Managing Your Practice

CASE 1: Pregestational diabetes, large baby, birth injury

A 31-year-old gravida 1 is admitted to labor and delivery. She is at 39-5/7 weeks’ gestation, dated by last menstrual period and early sonogram. The woman is a pregestational diabetic and uses insulin to control her blood glucose level.

Three weeks before admission, ultrasonography (US) revealed an estimated fetal weight of 3,650 g—at the 71st percentile for gestational age.

After an unremarkable course of labor, delivery is complicated by severe shoulder dystocia. The newborn has a birth weight of 4,985 g and sustains an Erb’s palsy-type injury. The mother develops a rectovaginal fistula after a fourth-degree tear.

In the first part of this article, we discussed how an allegation of malpractice can arise because of an unexpected event or outcome for a mother in your care, or her baby, apart from any specific clinical action you undertook. We offered an example: Counseling that you provide about options for prenatal care that falls short of full understanding by the patient.

In this article, we enter the realm of the hands-on practice of medicine and discuss causation: namely, the actions of a physician, in the course of managing labor and delivering a baby, that put that physician at risk of a charge of malpractice because the medical care 1) is inconsistent with current medical practice and thus 2) harmed mother or newborn.

Let’s return to the opening case above and discuss key considerations for the physician. Three more cases follow that, with analysis and recommendations.

Considerations in CASE 1

• A woman who has pregestational diabetes should receive ongoing counseling about the risks of fetal anomalies, macrosomia, and problems in the neonatal period. Be certain that she understands that these risks can be ameliorated, but not eliminated, with careful blood glucose control.
• The fetus of a diabetic gravida develops a relative decrease in the ratio of head circumference-to-abdominal circumference that predisposes it to shoulder dystocia. Cesarean delivery can decrease, but not eliminate, the risk of traumatic birth injury in a diabetic mother. (Of course, cesarean delivery will, on its own, substantially increase the risk of maternal morbidity—including at any subsequent cesarean delivery.)

What do they mean? terms and concepts intended to bolster your work and protect you

It’s not easy to define what constitutes “best care” in a given clinical circumstance. Generalizations are useful, but they may possess an inherent weakness: “Best practices,” “evidence-based care,” “standardization of care,” and “uniformity of care” usually apply more usefully to populations than individuals.

Such concepts derive from broader applications in economics, politics, and science. They are useful to define a reasonable spectrum of anticipated practices, and they certainly have an expanding role in the care of patients and in medical education (TABLE). Clinical guidelines serve as strategies that may be very helpful to the clinician. All of us understand and implement appropriate care in the great majority of clinical scenarios, but none of us are, or can be, expert in all situations. Referencing and using guidelines can fill a need for a functional starting point when expertise is lacking or falls short.

Best practices result from evidence-directed decision-making. This concept logically yields a desirable uniformity of practice. Although we all believe that our experience is our best teacher, we may best serve patients if we sample knowledge and wisdom from controlled clinical trials and from the experiences of others. What is accepted local practice must also be considered important when you devise a plan of care.^1,2

A selected glossary of clinical care guidelines

Consider the management of breech presentation that is recognized at the 36th week antepartum visit: Discussion with the patient should include 1) reference to concerns with congenital anomalies and genetic syndromes, 2) in-utero growth and development, and 3) the delivery process. The management algorithm may include external cephalic version, elective cesarean delivery before onset of labor, or cesarean delivery after onset of labor. Each approach has advocates—based on expert opinion clinical trials.

Management options may vary from institution to institution, however, because of limited availability of certain services—such as the expertise required for a trial of external cephalic version, the availability of on-site cesarean delivery capabilities, and patient and clinician preferences.

Uniformity of care, based on best practices, can therefore simplify the care process and decrease the risk that may be associated with individual experience-based management. Adhering to a uniform practice augments the clinician’s knowledge and allows for enhanced nursing and therapeutic efficiency.

The greatest benefit of using an evidence-based, widely accepted approach, however, is the potential to diminish poor practice and consequent malpractice exposure for both clinicians and the hospital.

Note: Although your adherence to clinical guidelines, best practices, and uniformity of care ought to be consistent with established standards of care, don’t automatically consider any deviation a lapse or failing because it’s understood and accepted that some local variability exists in practice.

Prelude to birth: triage and admission Triage. Most women in labor arrive at the hospital or birthing center to an area set aside for labor and delivery triage. There, 1) recording of the chief complaint and vital signs and 2) completion of a brief history and physical generate a call to the clinician.

The record produced in triage should be scrutinized carefully for accuracy. Clarify, in as timely a manner as possible, any errors in:

• timing (possibly because of different clocks set to different times)
• the precise capture of the chief complaint
• reporting difficulty or ease in reaching the responsible clinician.

Whether these records are electronic or paper, an addendum marked with the time is always acceptable. Never attempt to correct a record! Always utilize a late entry or addendum.

Admission. After the patient is admitted, she generally undergoes an admission protocol, specific to the hospital, regarding her situation. This includes:

• the history
• special requests
• any previously agreed-on plan of care
• any problems that have developed since her last prenatal visit.

This protocol is generally completed by a nurse, resident, nurse practitioner, or physician assistant.

Hospitals generally request input from the attending physician on the specifics of the admission, based on those hospital protocols. There may be some room to individualize the admission process to labor and delivery.

4 pillars of care during labor

In general, labor is defined as progressive dilation of the cervix. Several parameters serve as guidelines regarding adequate progress through the various stages of labor.

Fetal monitoring. Continuous evaluation of the fetus during labor is a routine part of intrapartum care. Recording and observing the FHR tracing is an accepted—and expected—practice. Documentation of the FHR in the medical record is specifically required, and should include both the physician’s and nursing notes.

Anesthesia care. The patient’s preference and the availability of options allows for several accepted practices regarding anesthesia and analgesia during L & D. Does she want epidural anesthesia during labor, for example? Intravenous narcotics? Her choice is an important facet of your provision of care.

However, such choice requires the patient to give consent and to understand the risk-benefit equation. Documentation by nursing of the patient’s consent and understanding should be complete, including discussion and administration. Anesthesia staff should be clear, complete, and legible in making a record.

Neonatal care. If logistics permit, a member of the pediatrics service should be routinely available to see the newborn at delivery. The patient should view the pediatrician and obstetrician as partners working as a team for the benefit of the mother and her family. This can enhance the patient’s understanding and confidence about the well being of her baby.

Documentation. Although deficient documentation does not, itself, lead to a finding of malpractice, appropriate documentation plays an important role in demonstrating that clinical practices have addressed issues about both allegation and causation of potential adverse outcomes.

We cannot overemphasize that nursing documentation should complement and be consistent with notes made by the physician. That said, nursing notes are not a substitute for the physician’s notes. Practices that integrate the written comments of nursing and physician into a single set of progress notes facilitate this complementary interaction.

3 more clinical scenarios

CASE 2: Admitted at term with contractions

The initial exam determines that this 21-year-old gravida 1 is 2/80/-1. Re-examination in 3 hours finds her at 3-4/80/0.

She requests pain relief and states that she wants epidural anesthesia.

Evaluation 2 hours later suggests secondary arrest of dilation. Oxytocin is begun.

Soon after, late decelerations are observed on the FHR monitor.

Use of exogenous oxytocin in L & D is a double-edged sword: The drug can enhance the safety and efficacy of labor and delivery for mother and fetus, but using it in an unregulated manner (in terms of its indication and administration) can subject both to increased risk.

In fact, it is fair to say that the most widespread and potentially dangerous intervention during labor is the administration of oxytocin. Many expert opinions, guidelines, and strategies have been put forward about intrapartum use of oxytocin. These include consideration of:

• indications
• dosage (including the maximum)
• interval
• fetal response
• ultimately, the availability of a physician during administration to manage any problem that arises.

Considerations in CASE 2

• Always clearly indicate the reason for using oxytocin: Is this an induction? Or an augmentation? Was there evidence of fetal well-being, or non-reassurance, before oxytocin was administered? Certainly, there are circumstances in which either fetal status or non-progression of labor (or both) are an indication for oxytocin. A clear, concise, and properly timed progress note is always appropriate under these circumstances.
• Discuss treatment with the patient. Does she understand why this therapy is being recommended? Does she agree to its use? And does she understand what the alternatives are?
• Verify that nursing has accurately charted this process. Ensure that the nursing staff’s notes are complete and are consistent with yours.
• Simplify the entire process: Use premixed solution and protocol-driven orders. Know what the standards and protocols are in your department. Minimizing patient-to-patient variability should lessen the risk of error.
• Always be available in L & D for the first 30 minutes that oxytocin is being administered. If a problem with excessive uterine activity is going to occur, it is most likely to do so upon initial administration.
• Monitor the FHR continuously. At the first suggestion of a change in fetal status, discontinue oxytocin. Perform a pelvic exam to reassess the situation. Understand and apply appropriate inutero resuscitative measures (IV fluids, O₂, change in maternal position). Depending on circumstances, you can consider a restart of oxytocin after the FHR returns to its pre-oxytocin pattern.
• Monitor uterine response to oxytocin. If the membranes are ruptured and if it is clinically feasible, an intrauterine pressure transducer will allow you to more objectively assess the uterine response to oxytocin and make decisions on that basis. Determine beforehand whether the patient is agreeable to this intervention.
• When oxytocin is used for augmentation, reassess labor within 4 hours of achieving a satisfactory pattern. If minimal progress is not made, assess the clinical situation to determine why oxytocin, at an adequate response level, has failed to return labor to a normal active phase slope. Are there minor degrees of malposition? Is there an element of cephalopelvic disproportion? Recall that progress in labor is dependent on multiple factors.
• Chart the process concurrently. Specify options for delivery before delivery.

CASE 3: Spontaneous delivery arrests after delivery of the head

The patient is a multipara with three prior normal vaginal deliveries. Her diabetic screen is negative. At admission, the estimated fetal weight was 3,628 g—in the same range as her other deliveries. A nuchal cord is absent.

After the patient assumes the McRobert’s position, delivery is accomplished with suprapubic pressure. Weakness is noted in the newborn’s right upper extremity. Birth weight is 3,515 g.

Maneuvers to manage shoulder dystocia should be part of all clinicians’ skill set. The sequence of those maneuvers, and their timing, are subject to some variation. Efficacy seems to be related most to recognizing and performing each maneuver properly.

Guidelines for managing shoulder dystocia should include reference to 1) the initial evaluation of the patient on admission to labor and delivery and 2) the delivery itself.³

Considerations in CASE 3

• Before you admit them to L & D, counsel patients who have diabetes, morbid obesity (body mass index >40), or birth trauma in a prior delivery, or who have had a prior large infant (>9 lb birth weight), about the risk of shoulder dystocia. Present possible alternatives, and draw the patient into the conversation.
• Consider delivering all women at term in the McRobert’s position, prophylactically.
• Always check for a nuchal cord after delivery of the head. If you find one, reduce it if possible. Take a few seconds and carefully assess the situation before you cut the umbilical cord.
• Lateral traction on the fetus’ head has the potential to cause tension on the brachial plexus, or make it worse. Gentle rotation of the head (<90 degrees) can move the shoulders into a more favorable location for delivery. Don’t rush—call for assistance! Continuously explain to the patient what you are doing; reassure her about the process.
• Use suprapubic pressure wisely. The anterior shoulder may be dislodged by direct downward force; suprapubic force in a lateral direction may also dislodge the shoulder. Apply force from above the patient’s pelvis. Your assistant will have the best mechanical advantage by standing on a stool.
• Is an episiotomy or episioproctotomy advantageous? In attempting to reach either the anterior or posterior shoulder vaginally, individualized assessment is called for.
• When the posterior shoulder cannot be satisfactorily engaged and moved, try doing so with the anterior shoulder. Insert your hand between the symphysis and the fetal head and place downward pressure on the head to dislodge it and complete the delivery.
• If it becomes necessary to attempt delivery by direct traction on the posterior hand or arm, try to avoid extension. Maintain flexion and move the upper extremity across the fetal chest before you attempt extension.
• Repeat these maneuvers a second time before you attempt cephalic replacement or other maneuvers. Remember to move with deliberate speed to lessen the risk of making the injury worse. Have pediatric support present. Continue speaking with and reassuring the patient.
• Under anesthesia in the operating room, perform a hysterotomy incision. With an assistant working through the vagina, combine the forces available to complete the delivery.
• After delivery is complete, take time to write a note. (Speak with the patient and her family first, however.) Read the notes written by nursing. If they are not available when you write your note, mention that. Add a second note later, when nursing notes become available.

CASE 4: Meconium-stained fluid

A 35-year-old multigravida is 6 to 7 cm dilated. Her membranes have just spontaneously ruptured; you note copious meconium-stained fluid. The FHR demonstrates recurrent variable decelerations; baseline fetal heart rate remains normal.

The description and implications of various FHR patterns are important when documenting the fetal metabolic state during the birth process. Current guidelines have attempted to simplify, standardize, and clarify the interpretation of the FHR tracing.⁴

Considerations in CASE 4

• Explain the situation to the patient. Perform a pelvic examination. If possible, wait for nursing assistance to ensure accurate documentation.
• Reassure the patient; help her move to a lateral position. Observe the FHR monitor for a response.
• Administer supplemental O₂. Increase IV fluids to facilitate utero-placental perfusion.
• If useful or necessary, consider attaching a fetal scalp electrode to better delineate fetal status.
• When the FHR returns to baseline state (before spontaneous rupture of membranes), perform vibro-acoustic stimulation as a test to support fetal well-being.
• Engage the patient and her family in a discussion about the sequence of events. Depending on the acuity of the situation, allow her to voice her concerns and reiterate what has occurred, and what will occur.
• Outline a plan of management to the patient—verbally and in the record—with clear reference to events that have occurred. Then, stick to that plan!
• Carefully review corresponding nursing notes. Always write your own assessment of events and actions.

Summing up: three “keepers”

First, the cornerstones of your effort to reduce malpractice risk are 1) thoughtful and informed discussion with the patient and 2) clear, concise documentation.

Second, don’t expect to be able to eliminate unnecessary or inappropriate allegations of medical malpractice; the best you can do is limit them.

Third, and most important, remember: The knowledgeable clinician you strive to be will make appropriate judgments in a timely fashion and will take appropriate actions to provide good medical care.

We want to hear from you! Tell us what you think.

CASE 1: Pregestational diabetes, large baby, birth injury

A 31-year-old gravida 1 is admitted to labor and delivery. She is at 39-5/7 weeks’ gestation, dated by last menstrual period and early sonogram. The woman is a pregestational diabetic and uses insulin to control her blood glucose level.

Three weeks before admission, ultrasonography (US) revealed an estimated fetal weight of 3,650 g—at the 71st percentile for gestational age.

After an unremarkable course of labor, delivery is complicated by severe shoulder dystocia. The newborn has a birth weight of 4,985 g and sustains an Erb’s palsy-type injury. The mother develops a rectovaginal fistula after a fourth-degree tear.

In the first part of this article, we discussed how an allegation of malpractice can arise because of an unexpected event or outcome for a mother in your care, or her baby, apart from any specific clinical action you undertook. We offered an example: Counseling that you provide about options for prenatal care that falls short of full understanding by the patient.

In this article, we enter the realm of the hands-on practice of medicine and discuss causation: namely, the actions of a physician, in the course of managing labor and delivering a baby, that put that physician at risk of a charge of malpractice because the medical care 1) is inconsistent with current medical practice and thus 2) harmed mother or newborn.

Let’s return to the opening case above and discuss key considerations for the physician. Three more cases follow that, with analysis and recommendations.

Considerations in CASE 1

• A woman who has pregestational diabetes should receive ongoing counseling about the risks of fetal anomalies, macrosomia, and problems in the neonatal period. Be certain that she understands that these risks can be ameliorated, but not eliminated, with careful blood glucose control.
• The fetus of a diabetic gravida develops a relative decrease in the ratio of head circumference-to-abdominal circumference that predisposes it to shoulder dystocia. Cesarean delivery can decrease, but not eliminate, the risk of traumatic birth injury in a diabetic mother. (Of course, cesarean delivery will, on its own, substantially increase the risk of maternal morbidity—including at any subsequent cesarean delivery.)

What do they mean? terms and concepts intended to bolster your work and protect you

It’s not easy to define what constitutes “best care” in a given clinical circumstance. Generalizations are useful, but they may possess an inherent weakness: “Best practices,” “evidence-based care,” “standardization of care,” and “uniformity of care” usually apply more usefully to populations than individuals.

Such concepts derive from broader applications in economics, politics, and science. They are useful to define a reasonable spectrum of anticipated practices, and they certainly have an expanding role in the care of patients and in medical education (TABLE). Clinical guidelines serve as strategies that may be very helpful to the clinician. All of us understand and implement appropriate care in the great majority of clinical scenarios, but none of us are, or can be, expert in all situations. Referencing and using guidelines can fill a need for a functional starting point when expertise is lacking or falls short.

Best practices result from evidence-directed decision-making. This concept logically yields a desirable uniformity of practice. Although we all believe that our experience is our best teacher, we may best serve patients if we sample knowledge and wisdom from controlled clinical trials and from the experiences of others. What is accepted local practice must also be considered important when you devise a plan of care.^1,2

A selected glossary of clinical care guidelines

Consider the management of breech presentation that is recognized at the 36th week antepartum visit: Discussion with the patient should include 1) reference to concerns with congenital anomalies and genetic syndromes, 2) in-utero growth and development, and 3) the delivery process. The management algorithm may include external cephalic version, elective cesarean delivery before onset of labor, or cesarean delivery after onset of labor. Each approach has advocates—based on expert opinion clinical trials.

Management options may vary from institution to institution, however, because of limited availability of certain services—such as the expertise required for a trial of external cephalic version, the availability of on-site cesarean delivery capabilities, and patient and clinician preferences.

Uniformity of care, based on best practices, can therefore simplify the care process and decrease the risk that may be associated with individual experience-based management. Adhering to a uniform practice augments the clinician’s knowledge and allows for enhanced nursing and therapeutic efficiency.

The greatest benefit of using an evidence-based, widely accepted approach, however, is the potential to diminish poor practice and consequent malpractice exposure for both clinicians and the hospital.

Note: Although your adherence to clinical guidelines, best practices, and uniformity of care ought to be consistent with established standards of care, don’t automatically consider any deviation a lapse or failing because it’s understood and accepted that some local variability exists in practice.

Prelude to birth: triage and admission Triage. Most women in labor arrive at the hospital or birthing center to an area set aside for labor and delivery triage. There, 1) recording of the chief complaint and vital signs and 2) completion of a brief history and physical generate a call to the clinician.

The record produced in triage should be scrutinized carefully for accuracy. Clarify, in as timely a manner as possible, any errors in:

• timing (possibly because of different clocks set to different times)
• the precise capture of the chief complaint
• reporting difficulty or ease in reaching the responsible clinician.

Whether these records are electronic or paper, an addendum marked with the time is always acceptable. Never attempt to correct a record! Always utilize a late entry or addendum.

Admission. After the patient is admitted, she generally undergoes an admission protocol, specific to the hospital, regarding her situation. This includes:

• the history
• special requests
• any previously agreed-on plan of care
• any problems that have developed since her last prenatal visit.

This protocol is generally completed by a nurse, resident, nurse practitioner, or physician assistant.

Hospitals generally request input from the attending physician on the specifics of the admission, based on those hospital protocols. There may be some room to individualize the admission process to labor and delivery.

4 pillars of care during labor

In general, labor is defined as progressive dilation of the cervix. Several parameters serve as guidelines regarding adequate progress through the various stages of labor.

Fetal monitoring. Continuous evaluation of the fetus during labor is a routine part of intrapartum care. Recording and observing the FHR tracing is an accepted—and expected—practice. Documentation of the FHR in the medical record is specifically required, and should include both the physician’s and nursing notes.

Anesthesia care. The patient’s preference and the availability of options allows for several accepted practices regarding anesthesia and analgesia during L & D. Does she want epidural anesthesia during labor, for example? Intravenous narcotics? Her choice is an important facet of your provision of care.

However, such choice requires the patient to give consent and to understand the risk-benefit equation. Documentation by nursing of the patient’s consent and understanding should be complete, including discussion and administration. Anesthesia staff should be clear, complete, and legible in making a record.

Neonatal care. If logistics permit, a member of the pediatrics service should be routinely available to see the newborn at delivery. The patient should view the pediatrician and obstetrician as partners working as a team for the benefit of the mother and her family. This can enhance the patient’s understanding and confidence about the well being of her baby.

Documentation. Although deficient documentation does not, itself, lead to a finding of malpractice, appropriate documentation plays an important role in demonstrating that clinical practices have addressed issues about both allegation and causation of potential adverse outcomes.

We cannot overemphasize that nursing documentation should complement and be consistent with notes made by the physician. That said, nursing notes are not a substitute for the physician’s notes. Practices that integrate the written comments of nursing and physician into a single set of progress notes facilitate this complementary interaction.

3 more clinical scenarios

CASE 2: Admitted at term with contractions

The initial exam determines that this 21-year-old gravida 1 is 2/80/-1. Re-examination in 3 hours finds her at 3-4/80/0.

She requests pain relief and states that she wants epidural anesthesia.

Evaluation 2 hours later suggests secondary arrest of dilation. Oxytocin is begun.

Soon after, late decelerations are observed on the FHR monitor.

Use of exogenous oxytocin in L & D is a double-edged sword: The drug can enhance the safety and efficacy of labor and delivery for mother and fetus, but using it in an unregulated manner (in terms of its indication and administration) can subject both to increased risk.

In fact, it is fair to say that the most widespread and potentially dangerous intervention during labor is the administration of oxytocin. Many expert opinions, guidelines, and strategies have been put forward about intrapartum use of oxytocin. These include consideration of:

• indications
• dosage (including the maximum)
• interval
• fetal response
• ultimately, the availability of a physician during administration to manage any problem that arises.

Considerations in CASE 2

• Always clearly indicate the reason for using oxytocin: Is this an induction? Or an augmentation? Was there evidence of fetal well-being, or non-reassurance, before oxytocin was administered? Certainly, there are circumstances in which either fetal status or non-progression of labor (or both) are an indication for oxytocin. A clear, concise, and properly timed progress note is always appropriate under these circumstances.
• Discuss treatment with the patient. Does she understand why this therapy is being recommended? Does she agree to its use? And does she understand what the alternatives are?
• Verify that nursing has accurately charted this process. Ensure that the nursing staff’s notes are complete and are consistent with yours.
• Simplify the entire process: Use premixed solution and protocol-driven orders. Know what the standards and protocols are in your department. Minimizing patient-to-patient variability should lessen the risk of error.
• Always be available in L & D for the first 30 minutes that oxytocin is being administered. If a problem with excessive uterine activity is going to occur, it is most likely to do so upon initial administration.
• Monitor the FHR continuously. At the first suggestion of a change in fetal status, discontinue oxytocin. Perform a pelvic exam to reassess the situation. Understand and apply appropriate inutero resuscitative measures (IV fluids, O₂, change in maternal position). Depending on circumstances, you can consider a restart of oxytocin after the FHR returns to its pre-oxytocin pattern.
• Monitor uterine response to oxytocin. If the membranes are ruptured and if it is clinically feasible, an intrauterine pressure transducer will allow you to more objectively assess the uterine response to oxytocin and make decisions on that basis. Determine beforehand whether the patient is agreeable to this intervention.
• When oxytocin is used for augmentation, reassess labor within 4 hours of achieving a satisfactory pattern. If minimal progress is not made, assess the clinical situation to determine why oxytocin, at an adequate response level, has failed to return labor to a normal active phase slope. Are there minor degrees of malposition? Is there an element of cephalopelvic disproportion? Recall that progress in labor is dependent on multiple factors.
• Chart the process concurrently. Specify options for delivery before delivery.

CASE 3: Spontaneous delivery arrests after delivery of the head

The patient is a multipara with three prior normal vaginal deliveries. Her diabetic screen is negative. At admission, the estimated fetal weight was 3,628 g—in the same range as her other deliveries. A nuchal cord is absent.

After the patient assumes the McRobert’s position, delivery is accomplished with suprapubic pressure. Weakness is noted in the newborn’s right upper extremity. Birth weight is 3,515 g.

Maneuvers to manage shoulder dystocia should be part of all clinicians’ skill set. The sequence of those maneuvers, and their timing, are subject to some variation. Efficacy seems to be related most to recognizing and performing each maneuver properly.

Guidelines for managing shoulder dystocia should include reference to 1) the initial evaluation of the patient on admission to labor and delivery and 2) the delivery itself.³

Considerations in CASE 3

• Before you admit them to L & D, counsel patients who have diabetes, morbid obesity (body mass index >40), or birth trauma in a prior delivery, or who have had a prior large infant (>9 lb birth weight), about the risk of shoulder dystocia. Present possible alternatives, and draw the patient into the conversation.
• Consider delivering all women at term in the McRobert’s position, prophylactically.
• Always check for a nuchal cord after delivery of the head. If you find one, reduce it if possible. Take a few seconds and carefully assess the situation before you cut the umbilical cord.
• Lateral traction on the fetus’ head has the potential to cause tension on the brachial plexus, or make it worse. Gentle rotation of the head (<90 degrees) can move the shoulders into a more favorable location for delivery. Don’t rush—call for assistance! Continuously explain to the patient what you are doing; reassure her about the process.
• Use suprapubic pressure wisely. The anterior shoulder may be dislodged by direct downward force; suprapubic force in a lateral direction may also dislodge the shoulder. Apply force from above the patient’s pelvis. Your assistant will have the best mechanical advantage by standing on a stool.
• Is an episiotomy or episioproctotomy advantageous? In attempting to reach either the anterior or posterior shoulder vaginally, individualized assessment is called for.
• When the posterior shoulder cannot be satisfactorily engaged and moved, try doing so with the anterior shoulder. Insert your hand between the symphysis and the fetal head and place downward pressure on the head to dislodge it and complete the delivery.
• If it becomes necessary to attempt delivery by direct traction on the posterior hand or arm, try to avoid extension. Maintain flexion and move the upper extremity across the fetal chest before you attempt extension.
• Repeat these maneuvers a second time before you attempt cephalic replacement or other maneuvers. Remember to move with deliberate speed to lessen the risk of making the injury worse. Have pediatric support present. Continue speaking with and reassuring the patient.
• Under anesthesia in the operating room, perform a hysterotomy incision. With an assistant working through the vagina, combine the forces available to complete the delivery.
• After delivery is complete, take time to write a note. (Speak with the patient and her family first, however.) Read the notes written by nursing. If they are not available when you write your note, mention that. Add a second note later, when nursing notes become available.

CASE 4: Meconium-stained fluid

A 35-year-old multigravida is 6 to 7 cm dilated. Her membranes have just spontaneously ruptured; you note copious meconium-stained fluid. The FHR demonstrates recurrent variable decelerations; baseline fetal heart rate remains normal.

The description and implications of various FHR patterns are important when documenting the fetal metabolic state during the birth process. Current guidelines have attempted to simplify, standardize, and clarify the interpretation of the FHR tracing.⁴

Considerations in CASE 4

• Explain the situation to the patient. Perform a pelvic examination. If possible, wait for nursing assistance to ensure accurate documentation.
• Reassure the patient; help her move to a lateral position. Observe the FHR monitor for a response.
• Administer supplemental O₂. Increase IV fluids to facilitate utero-placental perfusion.
• If useful or necessary, consider attaching a fetal scalp electrode to better delineate fetal status.
• When the FHR returns to baseline state (before spontaneous rupture of membranes), perform vibro-acoustic stimulation as a test to support fetal well-being.
• Engage the patient and her family in a discussion about the sequence of events. Depending on the acuity of the situation, allow her to voice her concerns and reiterate what has occurred, and what will occur.
• Outline a plan of management to the patient—verbally and in the record—with clear reference to events that have occurred. Then, stick to that plan!
• Carefully review corresponding nursing notes. Always write your own assessment of events and actions.

Summing up: three “keepers”

First, the cornerstones of your effort to reduce malpractice risk are 1) thoughtful and informed discussion with the patient and 2) clear, concise documentation.

Second, don’t expect to be able to eliminate unnecessary or inappropriate allegations of medical malpractice; the best you can do is limit them.

Third, and most important, remember: The knowledgeable clinician you strive to be will make appropriate judgments in a timely fashion and will take appropriate actions to provide good medical care.

We want to hear from you! Tell us what you think.

CASE 1: Pregestational diabetes, large baby, birth injury

A 31-year-old gravida 1 is admitted to labor and delivery. She is at 39-5/7 weeks’ gestation, dated by last menstrual period and early sonogram. The woman is a pregestational diabetic and uses insulin to control her blood glucose level.

Three weeks before admission, ultrasonography (US) revealed an estimated fetal weight of 3,650 g—at the 71st percentile for gestational age.

After an unremarkable course of labor, delivery is complicated by severe shoulder dystocia. The newborn has a birth weight of 4,985 g and sustains an Erb’s palsy-type injury. The mother develops a rectovaginal fistula after a fourth-degree tear.

In the first part of this article, we discussed how an allegation of malpractice can arise because of an unexpected event or outcome for a mother in your care, or her baby, apart from any specific clinical action you undertook. We offered an example: Counseling that you provide about options for prenatal care that falls short of full understanding by the patient.

In this article, we enter the realm of the hands-on practice of medicine and discuss causation: namely, the actions of a physician, in the course of managing labor and delivering a baby, that put that physician at risk of a charge of malpractice because the medical care 1) is inconsistent with current medical practice and thus 2) harmed mother or newborn.

Let’s return to the opening case above and discuss key considerations for the physician. Three more cases follow that, with analysis and recommendations.

Considerations in CASE 1

• A woman who has pregestational diabetes should receive ongoing counseling about the risks of fetal anomalies, macrosomia, and problems in the neonatal period. Be certain that she understands that these risks can be ameliorated, but not eliminated, with careful blood glucose control.
• The fetus of a diabetic gravida develops a relative decrease in the ratio of head circumference-to-abdominal circumference that predisposes it to shoulder dystocia. Cesarean delivery can decrease, but not eliminate, the risk of traumatic birth injury in a diabetic mother. (Of course, cesarean delivery will, on its own, substantially increase the risk of maternal morbidity—including at any subsequent cesarean delivery.)

What do they mean? terms and concepts intended to bolster your work and protect you

It’s not easy to define what constitutes “best care” in a given clinical circumstance. Generalizations are useful, but they may possess an inherent weakness: “Best practices,” “evidence-based care,” “standardization of care,” and “uniformity of care” usually apply more usefully to populations than individuals.

Such concepts derive from broader applications in economics, politics, and science. They are useful to define a reasonable spectrum of anticipated practices, and they certainly have an expanding role in the care of patients and in medical education (TABLE). Clinical guidelines serve as strategies that may be very helpful to the clinician. All of us understand and implement appropriate care in the great majority of clinical scenarios, but none of us are, or can be, expert in all situations. Referencing and using guidelines can fill a need for a functional starting point when expertise is lacking or falls short.

Best practices result from evidence-directed decision-making. This concept logically yields a desirable uniformity of practice. Although we all believe that our experience is our best teacher, we may best serve patients if we sample knowledge and wisdom from controlled clinical trials and from the experiences of others. What is accepted local practice must also be considered important when you devise a plan of care.^1,2

A selected glossary of clinical care guidelines

Consider the management of breech presentation that is recognized at the 36th week antepartum visit: Discussion with the patient should include 1) reference to concerns with congenital anomalies and genetic syndromes, 2) in-utero growth and development, and 3) the delivery process. The management algorithm may include external cephalic version, elective cesarean delivery before onset of labor, or cesarean delivery after onset of labor. Each approach has advocates—based on expert opinion clinical trials.

Management options may vary from institution to institution, however, because of limited availability of certain services—such as the expertise required for a trial of external cephalic version, the availability of on-site cesarean delivery capabilities, and patient and clinician preferences.

Uniformity of care, based on best practices, can therefore simplify the care process and decrease the risk that may be associated with individual experience-based management. Adhering to a uniform practice augments the clinician’s knowledge and allows for enhanced nursing and therapeutic efficiency.

The greatest benefit of using an evidence-based, widely accepted approach, however, is the potential to diminish poor practice and consequent malpractice exposure for both clinicians and the hospital.

Note: Although your adherence to clinical guidelines, best practices, and uniformity of care ought to be consistent with established standards of care, don’t automatically consider any deviation a lapse or failing because it’s understood and accepted that some local variability exists in practice.

Prelude to birth: triage and admission Triage. Most women in labor arrive at the hospital or birthing center to an area set aside for labor and delivery triage. There, 1) recording of the chief complaint and vital signs and 2) completion of a brief history and physical generate a call to the clinician.

The record produced in triage should be scrutinized carefully for accuracy. Clarify, in as timely a manner as possible, any errors in:

• timing (possibly because of different clocks set to different times)
• the precise capture of the chief complaint
• reporting difficulty or ease in reaching the responsible clinician.

Whether these records are electronic or paper, an addendum marked with the time is always acceptable. Never attempt to correct a record! Always utilize a late entry or addendum.

Admission. After the patient is admitted, she generally undergoes an admission protocol, specific to the hospital, regarding her situation. This includes:

• the history
• special requests
• any previously agreed-on plan of care
• any problems that have developed since her last prenatal visit.

This protocol is generally completed by a nurse, resident, nurse practitioner, or physician assistant.

Hospitals generally request input from the attending physician on the specifics of the admission, based on those hospital protocols. There may be some room to individualize the admission process to labor and delivery.

4 pillars of care during labor

In general, labor is defined as progressive dilation of the cervix. Several parameters serve as guidelines regarding adequate progress through the various stages of labor.

Fetal monitoring. Continuous evaluation of the fetus during labor is a routine part of intrapartum care. Recording and observing the FHR tracing is an accepted—and expected—practice. Documentation of the FHR in the medical record is specifically required, and should include both the physician’s and nursing notes.

Anesthesia care. The patient’s preference and the availability of options allows for several accepted practices regarding anesthesia and analgesia during L & D. Does she want epidural anesthesia during labor, for example? Intravenous narcotics? Her choice is an important facet of your provision of care.

However, such choice requires the patient to give consent and to understand the risk-benefit equation. Documentation by nursing of the patient’s consent and understanding should be complete, including discussion and administration. Anesthesia staff should be clear, complete, and legible in making a record.

Neonatal care. If logistics permit, a member of the pediatrics service should be routinely available to see the newborn at delivery. The patient should view the pediatrician and obstetrician as partners working as a team for the benefit of the mother and her family. This can enhance the patient’s understanding and confidence about the well being of her baby.

Documentation. Although deficient documentation does not, itself, lead to a finding of malpractice, appropriate documentation plays an important role in demonstrating that clinical practices have addressed issues about both allegation and causation of potential adverse outcomes.

We cannot overemphasize that nursing documentation should complement and be consistent with notes made by the physician. That said, nursing notes are not a substitute for the physician’s notes. Practices that integrate the written comments of nursing and physician into a single set of progress notes facilitate this complementary interaction.

3 more clinical scenarios

CASE 2: Admitted at term with contractions

The initial exam determines that this 21-year-old gravida 1 is 2/80/-1. Re-examination in 3 hours finds her at 3-4/80/0.

She requests pain relief and states that she wants epidural anesthesia.

Evaluation 2 hours later suggests secondary arrest of dilation. Oxytocin is begun.

Soon after, late decelerations are observed on the FHR monitor.

Use of exogenous oxytocin in L & D is a double-edged sword: The drug can enhance the safety and efficacy of labor and delivery for mother and fetus, but using it in an unregulated manner (in terms of its indication and administration) can subject both to increased risk.

In fact, it is fair to say that the most widespread and potentially dangerous intervention during labor is the administration of oxytocin. Many expert opinions, guidelines, and strategies have been put forward about intrapartum use of oxytocin. These include consideration of:

• indications
• dosage (including the maximum)
• interval
• fetal response
• ultimately, the availability of a physician during administration to manage any problem that arises.

Considerations in CASE 2

• Always clearly indicate the reason for using oxytocin: Is this an induction? Or an augmentation? Was there evidence of fetal well-being, or non-reassurance, before oxytocin was administered? Certainly, there are circumstances in which either fetal status or non-progression of labor (or both) are an indication for oxytocin. A clear, concise, and properly timed progress note is always appropriate under these circumstances.
• Discuss treatment with the patient. Does she understand why this therapy is being recommended? Does she agree to its use? And does she understand what the alternatives are?
• Verify that nursing has accurately charted this process. Ensure that the nursing staff’s notes are complete and are consistent with yours.
• Simplify the entire process: Use premixed solution and protocol-driven orders. Know what the standards and protocols are in your department. Minimizing patient-to-patient variability should lessen the risk of error.
• Always be available in L & D for the first 30 minutes that oxytocin is being administered. If a problem with excessive uterine activity is going to occur, it is most likely to do so upon initial administration.
• Monitor the FHR continuously. At the first suggestion of a change in fetal status, discontinue oxytocin. Perform a pelvic exam to reassess the situation. Understand and apply appropriate inutero resuscitative measures (IV fluids, O₂, change in maternal position). Depending on circumstances, you can consider a restart of oxytocin after the FHR returns to its pre-oxytocin pattern.
• Monitor uterine response to oxytocin. If the membranes are ruptured and if it is clinically feasible, an intrauterine pressure transducer will allow you to more objectively assess the uterine response to oxytocin and make decisions on that basis. Determine beforehand whether the patient is agreeable to this intervention.
• When oxytocin is used for augmentation, reassess labor within 4 hours of achieving a satisfactory pattern. If minimal progress is not made, assess the clinical situation to determine why oxytocin, at an adequate response level, has failed to return labor to a normal active phase slope. Are there minor degrees of malposition? Is there an element of cephalopelvic disproportion? Recall that progress in labor is dependent on multiple factors.
• Chart the process concurrently. Specify options for delivery before delivery.

CASE 3: Spontaneous delivery arrests after delivery of the head

The patient is a multipara with three prior normal vaginal deliveries. Her diabetic screen is negative. At admission, the estimated fetal weight was 3,628 g—in the same range as her other deliveries. A nuchal cord is absent.

After the patient assumes the McRobert’s position, delivery is accomplished with suprapubic pressure. Weakness is noted in the newborn’s right upper extremity. Birth weight is 3,515 g.

Maneuvers to manage shoulder dystocia should be part of all clinicians’ skill set. The sequence of those maneuvers, and their timing, are subject to some variation. Efficacy seems to be related most to recognizing and performing each maneuver properly.

Guidelines for managing shoulder dystocia should include reference to 1) the initial evaluation of the patient on admission to labor and delivery and 2) the delivery itself.³

Considerations in CASE 3

• Before you admit them to L & D, counsel patients who have diabetes, morbid obesity (body mass index >40), or birth trauma in a prior delivery, or who have had a prior large infant (>9 lb birth weight), about the risk of shoulder dystocia. Present possible alternatives, and draw the patient into the conversation.
• Consider delivering all women at term in the McRobert’s position, prophylactically.
• Always check for a nuchal cord after delivery of the head. If you find one, reduce it if possible. Take a few seconds and carefully assess the situation before you cut the umbilical cord.
• Lateral traction on the fetus’ head has the potential to cause tension on the brachial plexus, or make it worse. Gentle rotation of the head (<90 degrees) can move the shoulders into a more favorable location for delivery. Don’t rush—call for assistance! Continuously explain to the patient what you are doing; reassure her about the process.
• Use suprapubic pressure wisely. The anterior shoulder may be dislodged by direct downward force; suprapubic force in a lateral direction may also dislodge the shoulder. Apply force from above the patient’s pelvis. Your assistant will have the best mechanical advantage by standing on a stool.
• Is an episiotomy or episioproctotomy advantageous? In attempting to reach either the anterior or posterior shoulder vaginally, individualized assessment is called for.
• When the posterior shoulder cannot be satisfactorily engaged and moved, try doing so with the anterior shoulder. Insert your hand between the symphysis and the fetal head and place downward pressure on the head to dislodge it and complete the delivery.
• If it becomes necessary to attempt delivery by direct traction on the posterior hand or arm, try to avoid extension. Maintain flexion and move the upper extremity across the fetal chest before you attempt extension.
• Repeat these maneuvers a second time before you attempt cephalic replacement or other maneuvers. Remember to move with deliberate speed to lessen the risk of making the injury worse. Have pediatric support present. Continue speaking with and reassuring the patient.
• Under anesthesia in the operating room, perform a hysterotomy incision. With an assistant working through the vagina, combine the forces available to complete the delivery.
• After delivery is complete, take time to write a note. (Speak with the patient and her family first, however.) Read the notes written by nursing. If they are not available when you write your note, mention that. Add a second note later, when nursing notes become available.

CASE 4: Meconium-stained fluid

A 35-year-old multigravida is 6 to 7 cm dilated. Her membranes have just spontaneously ruptured; you note copious meconium-stained fluid. The FHR demonstrates recurrent variable decelerations; baseline fetal heart rate remains normal.

The description and implications of various FHR patterns are important when documenting the fetal metabolic state during the birth process. Current guidelines have attempted to simplify, standardize, and clarify the interpretation of the FHR tracing.⁴

Considerations in CASE 4

• Explain the situation to the patient. Perform a pelvic examination. If possible, wait for nursing assistance to ensure accurate documentation.
• Reassure the patient; help her move to a lateral position. Observe the FHR monitor for a response.
• Administer supplemental O₂. Increase IV fluids to facilitate utero-placental perfusion.
• If useful or necessary, consider attaching a fetal scalp electrode to better delineate fetal status.
• When the FHR returns to baseline state (before spontaneous rupture of membranes), perform vibro-acoustic stimulation as a test to support fetal well-being.
• Engage the patient and her family in a discussion about the sequence of events. Depending on the acuity of the situation, allow her to voice her concerns and reiterate what has occurred, and what will occur.
• Outline a plan of management to the patient—verbally and in the record—with clear reference to events that have occurred. Then, stick to that plan!
• Carefully review corresponding nursing notes. Always write your own assessment of events and actions.

Summing up: three “keepers”

First, the cornerstones of your effort to reduce malpractice risk are 1) thoughtful and informed discussion with the patient and 2) clear, concise documentation.

Second, don’t expect to be able to eliminate unnecessary or inappropriate allegations of medical malpractice; the best you can do is limit them.

Third, and most important, remember: The knowledgeable clinician you strive to be will make appropriate judgments in a timely fashion and will take appropriate actions to provide good medical care.

We want to hear from you! Tell us what you think.

Pop quiz: How long have I been writing that private medical practices are businesses, whether we like it or not; and like any other business, they require consistent, sensible business management?

If you answered that I've been harping on that point from the very beginning, congratulations; you're a long-time reader. And yet, the most basic and important business tool – preparation of an annual budget – continues to be ignored by most private practitioners.

The usual excuse is lack of time – and besides, the practice seems to be doing fine without one. But like anything else, you can't fix problems you never look for.

You can't identify needless, wasteful, or redundant purchases, under- or overstaffing, or misappropriated funds if you don't track your practice's expenditure data.

There is no way to make intelligent decisions on such basic issues as fee adjustments, new equipment purchases, and marketing strategies without a firm grasp of your expenditures, and a reasonable idea of where those numbers may be going in the foreseeable future. Without a budget, you cannot know your costs of doing business, let alone whether they are too high or too low. Chances are excellent that you are overpaying your taxes, too.

Embezzlers typically continue their nefarious ways far longer than they should (and some are never caught at all) because all too often, nobody is watching the budget numbers. And if you are planning a refurbishment or expansion, no self-respecting bank will approve a loan in the post-TARP era without seeing a well-organized budget.

There is no need to wait to take action until, one day, your cash flow is too low to meet payroll, or a similar crisis convinces you that budgeting is important. Now, at the beginning of a new year, with last year's financial data accumulated and readily at hand – and before significant changes mandated by the recent health care reform legislation take effect – is an ideal time to get a budget in place.

If your practice is incorporated and your fiscal year does not begin on Jan. 1, don't use that as an excuse; draw up a limited, “partial” budget for the remainder of the fiscal year, then start a new one when your next fiscal period begins.

Creating a budget is not the formidable or expensive task you may be envisioning. Unless your practice situation is unusually complex, you can probably do it yourself – although, if this is your first time, you will probably want to enlist the help of your accountant. A good spreadsheet program such as Excel or iWork simplifies the process considerably, and financial software packages such as QuickBooks or NetSuite make it even easier. (As always, I have no financial interest in any company or product mentioned in this column.)

Start by creating a list of practice expense categories, or “chart of accounts” (COA) in financial lingo. Each component of a COA is called a “line item,” and in general, the more line items, the better. Commercial software products typically provide a standardized COA, but you will want to customize it to your individual needs. (Your accountant can help with that.)

This is a critical step, so take your time, and do it right. The more detailed you make your COA, the more flexible your budget will be, the easier it will be to identify deductible expenses at year's end, and the harder you will make it for an embezzler to operate unnoticed.

Then, using last year's records (or if possible, an average of several years'), assign a dollar amount to each line item. Right away, some rude surprises may be in store (“We spend how much on printer ink?”), but already you are gaining valuable information that can be acted on immediately.

If you are not sure whether you are over- or underspending on a specific line item, or the category is a new one and you don't know how much to allot, check with local colleagues or your accountant. Some practice management firms post lists of “benchmarks” averaged from surveys of their clients. Benchmark numbers can be deceptive, however, especially if the surveyed practices are in different parts of the country or have different socioeconomic populations.

Creating a budget is only the beginning; periodically, you must compare your actual expenditures with those you budgeted. (Most businesses do this quarterly; more frequent reviews can trigger needless worry over normal short-term fluctuations.)

Look for significant discrepancies and the reasons for them. Are your expenditures excessive, or was the budgeted amount unrealistic? Adjustments (of both expenditures and budget) will be frequent at first; but as time passes and your financial management skills improve, your practice will sail along on a progressively smoother financial course.

Pop quiz: How long have I been writing that private medical practices are businesses, whether we like it or not; and like any other business, they require consistent, sensible business management?

If you answered that I've been harping on that point from the very beginning, congratulations; you're a long-time reader. And yet, the most basic and important business tool – preparation of an annual budget – continues to be ignored by most private practitioners.

The usual excuse is lack of time – and besides, the practice seems to be doing fine without one. But like anything else, you can't fix problems you never look for.

You can't identify needless, wasteful, or redundant purchases, under- or overstaffing, or misappropriated funds if you don't track your practice's expenditure data.

There is no way to make intelligent decisions on such basic issues as fee adjustments, new equipment purchases, and marketing strategies without a firm grasp of your expenditures, and a reasonable idea of where those numbers may be going in the foreseeable future. Without a budget, you cannot know your costs of doing business, let alone whether they are too high or too low. Chances are excellent that you are overpaying your taxes, too.

Embezzlers typically continue their nefarious ways far longer than they should (and some are never caught at all) because all too often, nobody is watching the budget numbers. And if you are planning a refurbishment or expansion, no self-respecting bank will approve a loan in the post-TARP era without seeing a well-organized budget.

There is no need to wait to take action until, one day, your cash flow is too low to meet payroll, or a similar crisis convinces you that budgeting is important. Now, at the beginning of a new year, with last year's financial data accumulated and readily at hand – and before significant changes mandated by the recent health care reform legislation take effect – is an ideal time to get a budget in place.

If your practice is incorporated and your fiscal year does not begin on Jan. 1, don't use that as an excuse; draw up a limited, “partial” budget for the remainder of the fiscal year, then start a new one when your next fiscal period begins.

Creating a budget is not the formidable or expensive task you may be envisioning. Unless your practice situation is unusually complex, you can probably do it yourself – although, if this is your first time, you will probably want to enlist the help of your accountant. A good spreadsheet program such as Excel or iWork simplifies the process considerably, and financial software packages such as QuickBooks or NetSuite make it even easier. (As always, I have no financial interest in any company or product mentioned in this column.)

Start by creating a list of practice expense categories, or “chart of accounts” (COA) in financial lingo. Each component of a COA is called a “line item,” and in general, the more line items, the better. Commercial software products typically provide a standardized COA, but you will want to customize it to your individual needs. (Your accountant can help with that.)

This is a critical step, so take your time, and do it right. The more detailed you make your COA, the more flexible your budget will be, the easier it will be to identify deductible expenses at year's end, and the harder you will make it for an embezzler to operate unnoticed.

Then, using last year's records (or if possible, an average of several years'), assign a dollar amount to each line item. Right away, some rude surprises may be in store (“We spend how much on printer ink?”), but already you are gaining valuable information that can be acted on immediately.

If you are not sure whether you are over- or underspending on a specific line item, or the category is a new one and you don't know how much to allot, check with local colleagues or your accountant. Some practice management firms post lists of “benchmarks” averaged from surveys of their clients. Benchmark numbers can be deceptive, however, especially if the surveyed practices are in different parts of the country or have different socioeconomic populations.

Creating a budget is only the beginning; periodically, you must compare your actual expenditures with those you budgeted. (Most businesses do this quarterly; more frequent reviews can trigger needless worry over normal short-term fluctuations.)

Look for significant discrepancies and the reasons for them. Are your expenditures excessive, or was the budgeted amount unrealistic? Adjustments (of both expenditures and budget) will be frequent at first; but as time passes and your financial management skills improve, your practice will sail along on a progressively smoother financial course.

Pop quiz: How long have I been writing that private medical practices are businesses, whether we like it or not; and like any other business, they require consistent, sensible business management?

If you answered that I've been harping on that point from the very beginning, congratulations; you're a long-time reader. And yet, the most basic and important business tool – preparation of an annual budget – continues to be ignored by most private practitioners.

The usual excuse is lack of time – and besides, the practice seems to be doing fine without one. But like anything else, you can't fix problems you never look for.

You can't identify needless, wasteful, or redundant purchases, under- or overstaffing, or misappropriated funds if you don't track your practice's expenditure data.

There is no way to make intelligent decisions on such basic issues as fee adjustments, new equipment purchases, and marketing strategies without a firm grasp of your expenditures, and a reasonable idea of where those numbers may be going in the foreseeable future. Without a budget, you cannot know your costs of doing business, let alone whether they are too high or too low. Chances are excellent that you are overpaying your taxes, too.

Embezzlers typically continue their nefarious ways far longer than they should (and some are never caught at all) because all too often, nobody is watching the budget numbers. And if you are planning a refurbishment or expansion, no self-respecting bank will approve a loan in the post-TARP era without seeing a well-organized budget.

There is no need to wait to take action until, one day, your cash flow is too low to meet payroll, or a similar crisis convinces you that budgeting is important. Now, at the beginning of a new year, with last year's financial data accumulated and readily at hand – and before significant changes mandated by the recent health care reform legislation take effect – is an ideal time to get a budget in place.

If your practice is incorporated and your fiscal year does not begin on Jan. 1, don't use that as an excuse; draw up a limited, “partial” budget for the remainder of the fiscal year, then start a new one when your next fiscal period begins.

Creating a budget is not the formidable or expensive task you may be envisioning. Unless your practice situation is unusually complex, you can probably do it yourself – although, if this is your first time, you will probably want to enlist the help of your accountant. A good spreadsheet program such as Excel or iWork simplifies the process considerably, and financial software packages such as QuickBooks or NetSuite make it even easier. (As always, I have no financial interest in any company or product mentioned in this column.)

Start by creating a list of practice expense categories, or “chart of accounts” (COA) in financial lingo. Each component of a COA is called a “line item,” and in general, the more line items, the better. Commercial software products typically provide a standardized COA, but you will want to customize it to your individual needs. (Your accountant can help with that.)

This is a critical step, so take your time, and do it right. The more detailed you make your COA, the more flexible your budget will be, the easier it will be to identify deductible expenses at year's end, and the harder you will make it for an embezzler to operate unnoticed.

Then, using last year's records (or if possible, an average of several years'), assign a dollar amount to each line item. Right away, some rude surprises may be in store (“We spend how much on printer ink?”), but already you are gaining valuable information that can be acted on immediately.

If you are not sure whether you are over- or underspending on a specific line item, or the category is a new one and you don't know how much to allot, check with local colleagues or your accountant. Some practice management firms post lists of “benchmarks” averaged from surveys of their clients. Benchmark numbers can be deceptive, however, especially if the surveyed practices are in different parts of the country or have different socioeconomic populations.

Creating a budget is only the beginning; periodically, you must compare your actual expenditures with those you budgeted. (Most businesses do this quarterly; more frequent reviews can trigger needless worry over normal short-term fluctuations.)

Look for significant discrepancies and the reasons for them. Are your expenditures excessive, or was the budgeted amount unrealistic? Adjustments (of both expenditures and budget) will be frequent at first; but as time passes and your financial management skills improve, your practice will sail along on a progressively smoother financial course.

Pop quiz: How long have I been writing that private medical practices are businesses, whether we like it or not; and like any other business, they require consistent, sensible business management?

If you answered that I’ve been harping on that point from the very beginning, congratulations; you’re a long-time reader. And yet, the most basic and important business tool – preparation of an annual budget – continues to be ignored by most private practitioners.

The usual excuse is lack of time, and besides, the practice seems to be doing fine without one; but like anything else, you can’t fix problems you never look for.

You can’t identify needless, wasteful, or redundant purchases, under- or overstaffing, or misappropriated funds if you don’t track your practice’s expenditure data.

There is no way to make intelligent decisions on such basic issues as fee adjustments, new equipment purchases, and marketing strategies without a firm grasp of your expenditures, and a reasonable idea of where those numbers may be going in the foreseeable future. Without a budget you cannot know your costs of doing business, let alone whether they are too high or too low. Chances are excellent that you are overpaying your taxes, too.

Embezzlers typically continue their nefarious ways far longer than they should (and some are never caught at all) because all too often, nobody is watching the budget numbers. And if you are planning a refurbishment or expansion, no self-respecting bank will approve a loan in the post-TARP era without seeing a well-organized budget.

There is no need to wait to take action until, one day, your cash flow is too low to meet payroll, or a similar crisis convinces you that budgeting is important. Now, at the beginning of a new year, with last year’s financial data accumulated and readily at hand – and before significant changes mandated by the recent health care reform legislation take effect (more about that next month) – is an ideal time to get a budget in place.

If your practice is incorporated and your fiscal year does not begin on Jan. 1, don’t use that as an excuse; draw up a limited, "partial" budget for the remainder of this year, then start a new one when your next fiscal period begins.

Creating a budget is not the formidable or expensive task you may be envisioning. Unless your practice situation is unusually complex, you can probably do it yourself – although, if this is your first time, you will probably want to enlist the help of your accountant. A good spreadsheet program like Excel or iWork simplifies the process considerably, and financial software packages like QuickBooks or NetSuite make it even easier. (As always, I have no financial interest in any company or product mentioned in this column.)

Start by creating a list of practice expense categories, or "chart of accounts" (COA) in financial lingo. Each component of a COA is called a "line item," and in general, the more line items, the better. Commercial software products typically provide a standardized COA, but you will want to customize it to your individual needs. (Your accountant can help with that.) This is a critical step, so take your time, and do it right. The more detailed you make your COA, the more flexible your budget will be, the easier it will be to identify deductible expenses at year’s end, and the harder you will make it for an embezzler to operate unnoticed.

Then, using last year’s records (or if possible, an average of several years’), assign a dollar amount to each line item. Right away, some rude surprises may be in store ("We spend how much on printer ink?"), but already you are gaining valuable information that can be acted on immediately.

If you are not sure whether you are over- or underspending on a specific line item, or the category is a new one and you don’t know how much to allot, check with local colleagues or your accountant. Some practice management firms post lists of "benchmarks" averaged from surveys of their clients. Benchmark numbers can be deceptive, however, especially if the surveyed practices are in different parts of the country or have different socioeconomic populations.

Creating a budget is only the beginning; periodically, you must compare your actual expenditures with those you budgeted. (Most businesses do this quarterly; more frequent reviews can trigger needless worry over normal short-term fluctuations.)

Look for significant discrepancies and the reasons for them. Are your expenditures excessive, or was the budgeted amount unrealistic? Adjustments (of both expenditures and budget) will be frequent at first; but as time passes and your financial management skills improve, your practice will sail along on a progressively smoother financial course.

Pop quiz: How long have I been writing that private medical practices are businesses, whether we like it or not; and like any other business, they require consistent, sensible business management?

If you answered that I’ve been harping on that point from the very beginning, congratulations; you’re a long-time reader. And yet, the most basic and important business tool – preparation of an annual budget – continues to be ignored by most private practitioners.

The usual excuse is lack of time, and besides, the practice seems to be doing fine without one; but like anything else, you can’t fix problems you never look for.

You can’t identify needless, wasteful, or redundant purchases, under- or overstaffing, or misappropriated funds if you don’t track your practice’s expenditure data.

There is no way to make intelligent decisions on such basic issues as fee adjustments, new equipment purchases, and marketing strategies without a firm grasp of your expenditures, and a reasonable idea of where those numbers may be going in the foreseeable future. Without a budget you cannot know your costs of doing business, let alone whether they are too high or too low. Chances are excellent that you are overpaying your taxes, too.

Embezzlers typically continue their nefarious ways far longer than they should (and some are never caught at all) because all too often, nobody is watching the budget numbers. And if you are planning a refurbishment or expansion, no self-respecting bank will approve a loan in the post-TARP era without seeing a well-organized budget.

There is no need to wait to take action until, one day, your cash flow is too low to meet payroll, or a similar crisis convinces you that budgeting is important. Now, at the beginning of a new year, with last year’s financial data accumulated and readily at hand – and before significant changes mandated by the recent health care reform legislation take effect (more about that next month) – is an ideal time to get a budget in place.

If your practice is incorporated and your fiscal year does not begin on Jan. 1, don’t use that as an excuse; draw up a limited, "partial" budget for the remainder of this year, then start a new one when your next fiscal period begins.

Creating a budget is not the formidable or expensive task you may be envisioning. Unless your practice situation is unusually complex, you can probably do it yourself – although, if this is your first time, you will probably want to enlist the help of your accountant. A good spreadsheet program like Excel or iWork simplifies the process considerably, and financial software packages like QuickBooks or NetSuite make it even easier. (As always, I have no financial interest in any company or product mentioned in this column.)

Start by creating a list of practice expense categories, or "chart of accounts" (COA) in financial lingo. Each component of a COA is called a "line item," and in general, the more line items, the better. Commercial software products typically provide a standardized COA, but you will want to customize it to your individual needs. (Your accountant can help with that.) This is a critical step, so take your time, and do it right. The more detailed you make your COA, the more flexible your budget will be, the easier it will be to identify deductible expenses at year’s end, and the harder you will make it for an embezzler to operate unnoticed.

Then, using last year’s records (or if possible, an average of several years’), assign a dollar amount to each line item. Right away, some rude surprises may be in store ("We spend how much on printer ink?"), but already you are gaining valuable information that can be acted on immediately.

If you are not sure whether you are over- or underspending on a specific line item, or the category is a new one and you don’t know how much to allot, check with local colleagues or your accountant. Some practice management firms post lists of "benchmarks" averaged from surveys of their clients. Benchmark numbers can be deceptive, however, especially if the surveyed practices are in different parts of the country or have different socioeconomic populations.

Creating a budget is only the beginning; periodically, you must compare your actual expenditures with those you budgeted. (Most businesses do this quarterly; more frequent reviews can trigger needless worry over normal short-term fluctuations.)

Look for significant discrepancies and the reasons for them. Are your expenditures excessive, or was the budgeted amount unrealistic? Adjustments (of both expenditures and budget) will be frequent at first; but as time passes and your financial management skills improve, your practice will sail along on a progressively smoother financial course.

Pop quiz: How long have I been writing that private medical practices are businesses, whether we like it or not; and like any other business, they require consistent, sensible business management?

If you answered that I’ve been harping on that point from the very beginning, congratulations; you’re a long-time reader. And yet, the most basic and important business tool – preparation of an annual budget – continues to be ignored by most private practitioners.

The usual excuse is lack of time, and besides, the practice seems to be doing fine without one; but like anything else, you can’t fix problems you never look for.

You can’t identify needless, wasteful, or redundant purchases, under- or overstaffing, or misappropriated funds if you don’t track your practice’s expenditure data.

There is no way to make intelligent decisions on such basic issues as fee adjustments, new equipment purchases, and marketing strategies without a firm grasp of your expenditures, and a reasonable idea of where those numbers may be going in the foreseeable future. Without a budget you cannot know your costs of doing business, let alone whether they are too high or too low. Chances are excellent that you are overpaying your taxes, too.

Embezzlers typically continue their nefarious ways far longer than they should (and some are never caught at all) because all too often, nobody is watching the budget numbers. And if you are planning a refurbishment or expansion, no self-respecting bank will approve a loan in the post-TARP era without seeing a well-organized budget.

There is no need to wait to take action until, one day, your cash flow is too low to meet payroll, or a similar crisis convinces you that budgeting is important. Now, at the beginning of a new year, with last year’s financial data accumulated and readily at hand – and before significant changes mandated by the recent health care reform legislation take effect (more about that next month) – is an ideal time to get a budget in place.

If your practice is incorporated and your fiscal year does not begin on Jan. 1, don’t use that as an excuse; draw up a limited, "partial" budget for the remainder of this year, then start a new one when your next fiscal period begins.

Creating a budget is not the formidable or expensive task you may be envisioning. Unless your practice situation is unusually complex, you can probably do it yourself – although, if this is your first time, you will probably want to enlist the help of your accountant. A good spreadsheet program like Excel or iWork simplifies the process considerably, and financial software packages like QuickBooks or NetSuite make it even easier. (As always, I have no financial interest in any company or product mentioned in this column.)

Start by creating a list of practice expense categories, or "chart of accounts" (COA) in financial lingo. Each component of a COA is called a "line item," and in general, the more line items, the better. Commercial software products typically provide a standardized COA, but you will want to customize it to your individual needs. (Your accountant can help with that.) This is a critical step, so take your time, and do it right. The more detailed you make your COA, the more flexible your budget will be, the easier it will be to identify deductible expenses at year’s end, and the harder you will make it for an embezzler to operate unnoticed.

Then, using last year’s records (or if possible, an average of several years’), assign a dollar amount to each line item. Right away, some rude surprises may be in store ("We spend how much on printer ink?"), but already you are gaining valuable information that can be acted on immediately.

If you are not sure whether you are over- or underspending on a specific line item, or the category is a new one and you don’t know how much to allot, check with local colleagues or your accountant. Some practice management firms post lists of "benchmarks" averaged from surveys of their clients. Benchmark numbers can be deceptive, however, especially if the surveyed practices are in different parts of the country or have different socioeconomic populations.

Creating a budget is only the beginning; periodically, you must compare your actual expenditures with those you budgeted. (Most businesses do this quarterly; more frequent reviews can trigger needless worry over normal short-term fluctuations.)

Look for significant discrepancies and the reasons for them. Are your expenditures excessive, or was the budgeted amount unrealistic? Adjustments (of both expenditures and budget) will be frequent at first; but as time passes and your financial management skills improve, your practice will sail along on a progressively smoother financial course.

Lethal liver injury blamed on birth trauma

BECAUSE OF PREMATURE CONTRACTIONS and bleeding, a woman underwent cesarean delivery by her ObGyns. When Dr. A reached in to extract the fetus, it floated away. Dr. B then attempted delivery while Dr. A applied fundal pressure. Photographs of the baby taken by the father 2 minutes after birth showed severe bruising over the liver area. Sonography performed shortly after birth revealed a liver laceration. Surgery to repair the liver was unsuccessful. The infant died.

ESTATE’S CLAIM The trauma from improper fundal pressure and improper manipulation when extracting the infant through an inadequately sized incision caused the liver to rupture. A vertical incision should have been made initially, instead of a transverse incision, because of the small size of the fetus and uterus. When the fetus could not be extracted, a reverse “T” incision should have been made so the fetus could be extracted without trauma.

PHYSICIANS’ DEFENSE The mother had a preexisting disorder that caused bleeding before delivery; the liver laceration occurred hours before delivery.

VERDICT A $1,461,507 Maryland verdict was returned, including $461,507 to the infant’s estate, and $500,000 to each parent.

Perforated colon after hysteroscopy

A 44-YEAR-OLD WOMAN UNDERWENT hysteroscopic surgery to remove polyps and a fibroid tumor. During the procedure, the ObGyn used a hysteroscopic resection loop. Two days later, the patient developed peritonitis. A perforation was detected, requiring resection of part of the colon and a temporary colostomy.

PATIENT’S CLAIM The injury occurred when the ObGyn pushed the resection loop of the hysteroscope through the uterus, burning a hole in the uterus and the colon. The ObGyn should have performed a more extensive check to ensure that no perforation had occurred.

PHYSICIAN’S DEFENSE Perforation was a delayed thermal effect that did not occur until 2 days after the procedure. There was no negligence.

VERDICT A $1.55 million New York verdict was returned.

Did retractors cause neuropathy?

AFTER CERVICAL CANCER was diagnosed, a 37-year-old woman was referred to a gynecologic oncologist. He performed a modified radical hysterectomy with pelvic node dissection and lymphadenectomy. A Pfannenstiel incision was used, and the procedure involved removal of the uterus, cervix, upper quarter of the vagina, pelvic lymph nodes, and surrounding tissue. Surgery lasted longer than 5 hours.

The next day, the patient reported pain, burning, tingling, and numbness in her left thigh, which was eventually diagnosed as lateral femoral cutaneous neuropathy. This condition did not resolve.

PATIENT’S CLAIM The surgeon failed to reposition retractors with sufficient frequency. He allowed the retractor blades to press on the psoas muscles, thus injuring the lateral femoral cutaneous nerve.

PHYSICIAN’S DEFENSE The retractors were used properly; they were periodically shifted to gain better exposure to the surgical area. The surgeon also used his hands to determine that the retractors were properly positioned.

VERDICT An Illinois defense verdict was returned.

“I would have terminated my pregnancy if…”

A PREGNANT WOMAN UNDERWENT a blood test that indicated that the fetus had an elevated risk of being born with Down syndrome. The child was born 7 months later with Down syndrome.

PATIENT’S CLAIM She was not told of the increased risk that her child would have Down syndrome. If she had been informed, she would have terminated the pregnancy.

PHYSICIAN’S DEFENSE According to the physician’s records, the mother was told the blood test results many times. Amniocentesis was recommended, but the mother had declined.

VERDICT A Maryland defense verdict was returned.

Lethal liver injury blamed on birth trauma

BECAUSE OF PREMATURE CONTRACTIONS and bleeding, a woman underwent cesarean delivery by her ObGyns. When Dr. A reached in to extract the fetus, it floated away. Dr. B then attempted delivery while Dr. A applied fundal pressure. Photographs of the baby taken by the father 2 minutes after birth showed severe bruising over the liver area. Sonography performed shortly after birth revealed a liver laceration. Surgery to repair the liver was unsuccessful. The infant died.

ESTATE’S CLAIM The trauma from improper fundal pressure and improper manipulation when extracting the infant through an inadequately sized incision caused the liver to rupture. A vertical incision should have been made initially, instead of a transverse incision, because of the small size of the fetus and uterus. When the fetus could not be extracted, a reverse “T” incision should have been made so the fetus could be extracted without trauma.

PHYSICIANS’ DEFENSE The mother had a preexisting disorder that caused bleeding before delivery; the liver laceration occurred hours before delivery.

VERDICT A $1,461,507 Maryland verdict was returned, including $461,507 to the infant’s estate, and $500,000 to each parent.

Perforated colon after hysteroscopy

A 44-YEAR-OLD WOMAN UNDERWENT hysteroscopic surgery to remove polyps and a fibroid tumor. During the procedure, the ObGyn used a hysteroscopic resection loop. Two days later, the patient developed peritonitis. A perforation was detected, requiring resection of part of the colon and a temporary colostomy.

PATIENT’S CLAIM The injury occurred when the ObGyn pushed the resection loop of the hysteroscope through the uterus, burning a hole in the uterus and the colon. The ObGyn should have performed a more extensive check to ensure that no perforation had occurred.

PHYSICIAN’S DEFENSE Perforation was a delayed thermal effect that did not occur until 2 days after the procedure. There was no negligence.

VERDICT A $1.55 million New York verdict was returned.

Did retractors cause neuropathy?

AFTER CERVICAL CANCER was diagnosed, a 37-year-old woman was referred to a gynecologic oncologist. He performed a modified radical hysterectomy with pelvic node dissection and lymphadenectomy. A Pfannenstiel incision was used, and the procedure involved removal of the uterus, cervix, upper quarter of the vagina, pelvic lymph nodes, and surrounding tissue. Surgery lasted longer than 5 hours.

The next day, the patient reported pain, burning, tingling, and numbness in her left thigh, which was eventually diagnosed as lateral femoral cutaneous neuropathy. This condition did not resolve.

PATIENT’S CLAIM The surgeon failed to reposition retractors with sufficient frequency. He allowed the retractor blades to press on the psoas muscles, thus injuring the lateral femoral cutaneous nerve.

PHYSICIAN’S DEFENSE The retractors were used properly; they were periodically shifted to gain better exposure to the surgical area. The surgeon also used his hands to determine that the retractors were properly positioned.

VERDICT An Illinois defense verdict was returned.

“I would have terminated my pregnancy if…”

A PREGNANT WOMAN UNDERWENT a blood test that indicated that the fetus had an elevated risk of being born with Down syndrome. The child was born 7 months later with Down syndrome.

PATIENT’S CLAIM She was not told of the increased risk that her child would have Down syndrome. If she had been informed, she would have terminated the pregnancy.

PHYSICIAN’S DEFENSE According to the physician’s records, the mother was told the blood test results many times. Amniocentesis was recommended, but the mother had declined.

VERDICT A Maryland defense verdict was returned.

Lethal liver injury blamed on birth trauma

BECAUSE OF PREMATURE CONTRACTIONS and bleeding, a woman underwent cesarean delivery by her ObGyns. When Dr. A reached in to extract the fetus, it floated away. Dr. B then attempted delivery while Dr. A applied fundal pressure. Photographs of the baby taken by the father 2 minutes after birth showed severe bruising over the liver area. Sonography performed shortly after birth revealed a liver laceration. Surgery to repair the liver was unsuccessful. The infant died.

ESTATE’S CLAIM The trauma from improper fundal pressure and improper manipulation when extracting the infant through an inadequately sized incision caused the liver to rupture. A vertical incision should have been made initially, instead of a transverse incision, because of the small size of the fetus and uterus. When the fetus could not be extracted, a reverse “T” incision should have been made so the fetus could be extracted without trauma.

PHYSICIANS’ DEFENSE The mother had a preexisting disorder that caused bleeding before delivery; the liver laceration occurred hours before delivery.

VERDICT A $1,461,507 Maryland verdict was returned, including $461,507 to the infant’s estate, and $500,000 to each parent.

Perforated colon after hysteroscopy

A 44-YEAR-OLD WOMAN UNDERWENT hysteroscopic surgery to remove polyps and a fibroid tumor. During the procedure, the ObGyn used a hysteroscopic resection loop. Two days later, the patient developed peritonitis. A perforation was detected, requiring resection of part of the colon and a temporary colostomy.

PATIENT’S CLAIM The injury occurred when the ObGyn pushed the resection loop of the hysteroscope through the uterus, burning a hole in the uterus and the colon. The ObGyn should have performed a more extensive check to ensure that no perforation had occurred.

PHYSICIAN’S DEFENSE Perforation was a delayed thermal effect that did not occur until 2 days after the procedure. There was no negligence.

VERDICT A $1.55 million New York verdict was returned.

Did retractors cause neuropathy?

AFTER CERVICAL CANCER was diagnosed, a 37-year-old woman was referred to a gynecologic oncologist. He performed a modified radical hysterectomy with pelvic node dissection and lymphadenectomy. A Pfannenstiel incision was used, and the procedure involved removal of the uterus, cervix, upper quarter of the vagina, pelvic lymph nodes, and surrounding tissue. Surgery lasted longer than 5 hours.

The next day, the patient reported pain, burning, tingling, and numbness in her left thigh, which was eventually diagnosed as lateral femoral cutaneous neuropathy. This condition did not resolve.

PATIENT’S CLAIM The surgeon failed to reposition retractors with sufficient frequency. He allowed the retractor blades to press on the psoas muscles, thus injuring the lateral femoral cutaneous nerve.

PHYSICIAN’S DEFENSE The retractors were used properly; they were periodically shifted to gain better exposure to the surgical area. The surgeon also used his hands to determine that the retractors were properly positioned.

VERDICT An Illinois defense verdict was returned.

“I would have terminated my pregnancy if…”

A PREGNANT WOMAN UNDERWENT a blood test that indicated that the fetus had an elevated risk of being born with Down syndrome. The child was born 7 months later with Down syndrome.

PATIENT’S CLAIM She was not told of the increased risk that her child would have Down syndrome. If she had been informed, she would have terminated the pregnancy.

PHYSICIAN’S DEFENSE According to the physician’s records, the mother was told the blood test results many times. Amniocentesis was recommended, but the mother had declined.

VERDICT A Maryland defense verdict was returned.

OBG Management is blessed to have readers who are world-class clinical experts in obstetrics, gynecology, and women’s health. Thanks to your education, training, and experience, you are the women’s health experts of America, a unique resource.

We decided to tap into this resource by inviting members of our Virtual Board of Editors to offer a clinical pearl that has helped increase their efficacy or efficiency over the past year. The pearls contained in this article are well worth your time to read. (And we welcome your contributions, as well. Simply email them to [email protected], and we will publish a compilation in the future.)

As for my contribution, I have found the levonorgestrel-releasing intrauterine system (Mirena) to be invaluable in the provision of contraception and treatment of menorrhagia and pelvic pain, often averting the need for a surgical procedure. If it were more widely utilized—even in the face of a major price increase—it could reduce both the number of unintended pregnancies and hysterectomy procedures. As we become comfortable with the technique and clinical efficacy of this system, I expect utilization to increase significantly.

And now, we present eight other practice-enhancing pearls…. —Robert L. Barbieri, MD

1. Don’t underestimate the value of a phone call ($20,000, in one case)

Three-dimensional ultrasonography (US) is nice; fancy cystometrics are helpful; and electronic health records (EHR) may or may not reduce paperwork—but all of these technologies are expensive. In this era of plummeting reimbursement, the common telephone can help you pay the overhead.

Here’s an example: Mrs. Smith, a new patient, visited my office for a consultation about her difficulty in getting pregnant. It seems that my competitor in a nearby town had failed to telephone Mrs. Smith about her lab results, despite repeated attempts to obtain them on her part. His loss, my gain. I called her back multiple times to report lab values and coordinate the ovulation induction that ensued. She conceived, became an obstetric patient, and had a vaginal delivery. Laparoscopy followed several years later for pelvic pain. A second round of ovulation induction produced another pregnancy. She was pleased and always is pleasantly surprised when she gets a personal call from me. I consider it time well spent. And I estimate that, over the years I have managed this patient, she has brought at least $20,000 into my coffers.

A phone call is cheap, effective, and shows you care. Use your phone! You’re paying the monthly bill anyway! Make it work for you. It’s an asset, not a liability!

Dr. Franklin practices ObGyn in Lewisville, Tex.

Every summer, I hire a high school student to call every patient who has not been seen in the office over the past 13 to 36 months. I provide the student, who works for the minimum wage, with a script outlining different scenarios. The script includes inquiries about the patient’s current address and whether she wishes to be considered a patient of the practice. Most important, this script instructs the student to offer each patient an appointment.

Rather than waste time instructing the student how to schedule an appointment and enter the patient’s data, I have the employee simply transfer the call to an office scheduler when the patient wishes to make an appointment. This strategy has proved quite successful at generating office visits at minimal cost.

Dr. McGrath is Chief of Obstetrics and Gynecology at Baptist Medical Center Nassau in Fernandina Beach, Fla.

The one thing that has definitely made my life a little simpler is the transition from beepers and pagers to cell phones. Before this transition, I would get paged to a message. Then I would have to get to a phone and dial the number in the message. If I was in the car, this supposedly simple process was not so simple. And if the number was busy, that was another headache. Then I would have to start all over.

Now the message comes into my smart-phone as a text message with the callback number right there in the message. I click on it and, right then and there, I am connected to my patient!

For private practitioners out there who deal with emergency calls and patients in labor, the new technology is a life and time saver!

Dr. Zandieh practices ObGyn in Bethpage, NY.

2. Electronic health records are better for both physician and patient

Adoption of an EHR has made the biggest difference in my practice over the past year. The EHR is an electronic version of the patient record that includes documentation of the history and physical exam, progress notes, diagnoses, medications, laboratory and radiographic studies, US imaging, and immunizations. It has proved to be integral to the efficient and effective delivery of health care to my patients. Although my institution implemented the EHR in 2002, I have come to appreciate it more every year. Here are a few of the reasons:

Improved legibility Penmanship is not a virtue of most physicians. The EHR presents the patient’s record in a clear, readable format and reduces errors in care.

Portability The EHR can be viewed in the hospital, emergency room, or at home when the physician is on call.

Accessibility Multiple departments treating a patient may see one another’s work-up, records, and ancillary studies.

Easier and less expensive storage With the EHR, physical storage of records is minimal. There is also a reduction in staff to care for those records.

Security and liability The EHR provides more secure records and limits access. Once it is signed, the medical record in the EHR cannot be altered.

Improved coding High-quality, more legible medical records improve the accuracy of coding and the submission of more accurate claims.

Confidentiality The EHR is more confidential than paper records by virtue of its limited and controlled access.

Improved patient care is the most important part of medicine today. By virtue of its ease of use, great security, accessibility and portability, the EHR contributes to better care.

Dr. Avery is Professor and Chair of Obstetrics and Gynecology at the University of Alabama School of Medicine in Tuscaloosa, Ala.

Some things don’t help!

“The EHR interferes with my assessment of the patient”

Carolyn V. Brown, MD, MPH

One of the most important changes in my practice has been implementation of the electronic health record (EHR). Supposedly, that is a good thing, but I have found that utility of the EHR depends on who designs it. Before the EHR, I relied largely on the patient’s history to reveal clues to her condition. Now, when I go into an examination room, I have to spend precious minutes blowing through a screen of questions that a high school graduate has plugged into the computer. I no longer can spend my time observing the patient’s body language or listening to her stories to detect the “second agenda” that patients inevitably bring with them on their visits. Remember: I only have 7 minutes to spend with each patient!

What in the name of evidence-based medicine are we doing? (I think I am trainable, but this waste of time is beyond the pale!)

Dr. Brown practices ObGyn in Douglas, Alaska.

“Too much paperwork!”

Anthony T. Bozza, MD

This year I have seen an increase in paperwork—precertifications, email, e-billing, and faxes. The electronic era was supposed to herald a decrease in this traffic and make it easier for us to focus on direct patient care, but I have seen an increase in both paperwork and the demands of patients! That means longer hours for less reimbursement. Although my patients always come first, they seem to want more and more of my time—not only face-to-face time but also telephone and e-mail responses. I try to do the best I can by being there for them, but I hope the paperwork demands begin to ease!

Dr. Bozza practices ObGyn in Lake Success, NY.

3. A few preoperative measures can avert complications, ease discomfort

E. William McGrath Jr, MD

When I perform a suction D&C or D&E, I administer 20 U of intravenous oxytocin preoperatively and intraoperatively to reduce the risk of uterine perforation. The firmer uterine wall lowers this risk in even the most difficult cases.

And when I schedule a hysteroscopic tubal occlusion (i.e., sterilization), I pretreat the patient with a progestin-only minipill 1 month in advance. The birth control pill renders the endometrium completely atrophic, making the tubal ostia easy to identify.

Dr. McGrath is Chief of ObGyn at Baptist Medical Center Nassau in Fernandina Beach, Fla.

Robert del Rosario, MD

I have been performing endometrial ablations in my office for about 2 years. Over that interval, I have “tweaked” my preoperative local injection and medication regimen, based on feedback from patients, conversations with other physicians and our instrument representative, and clinical experience. Although patients tolerated the procedure, I still found myself trying to talk an occasional patient through her discomfort.

Two events led to remarkable improvement in patient comfort during ablations:

• One patient refused our then-standard preop diazepam because it made her feel “too weird.” After a brief discussion, we opted to use lorazepam instead, with the understanding that I had not given the drug before as part of my protocol.
• My instrument rep mentioned that he had seen some physicians inject normal saline paracervically in cases involving intraoperative breakthrough pain. I decided to try injecting it in addition to paracervical mepivicaine preoperatively.

These two refinements to my traditional protocol, I feel, have dramatically reduced, and, in many cases, eliminated, intraoperative discomfort for my patients.

Dr. del Rosario practices ObGyn in Camp Hill, Pa.

4. Evolving technology boosts value-added care

Soheil Hanjani, MD

Without a doubt, the biggest practice changer for me has been increasing use of the Essure device (Conceptus) for office hysteroscopic tubal occlusion. I place about four or five of these devices each month, after giving the patient the full range of contraceptive options. Those seeking permanent contraception appreciate this 5-minute, very-low-risk procedure, which offers minimal discomfort and a return to normal activity in 1 day.

Dr. Hanjani practices ObGyn in Brockton, Mass.

About 2 years ago, I began using a device called INSORB absorbable skin stapler (Incisive Surgical). This device places subcuticular staples for skin closure. Since I began using INSORB, I have noticed several benefits:

• The cosmetic result is as good as—and usually better than—that seen with skin staples.
• Seromas are less likely because this form of closure allows spontaneous wound drainage during the first 24 hours.
• Staple removal is not required, so patients are happier!

Dr. Clow practices ObGyn in Chillicothe, Mo.

Ponce D. Bullard, MD

Over the past year, I have increased my insertion rate for the Implanon contraceptive device (Schering-Plough). In my practice, Implanon has almost completely replaced the intrauterine device (IUD), thanks to issues of cost and a lack of interest in a 10-year method of contraception.

Dr. Bullard practices ObGyn in West Columbia, SC.

John Armstrong, MD, MS

In my 34-year career, high-resolution two-dimensional US has been the most significant breakthrough. Transvaginal US (office-based) for pelvic screening and diagnosis, and breast US for screening and diagnosis, have dramatically increased the accuracy of what we do on a daily basis. The technology is extremely accurate, painless, and cost-effective. I just hope that it becomes more widely available soon despite the bureaucratic nonsense we face at every turn.

Dr. Armstrong practices gynecology and women’s health in Napa, Calif.

5. Offer this simple remedy for refractory bacterial vaginosis

Mark A. Firestone, MD

Patients who experienced repeated bouts of bacterial vaginosis (BV) used to be an especially frustrating population for me. I would prescribe a myriad of antibiotics, both oral and vaginal. The patients would experience a short interval of relief, then return to my office 1 month later with the same complaints. Even prolonged courses of antibiotic therapy were of limited benefit and a great cost to them. Patients were encouraged to alter their sex habits, use yogurt formulations, and were instructed on how to properly wash themselves. These patients called my office often, demanding to be treated over the phone to avoid the expense of an office visit. As they became more frustrated, they began to doubt my abilities and sometimes sought medical care elsewhere.

One day, I discovered a probiotic blend containing 8 billion colony-forming units of various lactobacilli. I instructed my patients who were bothered by recurrent BV to use this product at least twice daily. Although the probiotic is usually taken orally, I had several patients who used it vaginally. The results have been astounding!

Now, I rarely see a patient who has recurrent BV complaints. Patients also report that they experience less abdominal bloating and improved bowel function after using the product.

This approach seems to me to be much more effective and safer than serial antibiotics. What a pleasure not to receive so many telephone calls with complaints of recurrent vaginal discharge and odor!

Dr. Firestone practices Gynecology in Aventura, Fla.

6. A change in practice can boost your quality of life

William H. Deschner, MD

About 18 months ago, I made a decision to leave private practice (after 33 years!) and take a position as an OB hospitalist. The move turned out to be a good one. I now enjoy freedom from the daily worries of running a business and securing reimbursement. The tradeoff? I no longer have my own patients or perform gynecologic surgery. Although I miss these aspects of practice, the change has been worthwhile. With the OB hospitalist model, patient safety is enhanced, as are the lifestyle of the attending physician and job satisfaction for the hospitalist.

I am glad to be involved in this model of care from the early days of its evolution. Although many questions remain unanswered—not the least of which is whether the model can achieve long-term economic viability—I believe the improvement in safety justifies its existence. In the long run, if we are truly committed to improving safety, then economics will have to become a secondary consideration.

Dr. Deschner practices as an OB hospitalist in Seattle, Wash.

7. Pap recommendations simplify care of young patients

Takeko Takeshige, DO

In February 2010, the New York State Medicaid program fully endorsed ACOG’s new recommendations on Pap testing, which call for no screening at all among adolescents and longer intervals between screenings among the rest of the population. Since then, we have modified our policy for cervical cytology to comply with the ACOG recommendations.

We are stringent about compliance. For low-risk patients, we perform no screening until 21 years of age. We then screen every other year in patients 21 to 29 years old and every 3 years in patients 30 years and older, provided there have been three consecutive negative Pap tests.

Not only does the new protocol reduce the financial burden of screening uninsured patients, it also alleviates anxiety among physicians as well as patients. We now know that, when a Pap test is found to be abnormal in the younger age group, watchful waiting is usually appropriate because human papillomavirus (HPV) regresses in a majority of patients.

For the same reason, we are less likely than before to perform an invasive procedure in a young woman who has an abnormal result. By abstaining from invasive interventions such as curettage, we preserve the integrity of her endocervical mucus and protect her reproductive capacity until such time as she is ready to conceive.

Dr. Takeshige practices ObGyn at Lincoln Hospital in Bronx, NY.

8. Documentation a problem? Redesign the form!

Raksha Joshi, MD

Monmouth Family Health Center, an outpatient facility, is a teaching institution for residents from the Monmouth Medical Center ObGyn program. Because the annual well-woman examination is an integral part of the care we provide, comprehensive documentation of it is vital. The exam covers all aspects of the patient’s gynecologic and obstetric history, including menses, contraception, Pap testing, sexually transmitted infection, sexual practices and partners, allergies, medications, and a review of systems. Also crucial is the patient’s medical, surgical, and family history.

In most cases at our center, although the examination was thorough, documentation was markedly deficient, especially among junior residents, despite regular review and feedback. To overcome this deficiency, I redesigned the documentation sheet so that all essential elements of the history and physical examination are printed on the form and documentation is achieved by circling the applicable element. For example, in regard to the uterus, the form lists the following:

• Parity: Nulliparous / Parous
• Size: 6 / 8 / 10 / 12 / >12 wks
• Position: Axial / Anteverted / Retroverted / Anteflexed / Retroflexed
• Consistency: Firm / Soft
• Contour: Regular / Irregular
• Mobility: Yes / No
• Tenderness: Yes / No
• Anterior fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Left fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Right fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Posterior fornix (cul de sac):
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No

After implementation of this form, documentation and completeness improved markedly.

Other advantages of the form: It can be completed quickly, and it is legible!

We also use the form to teach essential elements of the comprehensive examination to new residents and students.

Dr. Joshi is Chief Medical Officer and Medical Director of Monmouth Family Health Center in Long Branch, NJ.

We want to hear from you! Tell us what you think.

OBG Management is blessed to have readers who are world-class clinical experts in obstetrics, gynecology, and women’s health. Thanks to your education, training, and experience, you are the women’s health experts of America, a unique resource.

We decided to tap into this resource by inviting members of our Virtual Board of Editors to offer a clinical pearl that has helped increase their efficacy or efficiency over the past year. The pearls contained in this article are well worth your time to read. (And we welcome your contributions, as well. Simply email them to [email protected], and we will publish a compilation in the future.)

As for my contribution, I have found the levonorgestrel-releasing intrauterine system (Mirena) to be invaluable in the provision of contraception and treatment of menorrhagia and pelvic pain, often averting the need for a surgical procedure. If it were more widely utilized—even in the face of a major price increase—it could reduce both the number of unintended pregnancies and hysterectomy procedures. As we become comfortable with the technique and clinical efficacy of this system, I expect utilization to increase significantly.

And now, we present eight other practice-enhancing pearls…. —Robert L. Barbieri, MD

1. Don’t underestimate the value of a phone call ($20,000, in one case)

Three-dimensional ultrasonography (US) is nice; fancy cystometrics are helpful; and electronic health records (EHR) may or may not reduce paperwork—but all of these technologies are expensive. In this era of plummeting reimbursement, the common telephone can help you pay the overhead.

Here’s an example: Mrs. Smith, a new patient, visited my office for a consultation about her difficulty in getting pregnant. It seems that my competitor in a nearby town had failed to telephone Mrs. Smith about her lab results, despite repeated attempts to obtain them on her part. His loss, my gain. I called her back multiple times to report lab values and coordinate the ovulation induction that ensued. She conceived, became an obstetric patient, and had a vaginal delivery. Laparoscopy followed several years later for pelvic pain. A second round of ovulation induction produced another pregnancy. She was pleased and always is pleasantly surprised when she gets a personal call from me. I consider it time well spent. And I estimate that, over the years I have managed this patient, she has brought at least $20,000 into my coffers.

A phone call is cheap, effective, and shows you care. Use your phone! You’re paying the monthly bill anyway! Make it work for you. It’s an asset, not a liability!

Dr. Franklin practices ObGyn in Lewisville, Tex.

Every summer, I hire a high school student to call every patient who has not been seen in the office over the past 13 to 36 months. I provide the student, who works for the minimum wage, with a script outlining different scenarios. The script includes inquiries about the patient’s current address and whether she wishes to be considered a patient of the practice. Most important, this script instructs the student to offer each patient an appointment.

Rather than waste time instructing the student how to schedule an appointment and enter the patient’s data, I have the employee simply transfer the call to an office scheduler when the patient wishes to make an appointment. This strategy has proved quite successful at generating office visits at minimal cost.

Dr. McGrath is Chief of Obstetrics and Gynecology at Baptist Medical Center Nassau in Fernandina Beach, Fla.

The one thing that has definitely made my life a little simpler is the transition from beepers and pagers to cell phones. Before this transition, I would get paged to a message. Then I would have to get to a phone and dial the number in the message. If I was in the car, this supposedly simple process was not so simple. And if the number was busy, that was another headache. Then I would have to start all over.

Now the message comes into my smart-phone as a text message with the callback number right there in the message. I click on it and, right then and there, I am connected to my patient!

For private practitioners out there who deal with emergency calls and patients in labor, the new technology is a life and time saver!

Dr. Zandieh practices ObGyn in Bethpage, NY.

2. Electronic health records are better for both physician and patient

Adoption of an EHR has made the biggest difference in my practice over the past year. The EHR is an electronic version of the patient record that includes documentation of the history and physical exam, progress notes, diagnoses, medications, laboratory and radiographic studies, US imaging, and immunizations. It has proved to be integral to the efficient and effective delivery of health care to my patients. Although my institution implemented the EHR in 2002, I have come to appreciate it more every year. Here are a few of the reasons:

Improved legibility Penmanship is not a virtue of most physicians. The EHR presents the patient’s record in a clear, readable format and reduces errors in care.

Portability The EHR can be viewed in the hospital, emergency room, or at home when the physician is on call.

Accessibility Multiple departments treating a patient may see one another’s work-up, records, and ancillary studies.

Easier and less expensive storage With the EHR, physical storage of records is minimal. There is also a reduction in staff to care for those records.

Security and liability The EHR provides more secure records and limits access. Once it is signed, the medical record in the EHR cannot be altered.

Improved coding High-quality, more legible medical records improve the accuracy of coding and the submission of more accurate claims.

Confidentiality The EHR is more confidential than paper records by virtue of its limited and controlled access.

Improved patient care is the most important part of medicine today. By virtue of its ease of use, great security, accessibility and portability, the EHR contributes to better care.

Dr. Avery is Professor and Chair of Obstetrics and Gynecology at the University of Alabama School of Medicine in Tuscaloosa, Ala.

Some things don’t help!

“The EHR interferes with my assessment of the patient”

Carolyn V. Brown, MD, MPH

One of the most important changes in my practice has been implementation of the electronic health record (EHR). Supposedly, that is a good thing, but I have found that utility of the EHR depends on who designs it. Before the EHR, I relied largely on the patient’s history to reveal clues to her condition. Now, when I go into an examination room, I have to spend precious minutes blowing through a screen of questions that a high school graduate has plugged into the computer. I no longer can spend my time observing the patient’s body language or listening to her stories to detect the “second agenda” that patients inevitably bring with them on their visits. Remember: I only have 7 minutes to spend with each patient!

What in the name of evidence-based medicine are we doing? (I think I am trainable, but this waste of time is beyond the pale!)

Dr. Brown practices ObGyn in Douglas, Alaska.

“Too much paperwork!”

Anthony T. Bozza, MD

This year I have seen an increase in paperwork—precertifications, email, e-billing, and faxes. The electronic era was supposed to herald a decrease in this traffic and make it easier for us to focus on direct patient care, but I have seen an increase in both paperwork and the demands of patients! That means longer hours for less reimbursement. Although my patients always come first, they seem to want more and more of my time—not only face-to-face time but also telephone and e-mail responses. I try to do the best I can by being there for them, but I hope the paperwork demands begin to ease!

Dr. Bozza practices ObGyn in Lake Success, NY.

3. A few preoperative measures can avert complications, ease discomfort

E. William McGrath Jr, MD

When I perform a suction D&C or D&E, I administer 20 U of intravenous oxytocin preoperatively and intraoperatively to reduce the risk of uterine perforation. The firmer uterine wall lowers this risk in even the most difficult cases.

And when I schedule a hysteroscopic tubal occlusion (i.e., sterilization), I pretreat the patient with a progestin-only minipill 1 month in advance. The birth control pill renders the endometrium completely atrophic, making the tubal ostia easy to identify.

Dr. McGrath is Chief of ObGyn at Baptist Medical Center Nassau in Fernandina Beach, Fla.

Robert del Rosario, MD

I have been performing endometrial ablations in my office for about 2 years. Over that interval, I have “tweaked” my preoperative local injection and medication regimen, based on feedback from patients, conversations with other physicians and our instrument representative, and clinical experience. Although patients tolerated the procedure, I still found myself trying to talk an occasional patient through her discomfort.

Two events led to remarkable improvement in patient comfort during ablations:

• One patient refused our then-standard preop diazepam because it made her feel “too weird.” After a brief discussion, we opted to use lorazepam instead, with the understanding that I had not given the drug before as part of my protocol.
• My instrument rep mentioned that he had seen some physicians inject normal saline paracervically in cases involving intraoperative breakthrough pain. I decided to try injecting it in addition to paracervical mepivicaine preoperatively.

These two refinements to my traditional protocol, I feel, have dramatically reduced, and, in many cases, eliminated, intraoperative discomfort for my patients.

Dr. del Rosario practices ObGyn in Camp Hill, Pa.

4. Evolving technology boosts value-added care

Soheil Hanjani, MD

Without a doubt, the biggest practice changer for me has been increasing use of the Essure device (Conceptus) for office hysteroscopic tubal occlusion. I place about four or five of these devices each month, after giving the patient the full range of contraceptive options. Those seeking permanent contraception appreciate this 5-minute, very-low-risk procedure, which offers minimal discomfort and a return to normal activity in 1 day.

Dr. Hanjani practices ObGyn in Brockton, Mass.

About 2 years ago, I began using a device called INSORB absorbable skin stapler (Incisive Surgical). This device places subcuticular staples for skin closure. Since I began using INSORB, I have noticed several benefits:

• The cosmetic result is as good as—and usually better than—that seen with skin staples.
• Seromas are less likely because this form of closure allows spontaneous wound drainage during the first 24 hours.
• Staple removal is not required, so patients are happier!

Dr. Clow practices ObGyn in Chillicothe, Mo.

Ponce D. Bullard, MD

Over the past year, I have increased my insertion rate for the Implanon contraceptive device (Schering-Plough). In my practice, Implanon has almost completely replaced the intrauterine device (IUD), thanks to issues of cost and a lack of interest in a 10-year method of contraception.

Dr. Bullard practices ObGyn in West Columbia, SC.

John Armstrong, MD, MS

In my 34-year career, high-resolution two-dimensional US has been the most significant breakthrough. Transvaginal US (office-based) for pelvic screening and diagnosis, and breast US for screening and diagnosis, have dramatically increased the accuracy of what we do on a daily basis. The technology is extremely accurate, painless, and cost-effective. I just hope that it becomes more widely available soon despite the bureaucratic nonsense we face at every turn.

Dr. Armstrong practices gynecology and women’s health in Napa, Calif.

5. Offer this simple remedy for refractory bacterial vaginosis

Mark A. Firestone, MD

Patients who experienced repeated bouts of bacterial vaginosis (BV) used to be an especially frustrating population for me. I would prescribe a myriad of antibiotics, both oral and vaginal. The patients would experience a short interval of relief, then return to my office 1 month later with the same complaints. Even prolonged courses of antibiotic therapy were of limited benefit and a great cost to them. Patients were encouraged to alter their sex habits, use yogurt formulations, and were instructed on how to properly wash themselves. These patients called my office often, demanding to be treated over the phone to avoid the expense of an office visit. As they became more frustrated, they began to doubt my abilities and sometimes sought medical care elsewhere.

One day, I discovered a probiotic blend containing 8 billion colony-forming units of various lactobacilli. I instructed my patients who were bothered by recurrent BV to use this product at least twice daily. Although the probiotic is usually taken orally, I had several patients who used it vaginally. The results have been astounding!

Now, I rarely see a patient who has recurrent BV complaints. Patients also report that they experience less abdominal bloating and improved bowel function after using the product.

This approach seems to me to be much more effective and safer than serial antibiotics. What a pleasure not to receive so many telephone calls with complaints of recurrent vaginal discharge and odor!

Dr. Firestone practices Gynecology in Aventura, Fla.

6. A change in practice can boost your quality of life

William H. Deschner, MD

About 18 months ago, I made a decision to leave private practice (after 33 years!) and take a position as an OB hospitalist. The move turned out to be a good one. I now enjoy freedom from the daily worries of running a business and securing reimbursement. The tradeoff? I no longer have my own patients or perform gynecologic surgery. Although I miss these aspects of practice, the change has been worthwhile. With the OB hospitalist model, patient safety is enhanced, as are the lifestyle of the attending physician and job satisfaction for the hospitalist.

I am glad to be involved in this model of care from the early days of its evolution. Although many questions remain unanswered—not the least of which is whether the model can achieve long-term economic viability—I believe the improvement in safety justifies its existence. In the long run, if we are truly committed to improving safety, then economics will have to become a secondary consideration.

Dr. Deschner practices as an OB hospitalist in Seattle, Wash.

7. Pap recommendations simplify care of young patients

Takeko Takeshige, DO

In February 2010, the New York State Medicaid program fully endorsed ACOG’s new recommendations on Pap testing, which call for no screening at all among adolescents and longer intervals between screenings among the rest of the population. Since then, we have modified our policy for cervical cytology to comply with the ACOG recommendations.

We are stringent about compliance. For low-risk patients, we perform no screening until 21 years of age. We then screen every other year in patients 21 to 29 years old and every 3 years in patients 30 years and older, provided there have been three consecutive negative Pap tests.

Not only does the new protocol reduce the financial burden of screening uninsured patients, it also alleviates anxiety among physicians as well as patients. We now know that, when a Pap test is found to be abnormal in the younger age group, watchful waiting is usually appropriate because human papillomavirus (HPV) regresses in a majority of patients.

For the same reason, we are less likely than before to perform an invasive procedure in a young woman who has an abnormal result. By abstaining from invasive interventions such as curettage, we preserve the integrity of her endocervical mucus and protect her reproductive capacity until such time as she is ready to conceive.

Dr. Takeshige practices ObGyn at Lincoln Hospital in Bronx, NY.

8. Documentation a problem? Redesign the form!

Raksha Joshi, MD

Monmouth Family Health Center, an outpatient facility, is a teaching institution for residents from the Monmouth Medical Center ObGyn program. Because the annual well-woman examination is an integral part of the care we provide, comprehensive documentation of it is vital. The exam covers all aspects of the patient’s gynecologic and obstetric history, including menses, contraception, Pap testing, sexually transmitted infection, sexual practices and partners, allergies, medications, and a review of systems. Also crucial is the patient’s medical, surgical, and family history.

In most cases at our center, although the examination was thorough, documentation was markedly deficient, especially among junior residents, despite regular review and feedback. To overcome this deficiency, I redesigned the documentation sheet so that all essential elements of the history and physical examination are printed on the form and documentation is achieved by circling the applicable element. For example, in regard to the uterus, the form lists the following:

• Parity: Nulliparous / Parous
• Size: 6 / 8 / 10 / 12 / >12 wks
• Position: Axial / Anteverted / Retroverted / Anteflexed / Retroflexed
• Consistency: Firm / Soft
• Contour: Regular / Irregular
• Mobility: Yes / No
• Tenderness: Yes / No
• Anterior fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Left fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Right fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Posterior fornix (cul de sac):
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No

After implementation of this form, documentation and completeness improved markedly.

Other advantages of the form: It can be completed quickly, and it is legible!

We also use the form to teach essential elements of the comprehensive examination to new residents and students.

Dr. Joshi is Chief Medical Officer and Medical Director of Monmouth Family Health Center in Long Branch, NJ.

We want to hear from you! Tell us what you think.

OBG Management is blessed to have readers who are world-class clinical experts in obstetrics, gynecology, and women’s health. Thanks to your education, training, and experience, you are the women’s health experts of America, a unique resource.

We decided to tap into this resource by inviting members of our Virtual Board of Editors to offer a clinical pearl that has helped increase their efficacy or efficiency over the past year. The pearls contained in this article are well worth your time to read. (And we welcome your contributions, as well. Simply email them to [email protected], and we will publish a compilation in the future.)

As for my contribution, I have found the levonorgestrel-releasing intrauterine system (Mirena) to be invaluable in the provision of contraception and treatment of menorrhagia and pelvic pain, often averting the need for a surgical procedure. If it were more widely utilized—even in the face of a major price increase—it could reduce both the number of unintended pregnancies and hysterectomy procedures. As we become comfortable with the technique and clinical efficacy of this system, I expect utilization to increase significantly.

And now, we present eight other practice-enhancing pearls…. —Robert L. Barbieri, MD

1. Don’t underestimate the value of a phone call ($20,000, in one case)

Three-dimensional ultrasonography (US) is nice; fancy cystometrics are helpful; and electronic health records (EHR) may or may not reduce paperwork—but all of these technologies are expensive. In this era of plummeting reimbursement, the common telephone can help you pay the overhead.

Here’s an example: Mrs. Smith, a new patient, visited my office for a consultation about her difficulty in getting pregnant. It seems that my competitor in a nearby town had failed to telephone Mrs. Smith about her lab results, despite repeated attempts to obtain them on her part. His loss, my gain. I called her back multiple times to report lab values and coordinate the ovulation induction that ensued. She conceived, became an obstetric patient, and had a vaginal delivery. Laparoscopy followed several years later for pelvic pain. A second round of ovulation induction produced another pregnancy. She was pleased and always is pleasantly surprised when she gets a personal call from me. I consider it time well spent. And I estimate that, over the years I have managed this patient, she has brought at least $20,000 into my coffers.

A phone call is cheap, effective, and shows you care. Use your phone! You’re paying the monthly bill anyway! Make it work for you. It’s an asset, not a liability!

Dr. Franklin practices ObGyn in Lewisville, Tex.

Every summer, I hire a high school student to call every patient who has not been seen in the office over the past 13 to 36 months. I provide the student, who works for the minimum wage, with a script outlining different scenarios. The script includes inquiries about the patient’s current address and whether she wishes to be considered a patient of the practice. Most important, this script instructs the student to offer each patient an appointment.

Rather than waste time instructing the student how to schedule an appointment and enter the patient’s data, I have the employee simply transfer the call to an office scheduler when the patient wishes to make an appointment. This strategy has proved quite successful at generating office visits at minimal cost.

Dr. McGrath is Chief of Obstetrics and Gynecology at Baptist Medical Center Nassau in Fernandina Beach, Fla.

The one thing that has definitely made my life a little simpler is the transition from beepers and pagers to cell phones. Before this transition, I would get paged to a message. Then I would have to get to a phone and dial the number in the message. If I was in the car, this supposedly simple process was not so simple. And if the number was busy, that was another headache. Then I would have to start all over.

Now the message comes into my smart-phone as a text message with the callback number right there in the message. I click on it and, right then and there, I am connected to my patient!

For private practitioners out there who deal with emergency calls and patients in labor, the new technology is a life and time saver!

Dr. Zandieh practices ObGyn in Bethpage, NY.

2. Electronic health records are better for both physician and patient

Adoption of an EHR has made the biggest difference in my practice over the past year. The EHR is an electronic version of the patient record that includes documentation of the history and physical exam, progress notes, diagnoses, medications, laboratory and radiographic studies, US imaging, and immunizations. It has proved to be integral to the efficient and effective delivery of health care to my patients. Although my institution implemented the EHR in 2002, I have come to appreciate it more every year. Here are a few of the reasons:

Improved legibility Penmanship is not a virtue of most physicians. The EHR presents the patient’s record in a clear, readable format and reduces errors in care.

Portability The EHR can be viewed in the hospital, emergency room, or at home when the physician is on call.

Accessibility Multiple departments treating a patient may see one another’s work-up, records, and ancillary studies.

Easier and less expensive storage With the EHR, physical storage of records is minimal. There is also a reduction in staff to care for those records.

Security and liability The EHR provides more secure records and limits access. Once it is signed, the medical record in the EHR cannot be altered.

Improved coding High-quality, more legible medical records improve the accuracy of coding and the submission of more accurate claims.

Confidentiality The EHR is more confidential than paper records by virtue of its limited and controlled access.

Improved patient care is the most important part of medicine today. By virtue of its ease of use, great security, accessibility and portability, the EHR contributes to better care.

Dr. Avery is Professor and Chair of Obstetrics and Gynecology at the University of Alabama School of Medicine in Tuscaloosa, Ala.

Some things don’t help!

“The EHR interferes with my assessment of the patient”

Carolyn V. Brown, MD, MPH

One of the most important changes in my practice has been implementation of the electronic health record (EHR). Supposedly, that is a good thing, but I have found that utility of the EHR depends on who designs it. Before the EHR, I relied largely on the patient’s history to reveal clues to her condition. Now, when I go into an examination room, I have to spend precious minutes blowing through a screen of questions that a high school graduate has plugged into the computer. I no longer can spend my time observing the patient’s body language or listening to her stories to detect the “second agenda” that patients inevitably bring with them on their visits. Remember: I only have 7 minutes to spend with each patient!

What in the name of evidence-based medicine are we doing? (I think I am trainable, but this waste of time is beyond the pale!)

Dr. Brown practices ObGyn in Douglas, Alaska.

“Too much paperwork!”

Anthony T. Bozza, MD

This year I have seen an increase in paperwork—precertifications, email, e-billing, and faxes. The electronic era was supposed to herald a decrease in this traffic and make it easier for us to focus on direct patient care, but I have seen an increase in both paperwork and the demands of patients! That means longer hours for less reimbursement. Although my patients always come first, they seem to want more and more of my time—not only face-to-face time but also telephone and e-mail responses. I try to do the best I can by being there for them, but I hope the paperwork demands begin to ease!

Dr. Bozza practices ObGyn in Lake Success, NY.

3. A few preoperative measures can avert complications, ease discomfort

E. William McGrath Jr, MD

When I perform a suction D&C or D&E, I administer 20 U of intravenous oxytocin preoperatively and intraoperatively to reduce the risk of uterine perforation. The firmer uterine wall lowers this risk in even the most difficult cases.

And when I schedule a hysteroscopic tubal occlusion (i.e., sterilization), I pretreat the patient with a progestin-only minipill 1 month in advance. The birth control pill renders the endometrium completely atrophic, making the tubal ostia easy to identify.

Dr. McGrath is Chief of ObGyn at Baptist Medical Center Nassau in Fernandina Beach, Fla.

Robert del Rosario, MD

I have been performing endometrial ablations in my office for about 2 years. Over that interval, I have “tweaked” my preoperative local injection and medication regimen, based on feedback from patients, conversations with other physicians and our instrument representative, and clinical experience. Although patients tolerated the procedure, I still found myself trying to talk an occasional patient through her discomfort.

Two events led to remarkable improvement in patient comfort during ablations:

• One patient refused our then-standard preop diazepam because it made her feel “too weird.” After a brief discussion, we opted to use lorazepam instead, with the understanding that I had not given the drug before as part of my protocol.
• My instrument rep mentioned that he had seen some physicians inject normal saline paracervically in cases involving intraoperative breakthrough pain. I decided to try injecting it in addition to paracervical mepivicaine preoperatively.

These two refinements to my traditional protocol, I feel, have dramatically reduced, and, in many cases, eliminated, intraoperative discomfort for my patients.

Dr. del Rosario practices ObGyn in Camp Hill, Pa.

4. Evolving technology boosts value-added care

Soheil Hanjani, MD

Without a doubt, the biggest practice changer for me has been increasing use of the Essure device (Conceptus) for office hysteroscopic tubal occlusion. I place about four or five of these devices each month, after giving the patient the full range of contraceptive options. Those seeking permanent contraception appreciate this 5-minute, very-low-risk procedure, which offers minimal discomfort and a return to normal activity in 1 day.

Dr. Hanjani practices ObGyn in Brockton, Mass.

About 2 years ago, I began using a device called INSORB absorbable skin stapler (Incisive Surgical). This device places subcuticular staples for skin closure. Since I began using INSORB, I have noticed several benefits:

• The cosmetic result is as good as—and usually better than—that seen with skin staples.
• Seromas are less likely because this form of closure allows spontaneous wound drainage during the first 24 hours.
• Staple removal is not required, so patients are happier!

Dr. Clow practices ObGyn in Chillicothe, Mo.

Ponce D. Bullard, MD

Over the past year, I have increased my insertion rate for the Implanon contraceptive device (Schering-Plough). In my practice, Implanon has almost completely replaced the intrauterine device (IUD), thanks to issues of cost and a lack of interest in a 10-year method of contraception.

Dr. Bullard practices ObGyn in West Columbia, SC.

John Armstrong, MD, MS

In my 34-year career, high-resolution two-dimensional US has been the most significant breakthrough. Transvaginal US (office-based) for pelvic screening and diagnosis, and breast US for screening and diagnosis, have dramatically increased the accuracy of what we do on a daily basis. The technology is extremely accurate, painless, and cost-effective. I just hope that it becomes more widely available soon despite the bureaucratic nonsense we face at every turn.

Dr. Armstrong practices gynecology and women’s health in Napa, Calif.

5. Offer this simple remedy for refractory bacterial vaginosis

Mark A. Firestone, MD

Patients who experienced repeated bouts of bacterial vaginosis (BV) used to be an especially frustrating population for me. I would prescribe a myriad of antibiotics, both oral and vaginal. The patients would experience a short interval of relief, then return to my office 1 month later with the same complaints. Even prolonged courses of antibiotic therapy were of limited benefit and a great cost to them. Patients were encouraged to alter their sex habits, use yogurt formulations, and were instructed on how to properly wash themselves. These patients called my office often, demanding to be treated over the phone to avoid the expense of an office visit. As they became more frustrated, they began to doubt my abilities and sometimes sought medical care elsewhere.

One day, I discovered a probiotic blend containing 8 billion colony-forming units of various lactobacilli. I instructed my patients who were bothered by recurrent BV to use this product at least twice daily. Although the probiotic is usually taken orally, I had several patients who used it vaginally. The results have been astounding!

Now, I rarely see a patient who has recurrent BV complaints. Patients also report that they experience less abdominal bloating and improved bowel function after using the product.

This approach seems to me to be much more effective and safer than serial antibiotics. What a pleasure not to receive so many telephone calls with complaints of recurrent vaginal discharge and odor!

Dr. Firestone practices Gynecology in Aventura, Fla.

6. A change in practice can boost your quality of life

William H. Deschner, MD

About 18 months ago, I made a decision to leave private practice (after 33 years!) and take a position as an OB hospitalist. The move turned out to be a good one. I now enjoy freedom from the daily worries of running a business and securing reimbursement. The tradeoff? I no longer have my own patients or perform gynecologic surgery. Although I miss these aspects of practice, the change has been worthwhile. With the OB hospitalist model, patient safety is enhanced, as are the lifestyle of the attending physician and job satisfaction for the hospitalist.

I am glad to be involved in this model of care from the early days of its evolution. Although many questions remain unanswered—not the least of which is whether the model can achieve long-term economic viability—I believe the improvement in safety justifies its existence. In the long run, if we are truly committed to improving safety, then economics will have to become a secondary consideration.

Dr. Deschner practices as an OB hospitalist in Seattle, Wash.

7. Pap recommendations simplify care of young patients

Takeko Takeshige, DO

In February 2010, the New York State Medicaid program fully endorsed ACOG’s new recommendations on Pap testing, which call for no screening at all among adolescents and longer intervals between screenings among the rest of the population. Since then, we have modified our policy for cervical cytology to comply with the ACOG recommendations.

We are stringent about compliance. For low-risk patients, we perform no screening until 21 years of age. We then screen every other year in patients 21 to 29 years old and every 3 years in patients 30 years and older, provided there have been three consecutive negative Pap tests.

Not only does the new protocol reduce the financial burden of screening uninsured patients, it also alleviates anxiety among physicians as well as patients. We now know that, when a Pap test is found to be abnormal in the younger age group, watchful waiting is usually appropriate because human papillomavirus (HPV) regresses in a majority of patients.

For the same reason, we are less likely than before to perform an invasive procedure in a young woman who has an abnormal result. By abstaining from invasive interventions such as curettage, we preserve the integrity of her endocervical mucus and protect her reproductive capacity until such time as she is ready to conceive.

Dr. Takeshige practices ObGyn at Lincoln Hospital in Bronx, NY.

8. Documentation a problem? Redesign the form!

Raksha Joshi, MD

Monmouth Family Health Center, an outpatient facility, is a teaching institution for residents from the Monmouth Medical Center ObGyn program. Because the annual well-woman examination is an integral part of the care we provide, comprehensive documentation of it is vital. The exam covers all aspects of the patient’s gynecologic and obstetric history, including menses, contraception, Pap testing, sexually transmitted infection, sexual practices and partners, allergies, medications, and a review of systems. Also crucial is the patient’s medical, surgical, and family history.

In most cases at our center, although the examination was thorough, documentation was markedly deficient, especially among junior residents, despite regular review and feedback. To overcome this deficiency, I redesigned the documentation sheet so that all essential elements of the history and physical examination are printed on the form and documentation is achieved by circling the applicable element. For example, in regard to the uterus, the form lists the following:

• Parity: Nulliparous / Parous
• Size: 6 / 8 / 10 / 12 / >12 wks
• Position: Axial / Anteverted / Retroverted / Anteflexed / Retroflexed
• Consistency: Firm / Soft
• Contour: Regular / Irregular
• Mobility: Yes / No
• Tenderness: Yes / No
• Anterior fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Left fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Right fornix:
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No
• Posterior fornix (cul de sac):
  • Mass: Yes / No
  • Tenderness: Yes / No
  • Thickening: Yes / No
  • Fullness: Yes / No

After implementation of this form, documentation and completeness improved markedly.

Other advantages of the form: It can be completed quickly, and it is legible!

We also use the form to teach essential elements of the comprehensive examination to new residents and students.

Dr. Joshi is Chief Medical Officer and Medical Director of Monmouth Family Health Center in Long Branch, NJ.

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It doesn't occur to most physicians that a supplier might be ripping them off; but if adequate purchase controls are not in place, then it's possible, and even likely. Be aware of the common scams, how to avoid them, and the options if you're victimized.

Con artists take advantage of unsuspecting employees (and physicians) and lax purchasing procedures. Typically, the scam begins with a phone call from a “representative” who asks questions about the office and the supplies commonly ordered in bulk, such as paper, disposable gloves, printer cartridges, gauze pads, and cleaning supplies. (The caller might claim to be conducting a survey.)

The scammer might pretend to be a regular supplier who is “overstocked” on printer ink or toner. (Toner scams are so common that perpetrators are nicknamed “toner phoners.”)

Here is how this scenario might play out: You receive a shipment of poor quality merchandise you didn't order. Later, you receive an invoice for 5-10 times the amount you would pay a legitimate supplier for better quality supplies.

You can't be sure you didn't place the order, because you have no system in place for checking such things; your employees may have already opened the boxes; and you're under the mistaken impression that you have to return unordered merchandise or pay for it if you've started using it. (More on this later.)

Sometimes the caller offers your receptionist or office manager a free “promotional item” with “no further obligation.” Your employee figures why not, and accepts the gift. You receive overpriced unordered merchandise, followed by an invoice with the employee's name prominently displayed. The crooks are betting you will blame the employee, who you assume placed the order to get the gift (despite his or her denials), and now you have to pay.

Regardless of the method, the goal is the same: to get an invoice into your hands. Once that is accomplished, the scammers get very aggressive; they will dun you with letters and phone calls, send you to real or fake collection agents, and even threaten legal action.

You're at a disadvantage because you're not positive, and certainly can't prove, that you didn't order the supplies. And, if you pay the bill, you think maybe they will get off your back; however, you will only be targeted for additional scams. The scammer may even sell your “account” to other con artists.

Prevention is a matter of good organization and training. Put one person in charge of ordering supplies, and instruct everyone (including physicians) to tell all solicitors, “I'm not authorized to order anything or answer surveys. You'll need to speak to our purchaser.”

Instruct your purchaser to be suspicious of all cold calls and unfamiliar salespeople, and to never yield to pressure to make an immediate decision. If an offer appears legitimate, ask to see a catalog or printed price list before ordering anything.

Standardize your ordering procedure. Acquire a supply of purchase orders – electronic or written – and make sure one is filled out for every order, and every order is assigned a number. The employee who pays bills, ideally someone different from the one who does the ordering, should receive a copy of every purchase order. Keep blank order forms locked up or password protected.

When shipments arrive, verify they match the shipper's invoice and the purchase order. If everything reconciles, send a copy of the shipping invoice to your accounts payable employee. Bills for services should be reconciled the same way.

If a scammer still gets through your defenses, you have rights, and you should exercise them. According to the Federal Trade Commission, you are not required to pay for supplies or services you didn't order, nor are you required to return them. You may treat unordered merchandise as a gift. But you have to be able to prove you didn't order it, which should be easy if you use purchase orders.

The FTC has a good template of instructions for avoiding scams.

It doesn't occur to most physicians that a supplier might be ripping them off; but if adequate purchase controls are not in place, then it's possible, and even likely. Be aware of the common scams, how to avoid them, and the options if you're victimized.

Con artists take advantage of unsuspecting employees (and physicians) and lax purchasing procedures. Typically, the scam begins with a phone call from a “representative” who asks questions about the office and the supplies commonly ordered in bulk, such as paper, disposable gloves, printer cartridges, gauze pads, and cleaning supplies. (The caller might claim to be conducting a survey.)

The scammer might pretend to be a regular supplier who is “overstocked” on printer ink or toner. (Toner scams are so common that perpetrators are nicknamed “toner phoners.”)

Here is how this scenario might play out: You receive a shipment of poor quality merchandise you didn't order. Later, you receive an invoice for 5-10 times the amount you would pay a legitimate supplier for better quality supplies.

You can't be sure you didn't place the order, because you have no system in place for checking such things; your employees may have already opened the boxes; and you're under the mistaken impression that you have to return unordered merchandise or pay for it if you've started using it. (More on this later.)

Sometimes the caller offers your receptionist or office manager a free “promotional item” with “no further obligation.” Your employee figures why not, and accepts the gift. You receive overpriced unordered merchandise, followed by an invoice with the employee's name prominently displayed. The crooks are betting you will blame the employee, who you assume placed the order to get the gift (despite his or her denials), and now you have to pay.

Regardless of the method, the goal is the same: to get an invoice into your hands. Once that is accomplished, the scammers get very aggressive; they will dun you with letters and phone calls, send you to real or fake collection agents, and even threaten legal action.

You're at a disadvantage because you're not positive, and certainly can't prove, that you didn't order the supplies. And, if you pay the bill, you think maybe they will get off your back; however, you will only be targeted for additional scams. The scammer may even sell your “account” to other con artists.

Prevention is a matter of good organization and training. Put one person in charge of ordering supplies, and instruct everyone (including physicians) to tell all solicitors, “I'm not authorized to order anything or answer surveys. You'll need to speak to our purchaser.”

Instruct your purchaser to be suspicious of all cold calls and unfamiliar salespeople, and to never yield to pressure to make an immediate decision. If an offer appears legitimate, ask to see a catalog or printed price list before ordering anything.

Standardize your ordering procedure. Acquire a supply of purchase orders – electronic or written – and make sure one is filled out for every order, and every order is assigned a number. The employee who pays bills, ideally someone different from the one who does the ordering, should receive a copy of every purchase order. Keep blank order forms locked up or password protected.

When shipments arrive, verify they match the shipper's invoice and the purchase order. If everything reconciles, send a copy of the shipping invoice to your accounts payable employee. Bills for services should be reconciled the same way.

If a scammer still gets through your defenses, you have rights, and you should exercise them. According to the Federal Trade Commission, you are not required to pay for supplies or services you didn't order, nor are you required to return them. You may treat unordered merchandise as a gift. But you have to be able to prove you didn't order it, which should be easy if you use purchase orders.

The FTC has a good template of instructions for avoiding scams.

It doesn't occur to most physicians that a supplier might be ripping them off; but if adequate purchase controls are not in place, then it's possible, and even likely. Be aware of the common scams, how to avoid them, and the options if you're victimized.

Con artists take advantage of unsuspecting employees (and physicians) and lax purchasing procedures. Typically, the scam begins with a phone call from a “representative” who asks questions about the office and the supplies commonly ordered in bulk, such as paper, disposable gloves, printer cartridges, gauze pads, and cleaning supplies. (The caller might claim to be conducting a survey.)

The scammer might pretend to be a regular supplier who is “overstocked” on printer ink or toner. (Toner scams are so common that perpetrators are nicknamed “toner phoners.”)

Here is how this scenario might play out: You receive a shipment of poor quality merchandise you didn't order. Later, you receive an invoice for 5-10 times the amount you would pay a legitimate supplier for better quality supplies.

You can't be sure you didn't place the order, because you have no system in place for checking such things; your employees may have already opened the boxes; and you're under the mistaken impression that you have to return unordered merchandise or pay for it if you've started using it. (More on this later.)

Sometimes the caller offers your receptionist or office manager a free “promotional item” with “no further obligation.” Your employee figures why not, and accepts the gift. You receive overpriced unordered merchandise, followed by an invoice with the employee's name prominently displayed. The crooks are betting you will blame the employee, who you assume placed the order to get the gift (despite his or her denials), and now you have to pay.

Regardless of the method, the goal is the same: to get an invoice into your hands. Once that is accomplished, the scammers get very aggressive; they will dun you with letters and phone calls, send you to real or fake collection agents, and even threaten legal action.

You're at a disadvantage because you're not positive, and certainly can't prove, that you didn't order the supplies. And, if you pay the bill, you think maybe they will get off your back; however, you will only be targeted for additional scams. The scammer may even sell your “account” to other con artists.

Prevention is a matter of good organization and training. Put one person in charge of ordering supplies, and instruct everyone (including physicians) to tell all solicitors, “I'm not authorized to order anything or answer surveys. You'll need to speak to our purchaser.”

Instruct your purchaser to be suspicious of all cold calls and unfamiliar salespeople, and to never yield to pressure to make an immediate decision. If an offer appears legitimate, ask to see a catalog or printed price list before ordering anything.

Standardize your ordering procedure. Acquire a supply of purchase orders – electronic or written – and make sure one is filled out for every order, and every order is assigned a number. The employee who pays bills, ideally someone different from the one who does the ordering, should receive a copy of every purchase order. Keep blank order forms locked up or password protected.

When shipments arrive, verify they match the shipper's invoice and the purchase order. If everything reconciles, send a copy of the shipping invoice to your accounts payable employee. Bills for services should be reconciled the same way.

If a scammer still gets through your defenses, you have rights, and you should exercise them. According to the Federal Trade Commission, you are not required to pay for supplies or services you didn't order, nor are you required to return them. You may treat unordered merchandise as a gift. But you have to be able to prove you didn't order it, which should be easy if you use purchase orders.

The FTC has a good template of instructions for avoiding scams.

Year's end is a good time to pause and think about the various financial arrangements you’ve set up over the years, and consider whether the plans need to be updated.

Your estate plan, in particular, needs regular review and revision. Even if nothing important has changed in your life or the lives of those close to you since you drafted or last revised your will, chances are the laws have changed, or other factors may have rendered your plan obsolete without your even realizing it.

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

Such situations are all too common (the Dennis Hopper estate battle is a current, well-reported example); if you don’t have a will, regardless of your age or current financial status, have one written at your earliest possible convenience.

That said, let's consider some factors that may require modification of the estate plan you now (hopefully) have in place:

Laws change continually. Trust laws, in particular, have changed a great deal in recent years, and new trust strategies have been devised as a result. New instruments like perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won't know without asking. State laws affecting estate planning also change on a regular basis.

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

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

Financial markets change. It's not exactly a secret that asset values and interest rates have changed in big ways over the last few years. Those changes may have had a significant, unanticipated impact; large real estate or securities bequests could now be significantly smaller, and vice versa. Your accountant and estate lawyer should take a look at your assets periodically, and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if the value doesn’t. For example, selling a business or property and reinvesting the proceeds in something completely different could change how you leave that asset to your heirs because a different set of tax laws may apply.

Fiduciaries change. The executor of your estate and the trustee(s) of your trust(s) may need replacing as circumstances change. If your brother-in-law is your executor and your sister divorces him, you may want to find a new executor. Or your once-vigorous trustee could now be aging or in failing health. Trustees are often financial institutions; if one of your corporate trustees goes belly up, or the employee you were working with retires or changes firms, you'll need a replacement. Keep track of your fiduciaries, and be prepared to make changes as necessary.

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

Year's end is a good time to pause and think about the various financial arrangements you’ve set up over the years, and consider whether the plans need to be updated.

Your estate plan, in particular, needs regular review and revision. Even if nothing important has changed in your life or the lives of those close to you since you drafted or last revised your will, chances are the laws have changed, or other factors may have rendered your plan obsolete without your even realizing it.

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

Such situations are all too common (the Dennis Hopper estate battle is a current, well-reported example); if you don’t have a will, regardless of your age or current financial status, have one written at your earliest possible convenience.

That said, let's consider some factors that may require modification of the estate plan you now (hopefully) have in place:

Laws change continually. Trust laws, in particular, have changed a great deal in recent years, and new trust strategies have been devised as a result. New instruments like perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won't know without asking. State laws affecting estate planning also change on a regular basis.

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

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

Financial markets change. It's not exactly a secret that asset values and interest rates have changed in big ways over the last few years. Those changes may have had a significant, unanticipated impact; large real estate or securities bequests could now be significantly smaller, and vice versa. Your accountant and estate lawyer should take a look at your assets periodically, and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if the value doesn’t. For example, selling a business or property and reinvesting the proceeds in something completely different could change how you leave that asset to your heirs because a different set of tax laws may apply.

Fiduciaries change. The executor of your estate and the trustee(s) of your trust(s) may need replacing as circumstances change. If your brother-in-law is your executor and your sister divorces him, you may want to find a new executor. Or your once-vigorous trustee could now be aging or in failing health. Trustees are often financial institutions; if one of your corporate trustees goes belly up, or the employee you were working with retires or changes firms, you'll need a replacement. Keep track of your fiduciaries, and be prepared to make changes as necessary.

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

Year's end is a good time to pause and think about the various financial arrangements you’ve set up over the years, and consider whether the plans need to be updated.

Your estate plan, in particular, needs regular review and revision. Even if nothing important has changed in your life or the lives of those close to you since you drafted or last revised your will, chances are the laws have changed, or other factors may have rendered your plan obsolete without your even realizing it.

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

Such situations are all too common (the Dennis Hopper estate battle is a current, well-reported example); if you don’t have a will, regardless of your age or current financial status, have one written at your earliest possible convenience.

That said, let's consider some factors that may require modification of the estate plan you now (hopefully) have in place:

Laws change continually. Trust laws, in particular, have changed a great deal in recent years, and new trust strategies have been devised as a result. New instruments like perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won't know without asking. State laws affecting estate planning also change on a regular basis.

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

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

Financial markets change. It's not exactly a secret that asset values and interest rates have changed in big ways over the last few years. Those changes may have had a significant, unanticipated impact; large real estate or securities bequests could now be significantly smaller, and vice versa. Your accountant and estate lawyer should take a look at your assets periodically, and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if the value doesn’t. For example, selling a business or property and reinvesting the proceeds in something completely different could change how you leave that asset to your heirs because a different set of tax laws may apply.

Fiduciaries change. The executor of your estate and the trustee(s) of your trust(s) may need replacing as circumstances change. If your brother-in-law is your executor and your sister divorces him, you may want to find a new executor. Or your once-vigorous trustee could now be aging or in failing health. Trustees are often financial institutions; if one of your corporate trustees goes belly up, or the employee you were working with retires or changes firms, you'll need a replacement. Keep track of your fiduciaries, and be prepared to make changes as necessary.

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