The associate failed to respond to her declining postoperative condition in a timely manner.

DEFENDANTS’ DEFENSE Surgery was properly performed and postoperative care was appropriate. The bowel injury was a thermal or pressure necrosis that occurred 3 days after surgery. Two different consent forms signed by the patient included notification that a resident might assist; the resident was introduced to the patient prior to surgery. The patient’s injury claims were exaggerated; her future medical bills would be limited to colostomy supplies.

VERDICT A $1,926,069 Texas verdict was returned.

3 Were physicians qualified on robot?

A 48-YEAR-OLD WOMAN UNDERWENT robotic-assisted total hysterectomy and oophorectomy for uterine fibroids and cysts. During surgery, the physicians realized that the sigmoid colon had been perforated. A general surgeon repaired the injury with a loop ileostomy, which was successfully reversed 3 months later. The patient continues to have constipation, with occasional bleeding, pain, and burning.

PATIENT’S CLAIM The risks of robotic surgery were never fully explained to her. Failure to properly visualize her internal organs led to the injury; the extent of damage exceeded what is considered “acceptable risk” of the procedure. The physicians had little experience and training in robotic surgery.

PHYSICIANS’ DEFENSE The case was settled before trial.

VERDICT A $350,000 Massachusetts settlement was reached.

4 Adhesions limit view of bowel

A 76-YEAR-OLD WOMAN UNDERWENT surgical removal of an ovarian cyst. The ObGyn attempted a laparoscopic procedure but converted to laparotomy when extensive adhesions were encountered. The next morning, the patient discovered that her navel was discharging fecal matter. Exploratory surgery determined that the bowel had been perforated. She required additional surgery and had a long recovery.

PATIENT’S CLAIM The ObGyn was negligent in failing to diagnose and treat bowel perforation in a timely manner. An intraoperative bowel inspection should have occurred due to the likelihood of a bowel injury related to the adhesions.

PHYSICIAN’S DEFENSE Adhesions restricted inspection of every area.

VERDICT A $225,000 New York settlement was reached.

5 Skydiver’s ongoing postop pain

AFTER REPORTING DYSMENORRHEA and menometrorrhagia, a 34-year-old woman underwent dilatation and curettage, thermal endometrial ablation, and diagnostic laparoscopy. A day later, she reported increasing pain. The ObGyn’s examination revealed minimal abdominal distension, sluggish bowel sounds, and some guarding, with no rebound tenderness or acute distress. US showed a 3-cm pocket of fluid in the abdomen. Two hours later, an exam revealed a soft abdomen and normal bowel sounds. She was sent home with instructions to return the next day or, if her condition worsened, to go to the ED.

Her husband called the next day to report she was feeling better. The patient woke the following morning with massive distension, worse pain, and severe shortness of breath. At the ED, a CT scan revealed a large amount of abdominal fluid. During emergency laparotomy, an injury was found in the jejunum, necessitating a 3-inch resection.

PATIENT’S CLAIM The ObGyn was negligent in not treating her postoperative symptoms in a more proactive manner. Adhesions developed from peritonitis, leading to chronic abdominal pain. Several operations were required.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of the procedure. There was no indication during surgery or at the office visit that the jejunum was injured. Adhesions were not the cause of the patient’s ongoing pain; very few adhesions were found during subsequent operations. The woman was an avid skydiver who had completed 200 jumps since her initial surgery.

VERDICT An Illinois defense verdict was returned.

6 Bowel injury at laparoscopy

WHEN THE GYNECOLOGIST recognized a bowel injury during laparoscopic salpingectomy, he called a general surgeon, who repaired three areas of bowel. The patient was released 2 days after surgery. She called the gynecologist 2 days later to report fever and vaginal bleeding. She was told to come to the office, but she cancelled when the fever subsided. The next day, she went to the ED, where sepsis was diagnosed. She was flown to another hospital for surgery. A 1-cm small-bowel perforation was found in an area of earlier repair because a suture had been disrupted. A temporary colostomy was reversed 3 months later.

PATIENT’S CLAIM The gynecologist was negligent in performing laparoscopic salpingectomy. The patient should not have been discharged because her white blood cell count and heart rate were elevated.

DEFENDANTS’ DEFENSE Performance of a laparoscopic procedure was proper. Discharge was reasonable, as there was only a potential for complications with no evident problems.

 

VERDICT An Missouri defense verdict was returned.

7 Was treatment of abscess delayed?

A 49-YEAR-OLD WOMAN with menorrhagia underwent cryoablation. Two weeks later, she went to the ED with pain and constipation. Following CT scans and US, she was found to have a tubo-ovarian abscess. After an enema and subsequent bowel movement, her pain improved. She was discharged with instructions to follow-up with her gynecologist. Six days later, the gynecologist prescribed triple antibiotics, analgesics, and weekly visits for the abscess. Two weeks later, she reported unbearable pain and was sent to the ED. She was found to have a microperforation of the sigmoid colon and multiple gynecologic pathologies, including myomata, right serous cystadenoma, and left tubo-ovarian complex suggestive of endometriosis. Hysterectomy and colostomy were performed; the colostomy was reversed several months later.

PATIENT’S CLAIM She should have been hospitalized when the abscess was found so that the infection could be treated properly. She alleged lack of informed consent for the cryoablation.

PHYSICIAN’S DEFENSE Hospitalization was unnecessary; the patient had initially improved, and the outcome would not have changed with intravenous antibiotics. The patient was fully informed of the risks of the procedure.

VERDICT A Pennsylvania defense verdict was returned.

Woman told “Biopsy isn’t urgent”

TWO MONTHS AFTER HER INITIAL VISIT, a 58-year-old woman returned to the gynecologist with vaginal bleeding. In March 2004, ultrasonography (US) showed slight thickening of the endometrial lining and a “pin dot” described as being a prepolyp. Vaginal bleeding was determined to be due to thinning of the vaginal wall with menopause.

The patient reported daily vaginal bleeding when she saw the gynecologist in January 2005. A new, large, rounded, solid mass within the endometrial cavity consistent with a large endometrial polyp was seen on US. The radiologist recommended hysteroscopic biopsy with excision, but the gynecologist told the patient it was not urgent.

In March 2005, hysteroscopy confirmed carcinosarcoma of the uterus. The patient underwent a hysterectomy followed by pelvic radiation and brachytherapy.

Eight months later, metastasis was found in the lungs; she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to react when the patient first reported vaginal bleeding. An earlier diagnosis could have prevented her death.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT An $820,000 Massachusetts settlement was reached.

US report misses fetal abnormalities

A PREGNANT WOMAN UNDERWENT US. The preliminary report indicated echogenic cardiac focus and unilateral pyelectasis. Twenty-five days later, the mother underwent a level II US. A radiologist wrote that fetal anatomy was normal in both reports. The mother had two additional sonograms, with no reported abnormality.

The baby was born with aplasia and hypoplasia with both arms absent below a short humerus, an absent left leg, and a shortened right leg with a remnant foot and three small toes.

PARENTS’ CLAIM The radiologist’s US reports failed to accurately describe the fetal anatomy, depriving the parents of the chance to terminate the pregnancy.

DEFENDANTS’ DEFENSE Proper treatment was given.

VERDICT A $4.5 million Florida verdict was returned. Fault was assigned to the radiologist (85%) and the level II technologist (15%).

Forceps delivery injures mother’s pelvic floor

DURING A TRIAL OF LABOR, a 34-year-old woman experienced deep transverse arrest and lack of progress due to pelvic restriction. The ObGyn proceeded to deliver the baby vaginally using forceps, which caused pelvic floor injuries to the mother.

Several months later, she underwent corrective repair surgery for pelvic floor prolapse. She has continuing vaginal and rectal pain and dysfunction.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as pelvic restriction was found. The injuries reduce the woman’s chances of having another child.

PHYSICIAN’S DEFENSE A trial of labor was proper. The patient’s continuing fertility problems are related to chronic yeast infections and prescription birth control.

VERDICT A $1,716,469 Illinois verdict was returned, which included $484,000 to the patient’s husband for loss of consortium.

7 CASES OF INJURED BOWEL

1 Woman dies from bowel injury

DURING A SLING PROCEDURE for vaginal prolapse, a 50-year-old woman required a transfusion. The next day, she was nauseated and constipated. A day later, she went to the ED with shortness of breath and chest and abdominal pain. Her symptoms persisted for 8 days before an injury to her transverse colon was found during exploratory surgery. She suffered massive organ failure caused by sepsis and died 3 weeks after the initial surgery.

ESTATE’S CLAIM The gynecologist should have investigated why she needed a transfusion during surgery. He should have reacted earlier to her postsurgical complaints.

PHYSICIAN’S DEFENSE Bowel injury is a known risk of the procedure. The patient suffered multiple strokes after being readmitted to the hospital.

VERDICT A $2.4 million South Carolina verdict was returned.

2 Colostomy, coma after hysterectomy

DUE TO FIBROID TUMORS and pelvic pain, a 39-year-old woman’s ObGyn suggested laparoscopic-assisted vaginal hysterectomy. A third-year resident performed most of the procedure. The ObGyn’s associate covered postsurgical care.

When the patient reported increasing pain and rectal bleeding, an exploratory laparotomy was performed 3 days after surgery. Bowel and ureter injuries were repaired and a permanent colostomy was created. The patient developed septic shock with multiple organ failure, and was placed in a chemically induced coma for 3 weeks, after which she had to relearn to walk, talk, and care for herself.

 

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery. He failed to obtain consent for the resident’s participation. The associate failed to respond to her declining postoperative condition in a timely manner.

DEFENDANTS’ DEFENSE Surgery was properly performed and postoperative care was appropriate. The bowel injury was a thermal or pressure necrosis that occurred 3 days after surgery. Two different consent forms signed by the patient included notification that a resident might assist; the resident was introduced to the patient prior to surgery. The patient’s injury claims were exaggerated; her future medical bills would be limited to colostomy supplies.

VERDICT A $1,926,069 Texas verdict was returned.

3 Were physicians qualified on robot?

A 48-YEAR-OLD WOMAN UNDERWENT robotic-assisted total hysterectomy and oophorectomy for uterine fibroids and cysts. During surgery, the physicians realized that the sigmoid colon had been perforated. A general surgeon repaired the injury with a loop ileostomy, which was successfully reversed 3 months later. The patient continues to have constipation, with occasional bleeding, pain, and burning.

PATIENT’S CLAIM The risks of robotic surgery were never fully explained to her. Failure to properly visualize her internal organs led to the injury; the extent of damage exceeded what is considered “acceptable risk” of the procedure. The physicians had little experience and training in robotic surgery.

PHYSICIANS’ DEFENSE The case was settled before trial.

VERDICT A $350,000 Massachusetts settlement was reached.

4 Adhesions limit view of bowel

A 76-YEAR-OLD WOMAN UNDERWENT surgical removal of an ovarian cyst. The ObGyn attempted a laparoscopic procedure but converted to laparotomy when extensive adhesions were encountered. The next morning, the patient discovered that her navel was discharging fecal matter. Exploratory surgery determined that the bowel had been perforated. She required additional surgery and had a long recovery.

PATIENT’S CLAIM The ObGyn was negligent in failing to diagnose and treat bowel perforation in a timely manner. An intraoperative bowel inspection should have occurred due to the likelihood of a bowel injury related to the adhesions.

PHYSICIAN’S DEFENSE Adhesions restricted inspection of every area.

VERDICT A $225,000 New York settlement was reached.

5 Skydiver’s ongoing postop pain

AFTER REPORTING DYSMENORRHEA and menometrorrhagia, a 34-year-old woman underwent dilatation and curettage, thermal endometrial ablation, and diagnostic laparoscopy. A day later, she reported increasing pain. The ObGyn’s examination revealed minimal abdominal distension, sluggish bowel sounds, and some guarding, with no rebound tenderness or acute distress. US showed a 3-cm pocket of fluid in the abdomen. Two hours later, an exam revealed a soft abdomen and normal bowel sounds. She was sent home with instructions to return the next day or, if her condition worsened, to go to the ED.

Her husband called the next day to report she was feeling better. The patient woke the following morning with massive distension, worse pain, and severe shortness of breath. At the ED, a CT scan revealed a large amount of abdominal fluid. During emergency laparotomy, an injury was found in the jejunum, necessitating a 3-inch resection.

PATIENT’S CLAIM The ObGyn was negligent in not treating her postoperative symptoms in a more proactive manner. Adhesions developed from peritonitis, leading to chronic abdominal pain. Several operations were required.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of the procedure. There was no indication during surgery or at the office visit that the jejunum was injured. Adhesions were not the cause of the patient’s ongoing pain; very few adhesions were found during subsequent operations. The woman was an avid skydiver who had completed 200 jumps since her initial surgery.

VERDICT An Illinois defense verdict was returned.

6 Bowel injury at laparoscopy

WHEN THE GYNECOLOGIST recognized a bowel injury during laparoscopic salpingectomy, he called a general surgeon, who repaired three areas of bowel. The patient was released 2 days after surgery. She called the gynecologist 2 days later to report fever and vaginal bleeding. She was told to come to the office, but she cancelled when the fever subsided. The next day, she went to the ED, where sepsis was diagnosed. She was flown to another hospital for surgery. A 1-cm small-bowel perforation was found in an area of earlier repair because a suture had been disrupted. A temporary colostomy was reversed 3 months later.

PATIENT’S CLAIM The gynecologist was negligent in performing laparoscopic salpingectomy. The patient should not have been discharged because her white blood cell count and heart rate were elevated.

DEFENDANTS’ DEFENSE Performance of a laparoscopic procedure was proper. Discharge was reasonable, as there was only a potential for complications with no evident problems.

 

VERDICT An Missouri defense verdict was returned.

7 Was treatment of abscess delayed?

A 49-YEAR-OLD WOMAN with menorrhagia underwent cryoablation. Two weeks later, she went to the ED with pain and constipation. Following CT scans and US, she was found to have a tubo-ovarian abscess. After an enema and subsequent bowel movement, her pain improved. She was discharged with instructions to follow-up with her gynecologist. Six days later, the gynecologist prescribed triple antibiotics, analgesics, and weekly visits for the abscess. Two weeks later, she reported unbearable pain and was sent to the ED. She was found to have a microperforation of the sigmoid colon and multiple gynecologic pathologies, including myomata, right serous cystadenoma, and left tubo-ovarian complex suggestive of endometriosis. Hysterectomy and colostomy were performed; the colostomy was reversed several months later.

PATIENT’S CLAIM She should have been hospitalized when the abscess was found so that the infection could be treated properly. She alleged lack of informed consent for the cryoablation.

PHYSICIAN’S DEFENSE Hospitalization was unnecessary; the patient had initially improved, and the outcome would not have changed with intravenous antibiotics. The patient was fully informed of the risks of the procedure.

VERDICT A Pennsylvania defense verdict was returned.

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

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.