Wednesday, May 30, 2007

"Physician shortage"

You are a physician and as such probably familiar with multiple choice questions.
Here are a few true and false questions for you.

1. The gas prices are raising because we have either an oversupply of gas - or a decreased demand.
True or false?

2. The prices for computers and computer parts and accessories are going down because we have a shortage of manufacturing facilities.
True or false?

3. Real estate prices increased over the last 30 years because we have an oversupply of land, especially water front.
True or false?

4. Physician reimbursements have decreased continuously for the last 25 years because we have a shortage of physicians.
True or false?

5. The HMOs want to keep the number of physicians to a minimum, so that they can continue to pay less and less.
True or false?

You get the picture. I still cannot understand how some of my colleagues can be so incomprehensively stupid that they read about "decreasing reimbursements" and "physician shortage" in the same journal or magazine without wondering if it makes sense. I know we are notoriously bad in business matters, but do we have to be THAT bad and ignorant?

Close a few medical schools, improve the quality of training.
We need less physicians, more nurse practitoners and physician assistants. Tell someone.

Tuesday, May 22, 2007

What an EMR should be !

Electronic medical records should speed up documentation of the patient visits, make documentation more complete and extensive and include all the redundant things that we always say, but never document (because they are soooo obvious to us). Faster documentation means finishing earlier or seeing more patients and more complete documentation means more payment and higher coding levels! And the “redundant parts” may one day very well save your behind in court. With an EMR Patient charts are available wherever you are – office, hospital or home.

At least those are the benefits that the EMR companies keep on repeating. Those benefits nevertheless are by no means certain or even guaranteed!
To my big surprise I ended up being disappointed when my health care system bought and installed the GE product "Centricity" (it used to be sold as "Logician"). You get the feeling that it is an old system that has been updated over the years, but it is far from being as modern as what we are used to from working with Google or Yahoo.
GE is rather inflexible and is not too eager to individualize it to you (or they make it expensive). Using Centricity has drained my productivity rather than improving it. Visits take longer, I do not have an easy overview of my patients data as I had before, there is no space for personal notes on patients (!!). Personal notes on patients are very important to me. They make each patient unique and allow us to pick up a conversation where we left of the year before. A note could be "likes cold climate, considering moving to Maine", "loves teenageers, thinks that they are in the most interesting age", "has winter house in Florida, plans to move there in 5 years", "husband is in the national guard" and things like that. Those are all facts that not only make a patient unique and memorable, but also may serve as a basis for marketing to patients. Centricity offers absolutely no help in marketing. No field for the answer to "who referred you to us" at the first contact! No field for preferences of referring physicians. No thought of marketing has gone into that system. To market to patients based on patient information I would neede a separate database, and who wants to do that!

Yes, EMR software has the potential to do certain great things, but the real system you end up working with might not do nearly as much as it could. The dream is much better than reality!

So, find out about the systems that are out there, look at their websites and then have one or more demos in your office. I do not have a clear favorite yet; they all have their flaws. “Tops Suite” from “e-MDs” seems good and might be one of the lesser expensive solutions. It includes scheduling, billing and patient records.

I would only get a system that allows me to store all data in the office – I do not want to negotiate with someone who holds my data hostage. Information has to be accessible anywhere (home, hospital.) at any time, preferably over the net. The system should be VERY intuitive to use. Secretary and nurses should enter the demographics and history, and it should take you only a few clicks to finish the rest. The goal is the three click visit.

Patients should be able to request an appointment online or even book an appointment themselves. They should be able to fill out their patient history online, they should be able to fill out the complaint and history part of the visit / encounter form online before they come into the office.

As an alternative it would be nice to have patients fill out a questionnaire on a computer in the reception area or have your secretary fill it out for those patients who prefer not to deal with the computer. This questionnaire should be interactive, so that it asks only the questions that are relevant to the occasion, which could be an annual visit, postoperative visit, Ob visit, problem exam, follow up visit, etc. For each problem the software should ask tailored questions.
These data should be processed to give you a tentative diagnosis and algorithm to proceed, what points to focus on, what tests to do. These data should select (or offer to select) for you the template that you will document the visit on, and consequently also the billing codes etc. The system should offer templates categorized and accessible under diagnosis or treatment or SOAP notes from previous visits to be reused for faster documentation. The system should more or less automatically print prescriptions in the office - or fax them directly to the pharmacy, it should print patient instructions that correspond to the problem or diagnosis or time in pregnancy when the patient presents or age of the patient at the time of the annual visit - customized with name and issues, fill out any forms you may need (disability, booking for surgery, request to have a medication paid etc), fax prescriptions to the pharmacy and - very important for your practice marketing - fax letters to the referring doctor, so that they have the report the moment the patient leaves the office.
All this should be EASY, hear me, engineers, EASY.
The ideal is the “three click visit”. The system should offer alerts and reminders (pathological Pap, mammograms, overdue annuals etc.) and should offer the ability to email patients the results of tests and appointment reminders as well as monthly or three monthly practice newsletters.
The program should also send follow up emails where appropriate to increase compliance, such as more information on Kegel exercises, more information on how to stay health, how to continue to monitor the irregular, PMS, menopausal symptoms etc.
Administrator love to forget that an EMR should make life easier, oh, sorry, let me word it so they understand it, an EMR should make the physician faster and more efficient. An emphasis on safety is NOT an excuse for a cumbersome system that requires clicks and clicks and acknowledgments of pathetic detail after pathetic detail. Safety happens behind the scenes! I drive a Volvo for safety, but the car drives exactly the same as an unsafe car. I do not notice that it has extra airbags and a better suspension and electronic roll-over protection. "Safety" is a very important goal and the software has to accomplish it without annoying us! Software has to make us faster!
And essentially you should never ever have to enter any data twice. It should synchronize with the PDA you carry around and on which you capture billing data in the hospital. those billing data should be effortless be transmitted to the main system. Your PDA should receive your daily schedule including your operative schedule. In the office you should have a wireless network with tablet computers - make sure your EMR program actually can be handled with pen clicks alone!

When you consider buying, don’t fall for high monthly “maintenance” fees, which are just a way of charging you or for an outrageous purchase prices in the range of 100K. Forget the proprietary systems and the Unix systems. See what works and what did not work for colleagues in your area. Most systems are in the range of 5-10,000 per provider or even less and prices should go down in the future. Never buy without a 3 or 6-month money-back guarantee in case the system fails in everyday life. Make sure that you have it written in the contract that you can get your data back for a minimal fee if you do not want the system! Companies tend to abuse you with high fees for returning the data! They know that you desperately need them and take advantage of this.

Go to or org and take a look at an objective website without marketing hype where you colleagues give feedback on emr systems.

Monday, May 21, 2007

Your favorite headache: EMR

Choosing and buying an EMR is difficult, since an EMR always means a lot of work and turmoil in the office and a lot of expenses. EMR companies usually fill pages and pages with "benefits" of using their products instead of listing what specifically their software can do and, very importantly, what it cannot do! That essential piece of information is never mentioned in the glossy ads. EMR prices and functionality vary dramatically from zero to hundreds of thousands of dollars.

Therefore, the first thing to do is to get good info, objective and marketing-free by visiting the website "". This is a neutral site published by a colleague that was and is looking for a good EMR. The site does not promote any particular product, but rather reviews most available ones and gives very helpful hints.

I am presently using GE Logician, now called "Centricity Physician Office" and I was disappointed. I had been waiting and hoping for an EMR for 14 years and when I finally started using it, it was not I had expected.

1. I need more time than before to finish my charts. Most actions require just too many clicks.

2. It was like having a whole new set of paper forms that you have to get used to.

3. Your EMR is not like your paperchart. It was designed by someone else that does not work and think like you do.

4. You often cannot adapt the EMR to the way you think and work adn you can olny adapt it a little. Your boss will tell you: "We try to keep it standardized", which is another way of saying "The programming or consulting time to adapt this program to your needs is too expensive. Suck it up already and get used to what we give you!" One of the advantages of corporate medicine, by the way - you have to adapt to what they give you instead of you adapting things to your likings as it happens in private practice

5. The advantages such as having "access to patient records everywhere including at home" turn out not to be as amazing as you thought. The added work everyday more than outweighs the advantages.

6. My most important issue as a specialist was that I wanted a super-easy way to send a letter or fax or email to the referring doctors. I want to have the report of the visit to be on the desk of the referring doctor as soon as the patient leaves the office. This happens to be very difficult in Centricity with multipe clicks. A consultant has to create the templates you request, every time a change is necessary, a consultant has to do it and so on. You cannot even enter a new pharmacy address because stupid you could mess up the sytem.

7. Centricity does not have a space for email address, for primary care doctor, for cell phone etc. The system was created 20 years ago and it shows.

If I was in private practice I probably would get "Amazing charts", a system that give you the ost value. It was developed by a family practitioner in Rhode Island to avoid being taken advantage of by the IT industry (just my line of thinking). Costs only $1000 for the first physician, $250 for each next one. And it does not matter how many staff members use the program.

Amazing Charts: You can download it and try it for free for three months, and the three months do not begin to count until you have 10 or more patients in the system. Meaning, you can play around with 9 patients as long as you want. Use it with a standard off-the-shelf wireless network, desktop and tablet computers. You can almost do all the installation yourself. Keeps the office frugal. Amazing charts also offers to do your billing for a very good price, which makes sense. Google it and see.

Sunday, May 20, 2007

Marketing your medical practice

This weekend I attended a 2-day seminar in a Manhattan hotel by "Healthcare Success Strategies". It was run by its two founding partners which separated from "Practice Builders" after that company was sold repeatedly.

The seminar had pretty much the exact same content of their 8 CD set from Advanstar, the publisher of Medical Economics. It was so much the same that the layout of the talks was identical, the wording of their talks was exactly identical, and I mean literally identical and even the illustrative examples were exactly identical. They told me that before the meeting, but I was surprised HOW identical it was. I had hoped that the "marketing plan" for my practice would be something substantial, but I am not sure about that yet. The marketing plan is a list of points selected from the numerous things they talk about. The selection itself might have some value, I think it is important what marketing tools to use and what not, but I would probably would have selected the same things on my own if I had made the list. But then, I might not have made that list. Being motivated to actually do it was one of the reasons I went to the seminar.

I had suspected that the CD set ($200) is a way of motivating you to do the seminar ($1000) and the seminar is a way of reeling you in as a client and I was right. My next step is a website for $7000 or a combination of website and brochure for $11,000. Sticker shock! Printing of the brochure, hosting, pay-per-click advertising is all extra of course. Their plan is to start you with at least $2000 a month for the first year. And it goes up from there.

During the CD set they made sure that "a list of ideas is not a marketing plan" and of course "not as effective". During the seminar they make sure you hear that "little details in wording and in graphics may make all the difference", meaning if you want to be really successful, you have to hire them as your marketers.

Overall, their ideas sound very good and feel very real. I have read Neil Baum's book on ethical and effective marketing and it is very similar. The Healthcare Success Strategies guys offer a little bit more. And I believe that they actually have the experience they claim to have and I like their "test, track and adapt" of marketing moves.

I am not sure yet if their claims are correct and if they can be as successful as they say, but I suspect they are right. I am willing to try and see what happens with my practice. I'll keep you updated.

Tuesday, May 15, 2007

The Secret Golden Rules of Radiology

Last weekend while on call I got lost in the radiology department and suddenly found myself in a small, remote, dimly lit room that contained only one large beautifully ornamented bronze plaque:

On top of the plaque it read "The Three Golden Rules of Radiology"

and below:

1. Never let clinicians lock you into a diagnosis, always be vaguely descriptive and always end with the sentence "...has to be decided on clinical grounds"

2. Never exclude the dangerous diagnosis the clinician asks you to exclude. Never write: "No ectopic", "no cancer" etc. Always end with the sentence "(Enter diagnosis clinician wants to exclude here) cannot be excluded"

3. Always recommend another radiological study "for confirmation" or for "further clarification". If the patient has had an ultrasound, recommend a CT, if the patient has had a CT recommend an ultrasound and so on.

I always had suspected this.....

basics for a successful practice

The big idea, the overall strategy for a financially successful ObGyn practice is:

1. Do as much in the office as possible, spend as much time in your office as possible, do as many diagnostic and therapeutic procedures in the office.
Reason: This way you get paid for the procedure plus you receive the "facility fee". You also save yourself the wasted time of patient change over in the OR. It is YOUR office, you are in command and you can streamline all procedures to maximum efficiency. I heard it again and again from successful colleagues: if you can work most of the time in the office and avoid going to the hospital, you earn more.

2. Top procedures to do in the office at this time (May 2007) are:
a. endometrial ablation by Novasure, balloon, free water ablation
b. hysteroscopy, possibly with ultrasound
c. Essure
d. sonography, e.g. saline infusion hysterogram

3. Should you have to go to the OR, then try not to have block time, but try to get the first slot in the OR in the morning for one procedure. This way you avoid the loss of time involved with changing patients, whihc usually takes longer than you need to talk to the relatives and dictate you op note.
Do your surgeries on your on-call weekends, where you can't do much else anyway or have to be at the hospital anyway. Many hospitals allow scheduled surgeries on Saturdays.

4. Learn ultrasound and get AIUM certified, many HMOs require that certification for being able to bill the interpretation of sono pictures. Besides that: the optimal information comes from doing the ultrasound yourself. No still picture can replace that.

5. Learn coding well to maximize your reimbursement, attend courses, listen to your colleagues, and remember - the HMOs are using sophisticated, expensive, highly specialized software to aggressively downgrade your reimbursements no matter what you do. Visit an ACOG coding and billing course (one of those courses that are always sold out)

6. Market your practice like crazy, it pays off tremendously. Read the book by Neil Baum "Marketing your Clinical Practice - Ethically, Effectively, Economically" and follow the advice. You might also consider hiring a professional marketer for developing a marketing plan and for carrying it out. Consider Healthcare Success Strategies. Try the CD set for 200, then the course for 1000. Then you'll know if it works for you.

&. As soon as financially feasible, fire the HMO with the lowest reimbursements and with the biggest hassles (it is usually the same HMO). Repeat as often as possible.

Monday, May 14, 2007

More recruiter comments

CEO, Physician Recruitment and Retention said...

For all of you that read this, get ready as a candidate to pay thousands to the "new" search firm called Actually, the job sourcing they do was invented by and is utilized by EVERY firm that is out there, except that you do not have to pay for it with recruiting firms. Just ask any recruiter out there.

Also, just as he states, watch who you listen to and talk to...having placed thousands of physicians myself and with my colleagues I must admit, even physicians can be wrong.

Lastly most of recruiters are there to serve the following purpose: Do the work you do not have the time to, and do the work as your representative. If Dr. Muenzer is the expert on all recruiters, then I guess he has not talked to very many. The world is full enough of know it alls, and not enough of those that will do all it takes.

Dear CEO Physician Recruitment and Retention,

I am glad to hear a comment to my blog from an actual recruiter.

You are completely correct. The method of sending a professionally prepared CV and cover letter directly to all physicians in your area of interest is old. I started doing it 23 years ago back in Germany. It is being used by recruiters as one of many sourcing techniques, such as direct mail, mass mailing, mass faxing, mass emailing.
That of course raises the question: If you use it successfully why do you never mention it to your customers? Too good for them? Could it be that you are upset that someone is giving out the "secret recipe"?
The method of sending letters to potential employers is probably as old as letter writing itself. To claim it as an "invention" of recruiters seems just a bit short sighted. It reminds me of Al Gore inventing the internet.

I also agree that recruiters provide a service for physicians that do not want to do the recruiting themselves. That nevertheless requires a comment.
Recruiters help employers fill a position. Recruiters usually are called when positions cannot be filled easily through word of mouth or simple print advertising. Recruiters usually do not help physicians search for jobs. They may run a search in their databases to see if a job fits the requirement of a candidate. But recruiters are not hired and compensated by the job searching candidate. Therefore, they do not truly work for the candidate. They do not go out and do mailing specifically for that candidate. They do not help the candidate improve the CV or cover letter. Recruiters recruit for an employer. Otherwise they would be "search agents". Search agents do exist, but are not very popular.

This differentiation between working for an employer or for the candidate might sound like splitting hairs. Nevertheless it is a very important difference: "Whoever pays calls the shots".

I usually teach my residents that they can search actively or passively. With an active search they are in control. Active search includes networking methods such as calling every conceivable contact and talking to every person that is willing to listen to get in touch with a potential employer. Active search means: mailing out your CV and cover letter, faxing it or emailing it to potential employers. Click here to read more details.

Passive search means reacting, reading, listening. This includes reading advertisements, job postings, visiting websites, looking on the internet and also leaving your search in the hands of a recruiter. Once you do this, you are passive, you are responding, reacting, not acting and therefore you loose control and power.

You have to take what you are offered! You do not go out there and get it yourself.
Let me repeat that: You are limited to what is offered to you, you do not go out there and get exactly what you want. You do not create or uncover your own opportunities.

Recruiters love to claim that they "search for candidates". Recruiters usually only search recruiter databases. They search in a database of positions where employers have agreed to pay 20 K to have that position filled. This alone shows that they are not acting in the interest of the candidate. As a candidate I would never dream of approaching an employer with the condition that 20K has to be paid to a third party. That would be completely ridiculous. Imagine me applying to a Harvard hospital stating that hiring me required a payment of 20K. They would refer me to a psych clinic or to their social worker on call. You understand the point?

Mailings cost money. Nobody understand that better than a recruiter. For $1000-1500 I can do a mass mailing myself, for $1500-2500 I can have do it. If I have do it, I am still in command, I still search actively, since they just do the mailing for me. They do not search for me, they just write or improve the CV and cover letter and they have the list of doctors in my target area.
I determine where I search, I call the shots, and consequently, I pay.

And for a whopping $20,000 you can have a recruiter "do the search". Yes, I agree, the physician candidate "does not have to pay it". Formally it does not come out of the candidates pocket. Formally...but the candidate usually ends up paying it anyway. He pays by lowering his chances of getting the job - since he may be competing with candidates that do not come with a recruiter, he may pay by receiving less benefits, maybe even a lower salary. I have commented on that in a previous post. Recruiters do not want candidates to know that. An empployer once said: Sorry I cannot pay you more the first year, since I have to pay the recruiter. After I mentioned this to the recruiter, he answered: "she was not supposed to say that according to the contract". Literal quote!

Recruiters seem so intensly immersed in their recruiter world that they actually seem to believe this "at no cost to you" thing.

The big, huge, overwhelming cost to pay for a recruiter, is that recruiters do not get into the desirable areas. Wherever there are more candidates than jobs, jobs are filled without recruiters. And I have this quote from a recruiter, from one of hundreds I have spoken to. You know it, we both know it: recruiters get paid to fill the less desirable jobs. Period.

And who wants the less desirable jobs?

That is the true price you pay for using a recruiter: you get a less desirable job.

So, you have a choice: Search actively by networking and mass mailing (DIY or or search passively (e.g by answering recruiter calls) and accept a lesser job.

And, as the last point, I have been in touch with many, maybe too many recruiters by phone and email, nice ones and rushed ones, eager to sell recruiters and more relaxed ones, younger and older ones. In house recruiters, retained and commission driven ones. I think I have seen enough in the 6 or 7 years I have been in touch with them to be able to judge.

Maybe I am not a know-it-all, but when it comes to recruiters I definitely am a know-enough. I might even say I have had enough too.

Your Matthias Muenzer, MD

Friday, May 11, 2007

Practice Marketing

You might have maxed out the cost saving measures in your practice. The next step is to grow the number of patients that you like and love working with. Marketing will get you there.

You must buy and or read this book: "Marketing Your Clinical Practice: Ethically, Effectively, Economically", 3rd edition, Hardcover, by Neil Baum and Gretchen Henkel, about $90.

Neil Baum is a practicing urologist from New Orleans. His book contains the sum of all other advice that I had heard before plus a surprising amount of new ideas. No wonder nobody recommended it to me. Every resident should receive it as a graduation gift from the program director. It is an absolute must for private practice. Consultants are not going to tell you much more than what you will read in this book, they just charge you more. Read this book first and then attend the $ 2000 weekend courses (where you will be broadly solicited for more "consultant services").

"Guerrilla Marketing", the now classic text by Jay Conrad Levinson. The standard on marketing creatively and on succeeding against the big guys. Interesting, easy to read, stimulating, you get a lot of ideas and inspiration while reading it. Paperback, around $ 15. He has written numerous books on the subject in all its facets: guerrilla marketing handbook, guerilla marketing for free, on the Internet, guerilla job search etc etc.

"Healthcare Success Strategies" is a marketing company that specializes on private physician practices. They claim to have a lot of experience and success. They sell a good 8 CD set on marketing your practice, which gives you many insights, and also serves as a tool to more or less subtly convince you that marketing is more than a list of ideas and that you should have professionals (meaning to the authors) handle it. They offer a reasonably priced (about $1000) two day seminar (with preparation and follow up home work) to come up with a comprehensive marketing plan tailored to your practice. Take a look at their website, if you like it, buy their CD set for $200 and then decide if you want to go further. I think they are good and worth the money.


It's very strange. I started blogging to share my experiences gained during a job search. While searching I became increasingly fed up with physician recruiters until curiosity and respect had given way to dislike and lack of respect. When I found that it was actually very easy to find just the job you want by mailing your resume out to all doctors in your preferred area I wanted to share this. Nobody read, listened or reacted, except for the few people that do that kind of mailing for a living.
Now I have vented my frustration about recruiters and have moved to other topics. When I write about how to do something better, tips for everyday practice, nobody responds. Is nobody interested in tips to improve your practice? Does everybody just say "Aha, nice, I may be able to benefit from this, and I'll better keep this quiet"
My dream was a blog or website where people share what makes them successful, what makes their practice run smoothly, what makes more money, what doesn't. How can we succeed as doctors? Probably more the question to pose a consultant, not so much a fellow doctor. Doctors seem very very guarded about their success strategies...
But imagine (I could say "I have a dream") physicians sharing their ways to succeed - we wold be incredibly more efficient and powerful on all levels of practice and life.
That is my dream. We all have things that help us succeed, that work well, I am slowly sharing mine, maybe I get a reaction here and there...

When I post something that is "political buzz" then I suddenly get responses. Wow, it's certainly nice to talk, but my life will not be any different if I write or talk about medication politics, malpractice, new laws or guidelines etc etc. When did my opinion, my writing, my talking last change anything?

But if I learn how to run my practice more efficiently, my life will get better.
Actions matter, not talking.

Talk about politics and entertain the audience in the blogosphere, discuss until all Google servers go down, to me it would not make a difference.

Thursday, May 10, 2007

Zillow ! Just in case you did not know about it

Use when buying or selling a home. It’s the best thing that happened to buyers, sellers and in general to real estate in a very long time!
It is a free website with fabulous services, that so far were not available to the public and closely guarded by realtors in order to secure their territory and their income.
Now you are able to see almost ALL publicly available information on a house, an estimate of the current market value called "Zestimate", a list of comparable homes, a graph with the development of the value of the property over the last 10,5 or 1 year, a bird's eye view of the house, a view of the city or neighborhood with little price tags on each house. You are able to see which houses were recently sold ad the selling price, you are able to see which houses are for sale adn there is a feature called the "make me move price"! And the best of all this - no realtor involved! No pesky sales tactics....

Use it when buying to see the estimated value of a home that you are considering together with a list of 10 comparable properties, see what the development of the prices in that specific neighborhood was during the last 10 years and if it is going down, negotiate a little tougher.

You can post your home for sale on Zillow and you can advertise it by posting photos and a commentary. So, sell your home on Zillow and save yourself the realtor fees, which can quickly run into the tens of thousands. For that kind of fee you can show the home yourself and can easily hold a few open houses...
No need to support that BMW driving kid with the motor mouth that is out for the quick cash and other realtor types that make as much as we do with a background of education that can be obtained in a weekend! Their education includes less study material than we needed to pass a single subject in any given year in medical school.
And most of what realtors do is uttering profound sentences like: “That view is georgeous” “Look at this wonderful kitchen”, “Yes, the bathroom has been updated” I very much hope that realtors will fade away like travel agents after Orbitz, Priceline & others came along.

Fee only financial advisors

As soon as you get out of residency - or even before that - you will meet another predator that has his or her eyes trained on the new doctor with sudden increase in income. This predator is ready to take advantage of you.

They commmonly present as insurance salesperson and "financial advisor" wrapped in one. He or she offers insurance, many insurancesIt is completely up to you how much insurance you need, but, for example, you definitely do not need life insurance if you are single. You may need disability though.

Always comparison shop and never sign the first time you meet someone. Don't fall for the trick that life insurance, especially "whole life" is "a great investment". It is, but only for the insurance company and for the salesperson, not for you.

It is a great idea to get a financial consultant, but don’t fall prey to all the insurance scamsters and salespeople that pretend to be "financial counselors". Everybody seems to be a financial advisor, counselor or consultant these days.

I recommend to look for "fee only" financial advisers. They have their own professional organization. Fee-only consultants charge by the hour only. Therefore they are the only advisers that do not have a conflict of interest. Everybody else will tend to sell you something in order to benefit, silently or openly. Insurance people will sell you insurance, brokers will recommend to trade, trade, trade (and make commissions), investment advisers from big firms will recommend the stocks and investment vehicles of their own firms and so on.

Fee based advisers get paid the same no matter what you do, and that is a fee per hour. (At least in theory, who knows if they get kickbacks or not, I assume they do occasionally) But in theory they do not care what you do or do not do. Therefore their advise is more objective and less tainted by personal interest. And therefore more reliable.

I would not work with anybody else.

Wednesday, May 9, 2007

Recommended CME

As an ObGyn working in Boston I like the Harvard courses held in the Four Seasons in Boston called "Annual Update in ObGyn". Presented in spring and fall by the most excellent faculty of Brigham and Women's Hospital and the MGH. I attend every one to two years. You might check for alternatives at Yale, Duke, Cornell, UC San Francisco, etc. These courses allow you to get in touch on a personal basis with the very approachable faculty and you also get excellent materials with the course.

My daily dose of CME comes from Audio-Digest CDs, "the spoken medical journal". I get a CD in the mail every two weeks (it also comes as MP3 or cassette if you are one of those people who drive a Volvo 240 wagon and live in Cambridge). It is the best CME program I have found. The recorded lectures are given by good, renowned, expert speakers, many of them nationally known, on topics that really matter. I listen to the lectures in my car on the way to work and back, over and over again until I am bored. It is a very effortless way of learning, the material kind of diffuses in.

And, yes, I have tried the ACOG audio program. I did not like it, too superficial, not as relevant as Audio Digest for daily practice.

I have also tried and stopped a subscription to the cassettes by Oakstone Publishing in Alabama. They advertise that they scan the literature and select the most important articles, summarize them and comment them. Well, not quite. The selection is by far not as good as the ABOG selection and the comments are mostly simple repetitions of the summaries.

The other best CME is the ABOG list of publications and the corresponding questionnaires. Can't beat it - you keep your board certification up to date plus you get a select list of relevant publications plus you get CME credits.

My favorite other source besides the Green Journal of course, is the throw-away journal "OBG management". The chief editor is Robert Barbieri, the close-to-genius director of ObGyn of Brigham and Women's Hospital, who has an uncanny sense for what is truly important and relevant at any given time.

The best medical database that I consult frequently is "uptodate", written almost exclusively by Harvard faculty. It is very, very readable, precise, evidence based and last not least, up to its name it is up to date. About 500 a year. Uptodate also has some of the best medical information for patients on their website! Direct your patients there to avoid them falling prey to weird internet rumors.

Tuesday, May 8, 2007

WHO list of essential medications

Have you heard of the WHO list of essential medicines, and if so, have you bothered looking at it?

It is a list of truly necessary, not replaceable, basic ("essential") medicines. If you were about to be dropped of in Durfur to establish a general purpose clinic, that is what you would take with you.

Let's look at the birth control pills, which is something that I, as an ObGyn, can talk about: You will find just two, the combinations of EE and norethidrone, to us known as Necon and the combination of EE and levonorgestrel or Levora.

That's it. And let me tell you, it is enough, even for the US. With Necon you have an OCP with a progestin component that has little androgenic side effects, is very well tolerated, generic and dirt cheap. With Levora you have an OCP with a more androgenic profile with excellent bleeding control, which we use in Levora, Seasonale (just a re-packaged Levora, no misteries there), Plan B and Mirena. Also generic, also dirt cheap.

How come there are over 100 OCPs o the market? All "Me too" products, nothing revolutionary new, maybe, but only maybe, Jasmin. So why do the parmaceutical reps fill your ears with "information" about their fabulous new pill with oh-so-great bleeding pattern, side effect "profile" and other utter nonsense?
Plain profit making. Nothing else.

We do not need most of the medications that are not on the "essential list", or we need them only for extremely specialized purposes. We really do not need over 100 different oral contraceptives, since the only thing that makes a difference between them is the individual response of a woman's body to any given birth control pill. And that, dear pharma rep, was, is and will remain unpredictable. You just have to try. During my first residency, many years ago, I asked one of my attendings about what to do if a woman did not like her birth control pill. His answer was: "Just give her any, but really any, other pill". Back them I thought he was rude and maybe even stupid. Now I have experienced that it is in fact true.

Another example: I still prescribe good old Ibuprofen for pain. It is cheap and it works every time. And the fact that I never prescribed those fancy new cox-2 inhibitors saved me a few sleepless nights when some of them were withdrawn from the market.

My other rule about prescribing medications is:
If I see it on TV I don't prescribe it. My patients would just be paying for the TV ads. Also, if a phrama rep comes to my office and pitches a medication, I don't prescribe it. It has to be expensive, if not they would not pay for a rep to come over. And of course, most of the meds they pitch are "now tier 2, and only with such and such insurance tier 3, but we are working on that"...

So, take a look at the WHO list of essential medications and see which meds in your field are essential! And which ones you can do without.

Monday, May 7, 2007

what well paid lobbyists can do

WASHINGTON (MarketWatch) -- A Senate vote on Monday likely assures that U.S. borders will remain shut to lower-priced prescription-drug imports, marking a major victory for pharmaceutical manufacturers.
The Senate voted 49-40 to approve an amendment to a bill dealing with the Food and Drug Administration, which would require the secretary of the Health and Human Services Department to certify that drug imports would pose no safety risk to American consumers before allowing pharmacies to import prescription drugs from Canada and other countries. Health officials have said they can't provide that level of assurance.

Thank god, the drugs from Canada cannot come into our great safe and well protected country! I must have missed those newsflashes about the rampant deaths among the elderly, the children and in general the frail in Canada following ingestion of Canadian drugs...
We all know that the difference between drugs in Canada and the US is just the price (and the profit for the manufacturer). The drug manufacturers are the same in Canada and here, the production standards are the same, the hygiene standards are the same, the pharmacies have the same quality standards! Hey, this is Canada - we are not talking Afghanistan here.
But, the profits are less in Canada, and we cannot let that happen! So, the pharmaceutical companies give a few millions to lobbyists, and voila, the billions of profit continue to go into pharma's pockets.
This is a point where the HMOs should flex their muscle. Where were they when we needed them? Why have they not paid their lobbyists enough? Where were their millions?
This kind of obvious corruption is sad. Laws are maid by the wealthy and for the wealthy. Realistic, but very sad.
You understand now why I do not see pharmaceutical representatives? they get paid by the very same people who pushed this law through. Not only do pharmaceutical reps waste my time, they consistently overcharge my patients. And that is harmful.

patient education leaflets

The first choice for many are the ACOG leaflets – more expensive than other solutions, but they are “the standard” and therefore always defensible in court should an issue arise. They look nice, fit into most purses, can be conveniently kept in wall hangers - even in small examination rooms. They are just the best.

Significantly less expensive than ACOG leaflets: a subscription to “MD-Consult”, which is only $220 a year on the net. This service not only gives you a large amount of textbooks, journals and pharmaceutical and pharmacological information, but (and this is the great thing that alone makes it worth the annual subscription) it gives you access to about 3000 (!) patient instructions, very well written, a good number also in Spanish. Often they have a short and long version of the same topic. I print out the instructions leaflets, copy them and keep them organized in my drawer, so that I can hand them to patients as needed - without having to log on and print them out each time. Loggin on, selecting an printing is very tedious in I dropped the subscription due to this. Printouts can be personalized with your name and office address. Advantage: price. Drawback: plain black and white printouts, no graphics, no colors.

Easiest, cheapest solution, but it feels somewhat dated: Miller, McEvers, Griffith: “Instructions for obstetrical and gynecological patients”. Now in its third edition, $50-60. You are specifically allowed to copy all pages and hand them to your patients. The book comes with a CD that you can load onto your computer. It lets you easily print out all 200 plus patient instruction leaflets. The book also includes diets and illustrations. A steal. Has proven to be extremely cost effective.

Write your own leaflets and information material! This is probably the best way. You will have tailored and customized information from your practice. And, your patients will first hear it from you and then read the same information on a paper at home (hopefully). This achieves maximum retention and effect. This also eliminates mixed messages or confusion when you say one thing and some website recommends another thing.

I recommend not writing leaflets by a list or on demand, let's say, in response to the thought, "Well, what leaflets might I need?" and then sit down and write them...NO, do not do that. I recommend a different approach: as soon as you realize that you are explaining something several times, as soon as you find yourself talking about something repetitively, you simply write down exactly what you just said. You use spoken language, simple terms. Voila, your leaflet is done.

Then continue to correct and expand it with time, as the additional questions and ideas arise.

This is also the best way to write a practice newsletter. Write down the things you explain to your patients, or the things you would love to explain, but do not have the time and mail them out or email them out every so often. Nobody says that a practice newsletter has to come out every three months. Write them and mail them as the issues arise. For example in late 2006 it was HPV, and the answers to the questions " Do I need an HPV test? Do you recommend the HPV vaccine?"

Post this information on your website. A good place to keep the original files or master files is in "Google Docs and Spreadsheets"

I have used all the above in the past, and presently, based on my experience, I use a combination of my own leaflets and the ACOG leaflets.

Saturday, May 5, 2007

basic financial information

Get a financial education. Where do you start? Do you invest in stocks? How do you pick the right stock? Do you do the research? You are able to invest hours and hours into looking into companies? I constantly felt overwhelmed by the choices of stocks. I thought funds would be a good idea, more balanced, a bit more diverse, more stable, easier to research than individual companies. I invested into mutual funds that performed high the previous year, and shockingly, the performed below average the year I bought them. Then, by chance, I ran across the following book and absolutely loved it. It provided a completely new perspective on stocks and funds, it made a lot of sense and it seems to make investing very easy, more a place and forget thing:

"The Only Guide to a Winning Investment Strategy You'll Ever Need: The Way Smart Money Invests Today"
by Larry E. Swedroe

20 dollars that might save you thousands and make you much much more. Swedroe lays out, in a kind of evidence-based way, the "modern portfolio theory" and the "efficient market theory". The "efficient market theory" states that the stocks on present day markets are always efficiently priced, that there are no "hot secrets", no undervalued stocks that you can capitalize on. The reason is that thousands of full time analysts are constantly combing the market, examining and evaluating companies. It is close to impossible to beat the market by purchasing specific stocks. Stocks are priced right.
And, you cannot predict how the market will move in the future. Short term developments are literally random. You cannot know more than the market, especially in the long run.

The "modern portfolio theory" says that index funds perform better than individual stocks in the long run. Index funds are the best performers, better than any personally managed investement fund, better than "aggressive growth funds" in the long run. The index funds grow in the range of 9-11% on average, long term. Just for fun, check the performance of the Dow Jones against your personal performance. Did you beat it consistently over 15 years?

Why is trying to score with individual stocks in hopes of "beating the market" generally believed possible? The media and brokers make a very comfortable living using and spreading this misconception. Imagine if everybody just invested their money in index funds and let it grow - brokers and media types would have to look for new jobs...They have zero interest in telling you that index investing is better than what they offer...and cheaper.

Only rare, select managers beat the indexes over the long run, but chances of you personally investing their money with them are minimal. On the other hand, your chances of under-performing are vast. Index funds offer an investment vehicle that is incredibly and unbelievably easy. Almost no research required (after setting them up) and very rewarding. There are quit a few indexes, some of which are more heavily weighted to large stocks and others to smaller stocks. There also are international indexes. It seems important to maintain diversification among various asset classes, but the book explains that nicely. It also teaches how to build a portfolio.

It seems easier and better, why not check it out?

Thursday, May 3, 2007

My favorite patients

When I started with my new call group I was surprised to receive one or two calls almost regularly every Friday late afternoon about 1-2 hours after taking over that sounded like this: "I am / my daughter is in excruciating pain, we have called the office (of the doctors I am covering for) severla times today and nobody has called us back. The pain medicine Dr....has prescribed is not helping / doesn't touch it. Is there nothing you can do?" and somehow the conversation would always turn to the perception that a narcotic prescription really would be the only acceptable solution to the caller's "excruciating" pain.

Initially I was annoyed at the negligence of my colleagues and attributed it simply being very busy. Sometimes prescriptions are forgotten, or not picked up by the pharmacist etc.
Then I collected the names and phone numbers of the callers and asked the "forgetful" colleagues about these callers. It turned out that they in fact had returned all those calls, but simply had not seen a good reason to prescribe the desired narcotics. And, as we all know, "Ibuprofen just doesn't touch it". Not only had my colleagues answered all these phonecalls, they had also informed their patients about their policy of "no narcotics on call or outside of office hours" - a policy that I now happily quote to those callers.

As it turned out, one patient was particularly tenacious in her requests for the comforting Vicodin. Her request was denied by my colleagues during office hours and, sicne she lives hours away, she was told to go to a local ER. So the ER calls me about this patient. All I could do is to relate my experience: She has called me multiple times after hours, she always requests Vicodin, I have never seen her nor examined her in person, and she either tells me she is about to have surgery for pelvic pain or she just had surgery for pelvic pain.

My hopes that this would be it for the evening were disappointed. The patient herself called me after receiving a prescription for ibuprofen, furiously reprimaning me about "giving the wrong information to the ER" " that made them not give her the right pain medicine" and that she "had to wait in the ER for hours with three children" and on and on. The next time I spoke to my colleagues I asked them to consider releasing them from their practice. The next time she called, I reminded her that restricted substances are restricted for a reason, that she should go to the local ER and that I could not do anything for her long distance over the phone (she lives hours away, God knows why she is still in my colleagues' practice, I can only suspect the reasons why she has not been able to find a local doc). I am waiting for her next call, for now it has been quiet.

I also love those prescriptions that are forgotten far away in the next state, where the patient did spend the weekend (apparently the "excruciating pain" does not prevent them from traveling for hours and hours).

I love the stories where prescriptions are forgotten on the bus, in a pub or in other public places. I personally would stash away such a valuable prescription in a very safe, deep pocket that I would never had a chance of loosing it. Strangely, narcotics precriptions seem to be the only ones that are teated with such neglect that they disappear, since I have never heard that an Ibuprofen prescription has suffered such a fate...

The patients that request those prescriptions usually tell you that you are the "best doctor in the world" and frequently mention that their last doctor "was just not a good doctor" who did not take good care" of them. I simply do not understand that they abruptly leave and never come back to the "best doctor in the world" once I explain that I do not prescribe narcotics more than once...

I also am surprised that those patients seem to lack the most simple and basic ability of foresight. You know that you need narcotics, you see that the bottle is almost empty for days, and you do not call your doctor's office during the day, but call me after hours??? As if you didn't see that coming?

Wednesday, May 2, 2007

Art in your office

What's on YOUR walls? Those Mediterranean motives painted in fake impressionistic style usually sold to mass tourists on side walks, now available at your trusted Wal-Mart? That style of "art" that seems obligatory in medical offices if you believe your local decorator? You know, those pictures of Portofino, Lago di Garda, Lago di Como...

Try the following low cost – high style alternatives:

Nicholas Nixon “The Brown Sisters”. Shows 4 Massachusetts sisters as photographed yearly by one of their husbands over a time frame of 27 or 28 years now, one photo each year. A wonderful series – very suitable for an Ob/Gyn office. Buy 2 books for $39, tear out the pages and frame them. Or pay 100 K for a signed original 25-image-series available in a NYC gallery.

Take a look at the following artist websites (and remember that taste is subjective):
Photographies by Emerson Matabele

One great photographer, whom I happen to know in person, and whose art I have bought without regretting it one second is Martin Berinstein. Take a look at his photographies at

Dry pigment paintings by Diane French who has studios in La Crosse, WI and St. Augustine Beach, FL and

Ansel Adams never hurts either.

Should you have an Ikea nearby, they have very affordable framed and unframed art…

For nature images of the Everglades and Florida look up Clyde Butcher, who for me comes close to Ansel Adams. He photographs South Florida and its beaches, the Everglades, and the Big Cypress Swamp. On his website take a look at the “posters” section - for $40 you get excellent images…

Also good is Debby Krim, a photographer in Boston, whose work can be seen at She has excellent plant and nature photographs, she uses photographs in an innovative way by placing them on small rectangles and then combining many of those small rectangles to bigger pictures. This open almost unlimited possibilities for your office

I have the privilege to live in Boston (a privilege for which I pay dearly with lower income and higher malpractice rates) and we have a fabulous thing called "open studios". These are events, usually weekends, where many or most or all artists in one part of the city open their studios to the public. They even offer wine, mineral water, crackers, sometimes music and always conversation. Truly a wonderful thing, I love it. I consider it one of the best sides of Boston. If you are anywhere near the city look in the Boston Globe or on the Boston Globe website or google the term "Open Studios Boston" and visit...

Be different!


I am by far too serious in this blog, no wonder nobody is reading it. I just wandered around from one blog to the next finding fascinating, funny posts from ambulance drivers, ED nurses, medical students, all soo true and funny. I still remember the situations they describe, the weird and funny patients, the thoughts that I thought should never be published, but hey, here they are, readable for everybody.
Maybe I should stop blogging. Or maybe I should continue since this blog was created less for entertainment - I am not that funny, I know - but to post "what I wish somebody had taught me before I made a mistake or wasted my time". I guess I'll continue. And now I'll go and have some lunch, it is 12.38 and I hear the nurses laughing in the lounge of the office.

Medical Malpractice 3

Posted by Anonymous on Monday April 2nd 2007 as a comment on one of Flea's posts concerning medical malpractice:

"Human nature's a bitch, isn't it? Good doctors get sued, sometimes with little justification; sometimes the get away with an understandable error of judgement that teaches them to be a better doctor, but leaves some poor smuck with a life long problem; bad doctors sometimes get away with it because patients are ignorant of what really happened, or don't want to sue. A recent Harvard (I think) study showed that the "compensation culture" is a myth, as most people who were treated negligently either did not pursue claims, or were unsuccessful, and some people whose cases had no merit won. The system is a mess, but how can it be sorted out?"

This points out a problem of our system: Most people who suffer a "damage" are not compensated and on the other hand some that are treated correctly are compensated unnecessarily. The system "is a mess", and there is a way to sort this out.

Instead of a court system we need a administrative claim system. Should a patient feel treated incorrectly or damaged, he or she should be able to submit a claim for compensation - similar to Workman's Comp. Patient will be examined by one or two or more physicians, the report will be reviewed by one or more experts, who will award a compensation or not, according to documented lists.

This removes the "fault", the blame, the court, the heated emotions and the lawyer profits. It is shorter and more conducive to open communications between physicians and patients, and more conducive to data collections about complications.

More patients would be compensated, we would learn more about complications and how to avoid them.

This "mess" is actually not difficult to sort out, so ....Why do we not have such as system?

Because our lawyers do not want to give up the "golden goose". That's what is wrong, that's where the problem is. Lawyer greed prevents solving the mess. The lawyers working as politicians in Washington do not want to hurt their buddies by taking away the profitable medical malpractice system that has financed many a second and third villa, boat, luxury car etc

Also, physician do not have a lobby as well funded and powerful as the industry lobby that pushed through Workman's Comp!

Lawyers preserve a system that is inefficient, expensive and slow, not because it is just, fair and good, not because it is the right system, but because it makes them wealthy.
I am not just unhappy about the "lawsuit culture", I am unhappy about a flawed system that might benefit the lawyers more than the injured.

I want "Patient's Comp". Or let's say "Mother's Comp" for obstetrical complications.

Tuesday, May 1, 2007

Medical malpractice (2)

I am following Flea's malpractice story and the many comments about his posts.

When doctors complain that lawsuits are often "about the money", we are very aware that we all work for money. That is fine. And that is not what we mean. What we mean is that the financial incentive, the possibility for a large financial gain sometimes is the primary incentive to start the lawsuit. It is a chance to cash in, nothing else. Sometimes it is not about truth, justice and all that. We are not saying that lawsuits should not happen at all, we are not saying that all lawsuits are unjust and unfair. But we are saying that too many are unfair. 75% are decided in favor of the defending physician. What does that tell you? Successful, experienced lawyers will tell you that they review 10 to 20 claims before they take on one single claim! And of the ones they take 75% are not successful. Does that explain why physicians feel threatened and overall treated unfairly? Any more questions?

Example: A patient of mine tried to sue me and spoke to her primary care doctor about the situation. She told him: "I like him, but we just need the money". It could not be clearer! It could not be more plain and blunt! "We just need the money". What a great reason to sue a doctor! And this actually happened to me.
This attempt, by the way, never went beyond a request for medical records. Unfortunately for her, my documentation of our talks before the surgery was extensive.

Physicians do not say that lawsuits always are about money only, but it is sometimes. And this is very upsetting to us.

I did a little statistic of 120 ObGyns in South Florida that belong to one large group. Some of them practice in Miami Dade and some practice in Broward and some in Palm Beach County. The colleagues in Miami Dade work without malpractice insurance and the others work with malpractice insurance. Six % of the colleagues WITHOUT malpractice insurance had paid money after a judgment during the last 10 years and 19% of the colleagues WITH malpractice insurance had paid money after a judgment. Coincidence? I do not think so. More research is definitely needed. This is difficult, since (unfortunately) there are not many areas where you can practice without liability insurance.

Here is some anecdotal evidence, gathered through conversations with several lawyers in South Florida. I came to realize that lawyers are very, very hesitant to sue someone who does not carry malpractice insurance. Can’t get the millions! Representative quote of those conversations: “I did it once and I could not collect, so I worked for months and months for nothing. I will never do that again.”
Lawyers will not try to sue if there is no chance of a big cashout. They will rather tell clients that they "do not have a case”.