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Jennifer Frank, MD: Vulnerable to stress?

I recently took an online quiz to assess my vulnerability to stress. I was anxious to identify those areas that I needed to improve in order to lower my cortisol-induced stress haze.

I scored a perfect score of invulnerability. Seriously – I didn’t even fudge any of the answers. The questions were things like “Do you get regular dental care?” and “Do you get seven to eight hours of sleep at least four nights per week?” It didn’t even ask if I have kids! Needless to say, I don’t believe that quiz. I am vulnerable to stress, and I feel it on a fairly frequent basis.

These are my stress triggers:

1) Over-commitment. It is my modus operandi to say “yes” too frequently. As a result, I get stressed by competing appointments and demands.

2) No breaks. In medical school, you were better and tougher if you didn’t need to sleep, eat, or use the bathroom during a call shift. This has translated into marathon workdays in which I down a Power Bar on my way to the bathroom in a twisted unhealthy multi-tasking spree. Don’t even get me started on how the mother of four small kids is supposed to take a shower.

3) Perfectionism. Doctors are expected to know everything, do everything, be everything. Actually I think this is just what we expect of ourselves. During those (too frequent) times I have had to confess an error or mistake to a patient, they are much more forgiving of me than I am of myself.
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In looking at my quiz results, I realized there are a number of stress insulators – things that protect me from stress. Probably would be a good idea to maximize these areas. According to the authoritative stress vulnerability profile, this is what I have going for me to keep my stress to a minimum:

1) Healthy lifestyle habits. Okay, I admit to eating half of an apple streudel dessert and a handful of barbeque flavor rice chips for breakfast occasionally, but in general, I eat healthy, exercise, and get as much sleep as my children allow.

2) Friends and family. I do have a “four o’clock in the morning” friend (you know, the person you can call at 4 a.m. with any concern minor or serious) and am fortunate to have family close by.

3) Comfortable lifestyle. Physicians (even primary-care physicians) make a great salary. This enables me to afford all kinds of stress minimizers like dental care, babysitters for date night, and even a cleaning service for our house.

4) A strong marriage. A poem that hangs on the wall of our bedroom describes it perfectly: “You are the strong embrace in my challenge.”

5) Finally, spiritual grounding to give it all meaning.

You probably have your own list of stress inducers and stress deflectors. It is crucial to avoid those things that cause stress while soaking in the wonderful parts of life that reduce stress.

Melissa Young, MD: I need 36 hours in a day and two pairs of hands

I shouldn’t complain. Venturing out on my own has not been the financial disaster my former senior partner predicted despite the often miserable reimbursements. I have a steady stream of patients and the schedule is reasonably busy. After six months of practice, the current wait for a new patient is six weeks. For the coveted late afternoon slots, it’s about two months.

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So, yes, life is good. For me, anyway. For the most part. But for the patients who call and want to be seen ASAP, and for my poor office staff who get yelled at on a daily basis by these same patients, not so much. Not a day goes by that a patient doesn’t pour out her sob story, or name-drop, or just get plain nasty with my staff. Like doing any of those things will miraculously make a new appointment slot appear. Some of them hang up threatening (?) to find another doctor, only call back two hours later because at ever other practice the wait is six months.

I understand their frustration — their fear even. If your primary care doc says “You need to get in to see her right away,” you want an appointment right away. And yet, what am I to do? I can only see one patient at a time. I refuse to double book. I refuse to make patients wait for two hours because I am behind schedule. I get patients all the time who say they left another practice because they had to wait for two, three, or even 10 — oh, yes, 10! — hours to be seen. So while they may wait six weeks to come in and see me, once they are here, they are seen promptly and have my undivided attention. I’m not looking at the clock thinking, “Oh my God, I have eight more patients to see in the next 45 minutes”.

So what do I do? Do I accept the way things are, and say “sorry, such is life”? I will gladly take suggestions … or a time machine.

Randall Wong, MD: Tools for SEO

Last week, I introduced the concept of SEO (search engine optimization) and how it can be used for marketing. Good SEO is matching the content of your web page with the keywords used for an organic search (i.e., the words you type into "Google" or another search engine).

My Web site has become more visible on the Internet due to improved rankings on search pages. This is a result of my own SEO efforts.

While most blog software seems interchangeable, there are a few "themes" that are better at SEO than others. I recently bought "Thesis” for WordPress. Not only can I change the design of any element of the page (graphics, number of columns, font, background colors, etc.), but I can do it without knowing how to code.
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While most of the "themes" available for WordPress are free, Thesis (which is inexpensive) is designed to maximize the SEO of a Web site. It is written, or coded, so that search engines are able to easily find what they are looking for and rank your page.

Search engine optimization is the only way a page gets ranked, and stays ranked.

I also recently started using "Scribe." Scribe is a program that analyzes your article to maximize the SEO of your content.

After writing an article or post, I'll analyze it with "Scribe." Scribe will check for keyword usage (making sure I don't use a word too often) and review my excerpt, title, etc., to increase the SEO of my content. It makes my content more relevant for the search engines.

Scribe is a subscription service. It has a monthly fee and allows me up to 300 analyses per month.

Why bother?

I started using both of these tools about 6 weeks ago. Since then, my traffic has started to increase, I no longer write daily, and I don't have to "Tweet" to get traffic to my blog. It has saved me a tremendous amount of time.

My biggest source of traffic is now Google, and 70% of my traffic (an increase even from last week) is from search engines.

SEO can be done without these tools, but having software help you reduces the amount of work and time required to maximize your efforts. These tools allow me to spend more time writing and less time worrying about SEO.

Gerald O'Malley, DO: Sadao

My father-in-law passed away on Saturday.

Sadao Nagakuni was born in 1942 in Katsurahama, Kochi Prefecture on Shikoku, the smallest and least populated island in Japan. He lived through the occupation of Japan following World War II but he was too young to remember much of it. He loved to swim in the ocean when he was a child, even though it was prohibited because of the rough surf. He put himself through school as a guitar player in a “Hawaiian band” that would play in beer halls. He loved classical guitar and his favorite artist was the Spanish guitarist Andres Segovia. Nagakuni-san developed a method of playing traditional Japanese melodies with a flamenco/Spanish styling that was exquisitely beautiful and quite unlike anything I had ever heard.
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As a young man, Nagakuni-san was forced to work in his father’s factory making water tanks to hold fresh seafood. My father-in-law didn’t get along with his father and moved away from Shikoku to Tokyo where he met his wife. They settled in Osaka, the second largest city in Japan and started a company that designed, built and serviced water tanks to hold live seafood, mostly for restaurants and seafood suppliers.

In the early days of their marriage they had no money to rent a house so they lived in the workshop where they built the water tanks and slept on a futon in the corner of the building.

In Japan, you can judge the quality of a restaurant by the way they display their fish and seafood, Nagakuni-san created elaborate and beautiful and functional water tank/display systems for clients all over Japan. When Rika introduced us, her father treated me to many wonderful meals all over Osaka. He knew all the owners because they were his clients and we received VIP treatment wherever we ate.

Japan remains a very culturally closed and homogenous society. At the time that Rika and I became engaged I was stationed at the US Naval Hospital in Okinawa and relations between the Japanese and the US military were very strained because of some heinous and criminal behavior by one or two members of the more than 40,000 active duty members stationed in Japan. US military members were spit on and harassed by the Japanese in the streets of Okinawa.

None of that seemed to bother Sadao. I remember sitting at a lunch counter with him eating teriyaki and beef bowls surrounded by muttering construction workers and clucking housewives while we tried to communicate through his limited English and my nonexistent Japanese. We must have made a strange duo. I’m left to wonder if he ever wished that his daughter had fallen in love with a Japanese guy because he only ever treated me as his son-in-law.

Sadao suffered a cerebral aneurysm bleed in 2002 which robbed him of many of his cognitive faculties. Physically he appeared fine and he was even able to still play the guitar although not as easily or fluently as before and he would often play the same song over and over again for hours. It still sounded beautiful to me.

For the past several years, Nagakuni-san required around-the-clock supervision for his own safety. We saw him last March and visited with him several times and he remembered me and our daughter and surprisingly our son, whom he had only met once before. He reportedly woke up Saturday morning, walked out to the lounge area, sat down in front of the TV to watch the morning news show and didn’t respond when they called him for breakfast.

Sadao Nagakuni was a quiet man with an easy smile and a deep laugh. He worked hard, helped neighbors and strangers alike, was honest and generous to a fault and raised my wife and her brother in a loving and disciplined home. He was one of the millions of men that live their lives honorably and productively with a quiet nobility that are the soul of the family and the engine of the world. I will miss him.

Sayonara Nagakuni-san.

Physicians Practice LIVE is live!

Physicians Practice LIVE, our first ever virtual practice management conference opens this morning.

It's just like a physician conference, complete with an exhibit hall stocked with booths, an auditorium with presentations from the experts on everything from HITECH dollars to work flow fixes, and a networking lounge to chat with other attendees. Well, except that it all is happening online.

So, as people are interacting with colleagues, vendors, and experts today at Physicians Practice LIVE, we'll use the blog as an extension of the communications. We'll post updates here throughout the day. We welcome your comments and insights!

Trendspotter: Computer-Assisted Coding Is Coming

By Ken Terry


Are you ready for computer-assisted coding (CAC)? So far, it’s being used mainly in hospital outpatient departments, emergency rooms, imaging centers, and ambulatory surgery centers. But it’s starting to move into inpatient settings and ambulatory-care clinics, as well. So you might soon be receiving solicitations from CAC vendors such as CodeRyte, A-Life Medical, AMI and 3M Healthcare Solutions. Whether or not your practice can benefit may depend on such factors as EHR adoption, the types of work you and your colleagues do, and whether you employ professional coders.

There are at least two different forms of CAC. One is similar to the E&M code checkers found in many EHRs. Products from companies like IMO are integrated with EHRs and map the medical terms used in those records to diagnosis and procedure codes. So if you use drop-downs and pick lists for most of your documentation, the program can identify many of the codes you should be using, based on the discrete data in the EHR.
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A more common approach to CAC uses what is known as “natural language processing” to identify relevant terms in electronic text and analyze them in the context of coding logic. By using this kind of software, some radiology departments have been able to code up to 60 percent of their claims automatically and send them directly to the billing system. Radiology and a few other specialties are especially suited to CAC because they have so many repetitive cases. Because these are easy to code, CAC is fairly accurate in these areas.

In more complex care settings, CAC helps increase productivity by doing some of the basic coding work, while allowing human coders to make the final decisions. These programs reduce the amount of time that coders have to spend searching through documents to find relevant information. CAC software does not work with paper or scanned documents; it’s designed for electronic text, such as transcribed notes or reports. But since that’s all that the majority of practices have online right now, CAC might be useful to some groups in which physicians don’t code their own claims.CodeRyte, which has been around for a decade, claims that it “automates medical coding for leading multi-specialty clinics around the country.” It also automates coding for about 70 single-specialty, hospital-based practices. Most of them are radiology, pathology and ER groups, but their customers also include some cardiology practices. CodeRyte avers that its product can increase coder productivity by up to 200-300 percent.

A-Life Medical, another CAC leader, also says that it improves coder productivity and integrates with hundreds of billing, hospital and document management systems. According to the company, it assists coding operations for more than 40,000 physicians.

There are a few reasons why CAC is likely to become more prevalent. First, experienced coders are in short supply, which means that practices need to maximize the productivity of those who are available. Second, hospitals are using these products, and more and more physicians are working for hospitals. And third, the industry is on the verge of moving to ICD-10 diagnostic coding. When that happens, there will be a big expansion of codes, with an accompanying rise in the complexity of coding. Some observers believe that computer-assisted coding can help physicians and hospitals cope with this challenge.

One thing is for certain: physicians and their staffs spend far too much time on administrative tasks that take time away from patient care. If CAC can remove some of that burden, while helping practices code more appropriately, it will be welcomed in physician groups of all kinds.

Jennifer Frank, MD: Crazy busy

I am sure you can relate to the sense of being crazy busy – not just rushing from this thing to that but feeling completely overwhelmed with the multiple professional and personal commitments that line up, seemingly endlessly, before you. I am living this, and it’s not a comfortable place to be.

About six months ago, I was invited to speak at a conference occurring this past weekend. I enthusiastically accepted. It was a great opportunity which I thought would be personally enjoyable and professionally enriching. As the date got closer, the stress of actually preparing for and getting to the event outweighed my excitement. It didn’t help that I was flying out on my husband’s birthday or would be missing my daughter’s dance recital.
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My mixed feelings about making these personal sacrifices for a professional honor showed up in a late departure for the airport, poor concentration for the task at hand necessitating a U-turn to head back home to retrieve my forgotten thumb drive, and a series of mix-ups, hold-ups, and circumstances that had me arriving at the conference about 30 minutes prior to my talk (causing a minor panic attack for the poor woman organizing the conference).

After the talk (which went well despite the inauspicious events leading to my arrival at the conference center), I had time to reflect on my “balance” which was feeling quite out of whack. As I enjoyed the absolutely gorgeous scenery that spread out before, I had time to do something I rarely do – breathe deeply and ponder deep thoughts. I came back to something that has occurred to me on previous occasions when I find myself overwhelmed and underfocused: I am trying to do too much.

I was well prepared for the talk and excited to give it. I had allowed some wiggle room in my schedule, which I did have to use. However, I still arrived with (some) time to spare. My husband, left in charge of kids, house, and pets for the weekend, was supportive of my going, even on his birthday weekend. I was, however, trying to balance my professional role with the guilt of choosing to be away from my family during a time we would normally have spent together (our weekend).

Instead of accepting this as the necessary cost of pursuing a professional opportunity, I was going back and forth in my mind between my role as a physician and my role as a wife and mother, feeling unprepared for one role and guilty about not doing the other well.

In reality, I was upset that I couldn’t have it all – you know, being the star speaker of the conference while also being a perfect wife (home for her husband’s birthday) and mother (clapping enthusiastically in the front row at the recital). In the future, I will need to do a better job accepting that choosing one thing (a speaking engagement or staying home to attend a family event) is often choosing not to do something else. That is the cost of the choice, and consciously deciding to pay that price (or not) will hopefully prevent some of the guilt and a sense of imbalance that can accompany crazy busy weeks.

Telemedicine catching on

Virginia has become the 12th state to require health insurers cover telemedicine services. This includes interactive audio, video, and other electronic media used for diagnosis, consultation, and treatment, according to American Medical News.

The American Telemedicine Association estimates that all 50 states will begin paying physicians for telemedicine services within the next few years.

Telemedicine is often considered in the context of reaching rural or remote areas underserved by certain specialties. But I wonder if it can, and will, become more commonplace as just another way for any physician to interact with patients. In my research for the April cover story, The Future of Healthcare Revealed, telemedicine came up as an option for where care is headed.
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I am also curious what physicians think about it — not as a replacement to the office visit, but a supplement, another option. I just had a follow up appointment with my physician this morning, a short, 10-minute check-in, and even though I live in a city and getting to the doctor’s office is quick, I wonder how much more convenient —and just as effective — a televisit would have been. Could I have just dialed up via web cam and talked with her, saving me the trip? Would it have allowed her to schedule me at a different time, say on her off hours, since she wouldn’t have to staff the office or even come into the office?

During the Future of Healthcare article research, I spoke with a physician participating in online visits, which he called “a common sense, logical step.” It can offer flexibility for doctor and patient alike.

So what are the barriers to telemedicine? Of course, there is the technology. It requires both sides to have Internet access and in most cases a web cam and telephone line. But what about cultural barriers? Are physicians interested in a new model? Considering the low adoption rates of EHRs, would telemedicine be seen as just another high-tech hassle?

Please weigh in on the issue with poll on the right on comment below.

Congress passes another temporary payment fix

Last night, Congress passed legislation staving off the 21 percent Medicare cuts until June 1 — another temporary fix to the SGR-based payment formula.

This vote was the latest of several moves to push back the cuts. Twice this year, CMS has had to step in and tell contractors to hold claims for 10 business days until Congress can pass a fix. The most recent period ended this week.

And once that temporary fix expires again, Congress can pass another short-term solution. Or perhaps it is really time to change the flawed SGR formula once and for all?

Don McDaniel: RECs to the rescue

Many of the readers of Practice Notes are members of or affiliated with small physician practices — physician organizations of 10 physicians or less. As you are now undoubtedly aware, the U.S. government is making a significant investment, as a major component of the American Recovery and Reinvestment Act, to support the adoption of electronic health records.

EHR adoption is still very low in the United States, especially among smaller practices. Therefore, to facilitate the adoption and the achievement of meaningful use of these EHRs among small practices, the Office of National Coordination for Health Information Technology (ONC) has now designated some 60 Regional Extension Centers (REC).
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The mission of the RECs are to help primary-care physicians, small practices, and safety-net providers such as community health centers, rural health centers, and critical-access hospitals, through the provision of consultative support and advisory services to enable successful development of EHR systems, and ultimately achievement of meaningful use.

The REC program funding will create technical extension centers throughout the U.S., and each REC will target approximately 1,000 to 2,000 physicians. They are chartered to be vendor agnostic and to provide unbiased guidance — that is to say that they will not promote any specific application over others — with a goal of helping the smallest of practices manage the work flow and business process challenges of achieving meaningful use.

In total, the federal goal is to assist 100,000 physicians nationally by the end of 2012. Each REC will have access to a newly created, federally funded health IT research center — meant to act as a knowledge management hub and disseminator of best practices to the individual RECs and its clients, the physicians. The RECS will be moving to full operating status within the next six months and a list of each REC, as well as information about the REC program, can be accessed at HHS’ Web site. I encourage all practices to reach out to their assigned REC to ascertain how it can help you on your health IT journey.

Randall Wong, MD: What is SEO?

Search engine optimization (SEO) is a type of marketing strategy used to maximize the placement of your Web site on a search list. It is based upon the relevance of your site, and its content, to the keywords used to generate a search. It is the basis upon which search engines (Google, Bing, Yahoo) rank your web page on a search list.

It is not paid advertising - it's free.

The actual content of my Web site now attracts more visitors from search engines than any other source. As of this morning, 64 percent of the traffic to my blog comes from search engines. Most of my visitors arrive to my page after performing a search looking specifically for health information on retinal diseases.

This did not happen over night. Search engine optimization takes time and persistence. There are three basic concepts to establishing SEO:
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1.Relevance - The content of the your site must be relevant to the keywords, or search terms, used on the search. Google wants to provide Web sites that are highly relevant to the terms used for a search. The search engines want your search to be as successful as possible, that is, they want you to find what your looking for as fast as possible.

The key to successful searches: Relevance.

2. Referrals to your page - Other Web sites, with time, will be linking to your page. Based upon the content of site linking to you and the "anchor text" used to create the link, search engines will validate the relevance of your page. These are also called backlinks.

Anchor text is the words highlighted to create a hyperlink, or link, to a Web page.

Example #1: For more information on retinal detachments, click here.

Example #2: Retinal specialists fix retinal detachments.

Both links get you to the same place, but example #2 uses more relevant terms to guide you. This is noticed by the search engines. It tells Google that my Web site is related to retinal detachments and is a big endorsement with regard to my site's relevance to retinal disease.

3. Refreshed content - The more often your page is updated, the more attractive you'll be to the search engines. This is one reason blogs have become so popular. It's easy to add content to your Web site via blog software.

So, SEO is really about creating credible information. From a marketing standpoint, it is the most concrete way to get your Web page ranked and noticed. There really are no gimmicks. Although you can still pay to advertise your Web site, the only way to gain rankings is to create Web sites that provide relevant information.

From a consumers point of view, say our patients, SEO increases the credibility of the information provided and found on the Internet. It increases the likelihood that our patients may find health information that is really useful to them.

Next week I'll share some of the tools I now use to maximize the SEO on my site.

Gerald O'Malley, DO: On Precious

The other night my wife was working the overnight and I was tired of reading, so I took a break and bought and downloaded the movie “Precious” from the On Demand channel. Since the kids came along I rarely go to the theater — unless the movie has Hannah Montana or a talking fish, I’m usually watching it on my couch.

I watched about half the film but I couldn’t finish it. There is only so much brutality and cruelty and psychopathology that I can take outside of the ER. As I got deeper and deeper into the movie, I recoiled from the hyper-real depiction of violence and depravity.

Finally, as I literally became nauseated, the thought dawned on me – why and I subjecting myself to this? Don’t I get enough of this at work? Don’t I get enough ignorance and hostility and violence from the residents? Just kidding.

The movie was just too good. It was too real.
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To those that aren’t familiar with the movie “Precious” is about a very unattractive and unsympathetic young black woman (ironically named Precious) living with her sadistic, mentally unstable mother in Harlem. Precious is surrounded by ignorance, violence, and antisocial behavior by dysfunctional and psychotic characters including her father, who rapes her repeatedly and impregnates her twice. As the movie opens, Precious is dismissed from her public school because of the pregnancy. A dedicated counselor finds a place for her in a special school for girls with extracurricular obstacles, but every where she turns Precious is berated, beaten, and bullied.

Most of time, despite her enormous size and obesity, Precious is invisible to other people and when she is noticed, she is tortured. The major antagonist is her mother, played by an actress named Mo’nique, who, when she isn’t beating her with pots and pans, is drunk and high, smoking cigarettes and screaming at Precious to forget school and stay home and collect welfare.

After the third or fourth scene of Precious being beaten and seventh or eighth scene of illiterate black characters engaging in irresponsible, immature behavior and substance abuse, I just couldn’t take it anymore. Who wants to see a movie about this crap when I have to deal with this exact same set of problems every time I walk into the ER?

I’m sick of seeing the effects of drug and alcohol abuse on abused wives and children. I’m sick of trying to explain simple concepts of health maintenance like the importance of not smoking crack when you are pregnant to young women (who are generally more interested and engaged in texting while I’m trying to speak with them) that already have two other children from different sexual partners and haven’t read a book or magazine that doesn’t have a menacing tattooed hip-hop rapper thug felon on the cover. Does this have to be celebrated with a movie?

“Precious” the movie does an incredible job of realistically depicting the worst behavior of black inner city inhabitants. I watched as much of the movie that I could stand and I didn’t see a single heroic or even sympathetic character. That is not my experience.

In my years of practicing emergency medicine in the ghetto I have witnessed breathtaking examples of selflessness and honor. Instead of the disgusting and depressing “Precious,” give me a movie about a heroic inner city math teacher or a grade school spelling bee champ or basketball team that beats the odds any day.

Trendspotter: Many ED Visits Reflect Poor Access to Primary Care

By Ken Terry

In Voltaire’s book “Candide,” he lampooned a contemporary philosopher’s assertion that “this is the best of all possible worlds.” Now a pair of emergency department physicians argue in a Slate article that we don’t need to reform our system of emergency care because most ED visits are necessary and, besides, they don’t cost that much. Apparently, these doctors never read “Candide.”

Zachary F. Meisel and Jesse M. Pines state that just 12 percent of ED visits are “not urgent.” However, the National Health Statistics Report they cite says that 16 percent of visits are emergent, 36 percent are urgent, and 22 percent are “semi-urgent,” which leaves a lot of latitude for defining “non-urgent.” Moreover, during the period covered by the study (1996-2006), there was a 32 percent increase in ED visits, while the number of ED visits per 100 people increased 18 percent. So a growing number of people are coming to the ED more often. That suggests that more people are using the ER for primary care.
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The National Health Statistics report points out that 11 percent of all ambulatory-care visits are made to EDs, although those departments have only 3 percent of physicians in the U.S. “EDs provide unscheduled care for a wide variety of persons for reasons that range from sudden cardiac arrest or severe injury to minor acute problems that occur after business hours, or for which the patient is unable to access a primary care provider in a timely fashion. In 2005, approximately one-fifth of the U.S. population had made one or more ED visits within the past 12 months and some subgroups, such as infants, persons 75 years of age and older, Medicaid beneficiaries, and African Americans, had higher utilization rates than others.”

Another key part of Meisel and Pines’ argument is that because ED visits are only a small fraction of total health spending, they’re nothing to worry about. In fact, because EDs are open 24/7, they maintain, "the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors.” I don’t know how they calculate that, but other research contradicts it
In a large-scale study of the cost of non-urgent visits to Minute Clinics (retail clinics in pharmacies), primary-care offices, urgent-care centers, and emergency departments, researchers found that, for treating five common conditions, the adjusted mean pharmacy and medical costs per episode totalled $383 in the ED, versus $159 in the primary-care doctor’s office. Even if the primary-care physicians were paid a bit more for treating patients in off-hours—a rather odd scenario—the ED visit would cost twice as much.

The biggest flaw in Meisel and Pines’ theory is that they don’t consider how many of the emergent and urgent visits to the ED result from a lack of access to primary care. Sure, the majority of ED visitors are insured, but how many of them have comprehensive insurance, and how many shun doctors’ offices because of high copays and/or deductibles? Much has been made of the fact that roughly 20,000 people a year die because of lack of insurance. But people who have skimpy insurance and low wages may also avoid necessary care until it’s too late or until they’re compelled to seek aid in the emergency room.

Finally, Meisel and Pines make an outrageous statement about primary care that I cannot let pass. They say, “Most ‘frequent flyers’—a pejorative term used to describe patients who stop by ERs a lot—tend to be the very sick, those with severe asthma, heart failure, or diabetes. When these conditions flare up, patients do, and should,come to the ER. ERs are designed to take care of acutely ill patients, while doctors' offices are not [emphasis added].”

Now, it’s possible to interpret this statement as meaning that, in a true emergency, these patients should go to the ED. If so, I would not disagree with it. But if the ED physicians mean that primary-care doctors are not equipped to care for very sick patients, I think most generalist physicians would beg to differ.

The fact is that we need more and better primary care so that patients who have chronic conditions are properly cared for, and those who are at risk of developing chronic diseases do not get sick. While we need other kinds of prevention, as well, including better eating habits and smoking cessation, those are not a substitute for universal access to good primary care.

Poll: 1/3 of docs paid by drug companies for meetings

There has been a lot of discussion lately about physicians receiving gifts or payments from drug companies or others in the medical industry. And part of the healthcare reform law includes a so-called “sunshine provision” requiring docs to disclose the payment on a public Web site.

Now, a poll finds that about a third of physicians have been paid by pharmaceutical companies to attend meetings, present talks, or host a meeting, according to MomMD.com, which along with NetDoc.com ran the poll. The small poll didn’t include freebies from drug companies.

Does that number surprise you? Do you think the sunset provision will have any effect?

Jennifer Frank, MD: A reflection on me

I recently had to readmit a patient to the hospital for pneumonia. A lovely and delightful woman, she happens to have severe COPD exacerbated by continued smoking. She knows she shouldn’t smoke. I know she shouldn’t smoke. I know that she knows that she shouldn’t smoke. We have been over this countless times.

Speaking to the pulmonologist about her care, I was informed that she needs to quit smoking. I became embarrassed that my patient was still smoking, as if I was somehow responsible for this behavior. I have been scolded by consultants on other occasions when my patient was rude to the nurse in the hospital or didn’t keep a follow up appointment. Sometimes the consultant catches herself before continuing the tirade, and sometimes my therapeutic relationship is perceived to be so close with my patient that the patient’s behavior becomes one with my own.

Really it boils down to a blow to my professional pride.
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I cringe to call a specialist on those patients who continue to abuse their own bodies, eschewing medical care until they are practically in extremis. As a primary-care physician, I pride myself on the close relationships I establish over months and years with my patients. However, sometimes my role as the family doctor seems to carry the responsibility for my patients’ actions along with it.

I liken this to what happens when one of my kids goes to school with a stain on his shirt or her hair uncombed. This doesn’t happen most mornings, but occasionally, the juice spills on the shirt at breakfast and I don’t notice the stain until dinnertime. Or, in the mad rush to get out of the house I assume my husband will brush the girls’ hair and he assumes I will and then the bus is there and the opportunity is gone. When this does happen, I wonder if the kindergarten teacher or classroom parent thinks I am careless. I am already suspect as a working mother, so maybe this adds fuel to the fire of speculation about my commitment to my family.

There is an understandable element of pride in how our children behave, appear, and are regarded. We all want to have the most beautiful, talented, polite, and exceptionally bright kids. When our children make the inevitable mistakes or fail to practice the basic elements of personal hygiene, it is challenging as a parent to not inwardly wince at what this says about us.

It is similar being a primary-care doctor. I take pride (or not) in my patients’ performance – if their A1Cs are below 7, this not only reflects what “good” patients they are, but also what a “good” doctor I am. But just like we can’t pick our kids, we can’t pick our patients. So, I must deny the pull of professional (or parental) pride and accept my patients just as I accept my own children – as imperfect people who look to me for help and often for approval as well.

Melissa Young, MD: The voice and face of my practice

Several times a day, I hear patients complain that they can’t stand the staff at other doctors’ offices:
“I like my doctor, but his staff is rude.”
“The people over there don’t know what they’re doing.”
Even some patients from my old practice tell me, “I’m so glad you left that office. I couldn’t stand so and so.”

I also hear complaints from my staff all the time that they called another doctor’s office for lab results or something and were treated very rudely:
“I don’t have time for that now.”
“[exasperated sigh] We sent that already.”
“Yeah, I’ll get to that when I have time.”
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I am incredibly pleased when patients tell me how much they like my administrative assistant and my medical assistant:
“She was so helpful.”
“She’s very sweet.”
“They are very efficient.”

When a patient calls, it’s their voice they hear first (ok, technically, they hear mine first because I’m on the phone message, but you know what I’m saying). The tone they set when they answer the phone, and the attitude they project is a reflection of the practice, and, in essence, of me.

They are also the first faces my patients see when they walk in the office. The way they are greeted and the way they are treated before they see me, sets the tone for the entire visit.

I believe it’s important for a practice to choose staff members that will portray the practice in its best light. It goes without saying that you want to hire someone competent, but you can educate people and teach them skills. It’s hard if not impossible to teach attitude and demeanor.

Googling your patients?

Have you ever Googled a patient? Should you? It’s a question physician blogger Kevin MD raises, and it seems like an interesting consideration in the ever-changing Internet/social media world.

Of course patients Google their physicians all the time. But how often do doctors research their patients online? Maybe there are some contexts in which that would make sense (Kevin MD notes that primary care might not be among them, but perhaps psychiatry.)

This issue comes as I am writing a story on how physicians can ensure the privacy of their patients while engaging online through social media networks. The whole “to friend or not to friend on Facebook” question seems to get some docs in a bind. Now this seems like an entirely new dimension to delving into the ether.

The Googling your patients question also reminds me of an inquiry I received from a reader after our Lawyer Repellant story.
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For the story, experts told me that to help avoid lawsuits, be wary of problem patients – the ones who speak ill of their previous docs or have sued before. So the reader rightfully asked, how do you know if they have sued before? (I am not sure if this is information that is easily Googled, but I do know with a little digging it’s amazing what you can find.)

I asked Medical Justice Services’ Jeffrey Segal about that, and he said (via e-mail) that there really isn’t a practical way to know if a patient has sued a physician before. Even if you could see that they have sued before, you couldn’t tell whether any lawsuit had merit or was frivolous. Compiling that information in a database would make it hard for those patients to find care. Also, I can’t imagine digging around for that information on each patient, and if the patient relationship has pushed you to that point, perhaps it’s not a good fit.

All of this is to ask how much you can and should dig around and research a patient online? Lawsuits aside, what information would you find that is relevant to treating that patient? Kevin MD notes that the overriding question should be “Will researching my patient online improve their care?”

Randall Wong, MD: Blog saves vision

The Internet saved the sight in my patient's only eye! Using my blog about retinal disease as a tool for patient education and communication via e-mail, we saved his vision.

NOTE: Retinal tears, or retinal holes, cause retinal detachments. The most common symptoms of a retinal tear include flashes and floaters.

My patient was referred to me with a retinal detachment of the right eye. He is almost blind in that eye. The vision may have been lost for up to two years - we have no idea. He, incorrectly, had attributed the loss of vision to an unrelated problem.

Basically, he had been given bad information.

I scheduled him for retinal detachment surgery. I also instructed him to read about retinal detachments on my blog.

Over the weekend, he developed floaters in his other eye. He e-mailed me about his concerns of the new symptoms. He now knew the floaters in his remaining eye could mean a retinal tear. I e-mailed back recommending re-examination.
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Indeed, he had a retinal tear in his remaining "good" eye. I treated the eye with laser photo-coagulation, thereby preventing a retinal detachment from occurring.

I saved his sight, or rather, my patient saved his own site.

So what does this mean? Using the Internet can work. Though an isolated case, the Internet has changed the way we can educate our patients and communicate with them. For instance, after my initial consultation, I recommended that my patient read my blog about retinal detachments. I wrote these articles and they mimic what I say in the office.

My patient did read the articles and received, this time, some pretty credible information about retinal detachments and warning signs.
The blog taught him what he didn't know about his first eye. The blog gave him good information and also realigned his thinking about retinal detachments.

Even better, the blog "untaught" him about the erroneous information he had received previously. I don't know how about you, but "unteaching" a patient is one of the hardest things to do.

E-mail is convenient and easy. No phone tag, no receptionists, and less embarrassment over "dumb" questions. I recommend to all my patients that e-mail is a viable, non-emergent, way to communicate with me. I think it saves a lot of time for everyone.

E-mail is also easier than a phone call. My patient could have been intimidated about a phone call, afraid to ask a "dumb" question. Instead, he was able to communicate with me in a timely manner, and, using a medium convenient for both of us.

Gerald O'Malley, DO: Diet

Like most ER docs, my diet is atrocious. Shiftwork, the scheduling demands of raising two elementary school-age kids with a working wife and the unpredictable nature of the job conspire to interfere with a normal three-well-balanced-meals-a-day nutritional game plan.

My friends and colleagues that I work with all have the same excuses. Fried cafeteria crap for breakfast, lunch and dinner and fast food delivered to the ER all night to feed the graveyard shift. There is even a Chinese restaurant down the block that delivers until 5:00 a.m.! (We boycotted the place a few years ago when they sent out a 12-year-old kid at 3:00 a.m. on a school night to deliver our egg foo young. The boycott lasted nine days until, starving, we broke down and sheepishly ordered our 4 a.m. fried rice fix.)

Over the years I’ve tried to eat healthy, but have you ever tried to find a salad in the ghetto at 3:00 a.m.? You usually break down and feebly hunt through the left-over tuna sandwiches in the out-of-date box lunches that the ER keeps for the homeless, or the last resort of the starving – the vending machine.
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Before leaving for work I make sure to stuff my pockets with quarters for the gee-dunks (old Navy term) in the hopes that I might snag the last packet of trail mix but I usually have to settle for the pop-tarts or peanut M&Ms or little chocolate donuts.

Once I entered my 40s and the inexorable rise in my total body mass became hopeless to halt or even slow down, I tried a series of desperate and crazy diets – all miserable failures. But I started a new one on March 1st of this year and I think this one might actually work.

I stumbled across this diet while reading another blog. An advertisement on the side of the page showed a series of pictures of the diet developer beginning on the left with an old photo when he weighed 300+ lbs. and ending with a photo on the right in his new, svelte 165 lbs. chassis.

His story is amazing and inspirational and his reasoning and philosophy seemed to make a lot of sense – we eat too much processed food which is absent of omega-3 fatty acids and assimilable proteins, so incorporate foods and supplements with these elements in them and the weight will fall off you (I’m oversimplifying here – the name of the diet developer is Jon Gabriel and you can look him up yourself).

I thought – well, maybe this is worth a try. Mr. Gabriel extensively references his book with genuine scientific articles from biochemistry and hard-core physiology journals. So I bought a bunch of fish oil capsules and probiotics and digestive enzymes and flaxseeds and I incorporated them into a diet consisting of lots of raw greens, fruits, and vegetables, and I’ve been pretty compliant with the program (much to my own surprise).

St. Patrick’s day was brutal and I cheated with beer, soda bread, Irish beef stew, and my wife’s amazing whiskey tea brak, and I broke down a couple of weeks ago and savored every bite of one of famous Ray’s mushroom cheesesteaks, but I discovered that when you eat a ton of lettuce everyday, you really don’t have cravings for sweets or desserts.

My wife helped me by filling up the fridge with fresh vegetables and fruit and packing delicious salads for me while I napped before a night shift. I haven’t eaten this well in a long time and I actually feel great – I feel light and I’m sure I lost some weight, so I’m going to get up from this essay and weigh myself right now….

Six pounds? That’s it? In 5 weeks of dieting? I went from 234 lbs. to 228 lbs. (actually 228.5 lbs. so it’s not even 6 pounds!). Huh. What a disappointment.

Oh well, I feel like I’m doing something good for my body, so maybe I’ll continue with this diet for awhile more. Then I told my lovely Japanese wife that I lost 6 lbs., she said, “I can’t believe you weigh 230 lbs. – that’s as much as a sumo wrestler!”

I think famous Ray’s is open until 10:00 tonight.

Trendspotter: Safety Procedures Known to Save Lives Are Not Being Used

By Ken Terry

Safety and quality checklists can save lives in hospitals, as a new British Medical Journal study reiterates. Yet only a fraction of U.S. hospitals are using the World Health Organization (WHO) surgical safety checklist, which was introduced here 15 months ago. And the Leapfrog Group, a public-private consortium that presses for quality improvement in hospitals, has found that a minority of hospitals adhere to nationally endorsed process measures that have been shown to reduce mortality.

Interestingly, the checklist approach does not require electronic health records. Both the WHO surgical safety checklist and the “care bundle” approach used in three London hospitals rely on paper documentation. So, while there are indications that EHR use can save lives, much can be done even without information technology.

In the BMJ study, the care bundle method—which requires doctors to check off certain treatment steps—was associated with a major drop in patient deaths. While there were 255 fewer deaths in these hospitals during the study year than in the previous 12 months, 174 of those were related to the 13 targeted diagnoses. Despite a 5.7 percent increase in admissions, the mortality rate fell 14.5 percent. Both the drop in overall deaths and the decreased mortality among patients with the targeted conditions were statistically significant.
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The eight checklists addressed these diagnoses: peritonitis and intestinal abscess, senility and organic mental disorders, pleurisy pneumothorax pulmonary collapse, aspiration pneumonitis food/vomitus, skin and subcutaneous tissue infections, acute bronchitis, urinary tract infections, acute cerebrovascular disease, other gastrointestinal disorders, septicemia (except in labor), pneumonia, chronic obstructive pulmonary disease and bronchiectasis, and congestive heart failure (non-hypertensive).

The clinical areas covered by the checklists, which were introduced in April 2007, included central venous catheter/line sepsis, diarrhea and vomiting, stroke, ventilator acquired pneumonia, methicillin resistant Staphylococcus aureus infections, heart failure, surgical site infections, and chronic obstructive pulmonary disease.

Nearly 700 hospitals were using the WHO surgical safety checklist a year ago, and 300 more had committed to trying it, but there have been no updates since then from the Institute for Healthcare Improvement, which is spearheading the checklist campaign. The WHO checklist goes beyond the Joint Commission’s patient and site identification requirements by ensuring that everything is ready for an operation, that everybody on the team knows the safety procedures, and that there’s good communication among team members. A multinational WHO study showed the use of the checklist decreased mortality by nearly half. While it’s expected to have a much smaller impact in the U.S., where surgical mortality is fairly low, it could have a marked impact on reducing complications.

The Leapfrog survey, using 2008 data, found that relatively small percentages of U.S. hospitals were adhering to evidence-based guidelines that are known to save lives. Among the areas where compliance was poor: heart bypass surgery (43 percent), angioplasty (35 percent), high-risk deliveries (32 percent), pancreatic resection (23 percent), bariatric surgery (16 percent), esophagectomy (15 percent), aortic valve replacement (7 percent), and aortic abdominal aneurysm repair (5 percet). Moreover, 65 percent of Leapfrog’s participating hospitals lacked policies to prevent common hospital-acquired infections.

Now, it’s possible that the evidence is poor for some of the surgical protocols, and reducing infection rates poses a number of challenges, both human and technical. But physicians and hospitals that aim to be accountable and form “accountable care organizations” owe us all a better effort to improve patient safety. There’s no excuse for not trying to save lives when we know how to do it.

Jennifer Frank, MD: Discipline

While swimming this morning, I entertained self-congratulatory thoughts about my dedications and discipline. I got up this morning early to go to the pool before work. Okay, in all honesty, I slept through my alarm and was awoken by my youngest one’s cry to be rescued from his crib. Because I didn’t go back to bed like I wanted to, I count this as a plus in the discipline column.

I thought further about how I am trying to follow a workout routine (parts of which I really don’t like) in order to prepare for the triathlon. I have a workout schedule that I follow pretty faithfully. Having it written down in black and white seems more inviolable than just having an idea of what I planned to do in my head. I could continue with this illustration – swimming is methodical repetition of the same thing over and over again and involves “staying in your lane” while doing it. Both of these ideas have application for parenting and being a physician.

I recently received a rather strongly worded e-mail from the Wisconsin Medical Licensing Board stating that I (and all other licensed physicians) should read the quarterly newsletter to find out about new information that applied to our licensing. I ignored the first e-mail but did take a few minutes to read it after the second e-mail arrived.
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I never found the new information but I read with morbid curiosity about all the board actions against physicians occurring over the last few months. Truly shocking and surprising in both quality and quantity. Having sex with patients, dispensing vast amounts of controlled substances to patients or yourself, gross negligence.

Reading through this newsletter of shame, I realized why professionals need to have specific guidelines (you have to wait two years after termination of the patient-physician relationship before initiating a romantic relationship with a former patient, you cannot prescribe yourself or a close family member narcotics). These both seem pretty obvious, but I think it is easy to fudge the lines slowly, gradually, and unintentionally over time, so that you are no longer “swimming in the right lane.”

Just like the difficulty in getting up super early to immerse yourself in cold water, it can be difficult to adhere to standards when a questionable case is before you or when your own “needs” seem to be so compelling.

As a parent, self-control and discipline are important as well – not only to teach to your kids, but also to demonstrate yourself. It can be so hard to be consistent when you are tired, overwhelmed, or just at the end of your rope. It often seems easier to give in to their demands than to take the more challenging role of parent – in control and the same today as yesterday.

In all my roles – as fledgling triathlete, family physician, and mom – it is essential that I not only practice self-discipline but also recognize my own natural tendencies to fudge the lines when it is convenient to do so.

Melissa Young, MD: In house or not, that is the question

As an endocrinologist, I do fingerstick blood glucose readings in the office. I use the same glucometer a patient might use at home, courtesy of one of the companies that leaves me sample meters and strips. I charge for the service, and am paid anywhere from nothing to about $10. Not a substantial amount, won’t change my bank account by much, and I’d probably do it even if wasn’t reimbursed since it takes a couple of seconds and it doesn’t cost me anything.

Enter medical supply company reps hawking their Hba1c machines. They are fairly easy to use, they don’t take up a lot of staff or physician time, and allegedly they are decently reimbursed by most albeit not all payers. The machine is free, but the consumables are not. So after expenses, net reimbursement is about $5.

So the question is, is it worth it?
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Yes, I need the Hba1c in my clinical decision making, and yes, having the result in front of me while the patient is in the exam room sure beats calling them back with lab results. But I have a pretty good system in place, and although it doesn’t always work, the majority of the time, it does.

I have patients get their labs done before their visit. Like I said, not all of them do (“Really? Was I supposed to go to the lab?”, “Oh, yeah, I think you did tell me that.”), but most of them do. Besides, I have them get other labs, too – lipids, met panels, urine microalbumins – so if they come without an a1c I’d need to call them with their other labs anyway.

The rep’s argument was that I could order all those other labs to be done prior to the appointments, but plan on doing the Hba1c in the office, as an income generator. Really? For $5 a pop?

And just when he was beginning to sway me, he brought up other tests I could do, now or in the future. It started to feel too much like “business” than service, and that me uneasy.

In the end, I figured I’d give it a shot on a trial basis. I’ll have to see a) what it does to our work flow, b) whether or not it will actually get reimbursed as he claims, and c) how my patients feel about it.

What will the future of healthcare look like?

The healthcare reform debate, not to mention the rising costs and increasing demands, has forced many physicians to consider the future of their profession.

So for the April issue, we considered what the job of the private practice physician would look like in 10 or 20 years. I spoke with a host of innovative thinkers and practitioners who shared their views on how the profession would transform.

From virtual visits to more midlevels to a new reimbursement model, I heard many compelling predictions about the future of healthcare.

I invite you to check out the article and share your own notions of how the landscape will evolve.

Randall Wong, MD: Content is king

The success of any Web site is the content of that site. No matter what the nature of the content (i.e. health information, practice information, etc.), good content will increase the popularity of the site. Here are a few tips about writing good content to keep your readers happy and to maximize your SEO (search engine optimization).

Remember, Google and your patients like relevant and fresh content. There is nothing worse than going to a Web site that is old and stale (no new information) or to a Web site where portions are still "under construction."

People are eager for information. They want answers — now! Irrelevant information or stale Web sites are a huge turnoff.

If you want to add content to your Web site, I suggest starting with two or three topics. This is a small enough number of projects that you can complete in a reasonable amount of time. And remember that Google ranks Web pages, not Web sites. You want to have two or three "cornerstone" topics of your Web site. The more complete they are, the better they will rank.
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For instance, while I am a retina specialist, I only have three cornerstone areas: diabetic retinopathy, macular degeneration, and retinal detachment.

Once you have created a sound foundation, then branch out. Watch out, don't be surprised if this takes weeks!

Write in a style that is comfortable for you, but relates to the patient. My own bias is that too many docs speak in a so-called business phase. I am comfortable writing in the same style that I use when seeing patients in the office. This works for me.

By speaking and writing at the same level, you stand a better chance of engaging your readers, and thus lending more credibility to yourself. Writing above your readers’ level and using too much techno-mumbo-jumbo are two great ways to bore your readers. They'll never come back.

Write regularly and often. I try and write on my own blog at least four times a week Monday through Friday. Next month, I will be approaching my 200th post. I am not saying you have to write this much. I used myself as an example. I have now reduced my writing frequency to about three times a week after establishing a pretty comprehensive archive.

Sticking to a regime is the hardest part, but there are several ways to avoid self-exploitation:

Ghost writers - there is a huge market for this and I'll share more with you in the future, but there are a ton of good writers looking for work.

Guest bloggers - this may be hard to achieve in the beginning, but there are many bloggers looking for links back to their own blogs who might write an article or two for you. I do this myself.

Your colleagues could also chip in and create content articles for you.

Be thorough, but not too thorough. This is tough for us. We tend to be know-it-alls. Keep the length of your article similar to what you read here. I'd recommend no more than 500 words and I'd shoot for a good 350 each time you start. The cornerstone articles should be a bit longer, think of them as reviews. Perhaps choose a length of 500-1000 words for the main bits.

Too lengthy gets boring. Too wordy is dull. You don't have to include every detail that you know. Just share a part of what you know. The goal is to show off your knowledge (i.e. authority) without being cocky or boring. Break it up into parts if you have that much to write about.

Gerald O'Malley, DO: Secret myths and quiet truths of the ER

I was in the grocery store the other day and something caught my eye as I pushed the bananas and Ho-Hos through the price-check scanner. Reader’s Digest had an article about my childhood hero, Willie Mays (I know he was a Met, but even Yankee fans recognize greatness), but that wasn’t what made me buy the magazine.

It was the picture of the young woman dressed in scrubs accompanied by a headline like: “50 Secrets ER Doctors Won’t Tell You (Read This Before You Call 911).” I couldn’t resist.

The American ER (and the people that work in ERs) has always been fertile ground for urban myths and legends. I’ve heard the same outrageous stories told in ERs from Virginian Beach to Los Angeles: The violent PCP patient tossing around security guards after being tazed, the guy with the vibrator in his rectum, the “dead” patient that sits up and moans…

ERs all have similar stories and sometimes it gets hard to separate truth from fiction. Reader’s Digest actually picked some uncomfortable but undeniable truths to reveal as “secrets.”

Some of my favorites from the March issue of Reader’s Digest include:
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• Never, ever lie to your ER nurse. Their BS detectors are excellent and you lose all credibility when you lie.

• Standing in the doorway and staring at us while we work won’t help your loved one get treated more quickly. We’re pretty used to people trying to intimidate us.

• The busiest time starts around 6 p.m.; Mondays are the worst. We’re slowest from 3 a.m. to 9 a.m. If you have a choice, come in the early morning.

• If you come in with a bizarre or disgusting symptom, we’re going to talk about you. We won’t talk about you to people outside the ER, but doctors and nurses need to vent, just like everyone else.

Harsh to read, but I had to grudgingly admit that there was some truth to the “secrets.” The reality is that this can be a really crappy job a lot of the time. For every good, happy, positive outcome, there are a dozen that are heartbreaking and terrifying.

The first of the 50 secrets in the article seemed a little obnoxious and condescending. It read: “Denial kills people. Yes, you could be having a heart attack or a stroke, even if you’re only 39 or in good shape or a vegetarian.” Seemed a little self-evident to me.

Tonight I tried everything in my power to resuscitate a 43-year-old woman that I pulled out of the front seat of her boyfriend’s car. I remember smelling and seeing the burning cigarette in the car ashtray as I wrenched my back trying to untangle her feet from under the dash, lift her out of the car and drag her out onto the ER gurney. The boyfriend took the time to light and smoke a cigarette while he drove this dying woman to the ER.

I thought of the first secret as I sat to explain to her 13-year-old son why I couldn’t save his mother.