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 mdconsult.com. 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.
Monday, May 7, 2007
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?
"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?
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 http://www.emersonimages.com/
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 www.berinstein.com.
Dry pigment paintings by Diane French who has studios in La Crosse, WI and St. Augustine Beach, FL http://www.statestreetgallery.com/ and http://www.canvascompany.com/
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 http://www.clydebutcher.com/ 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 www.debbykrimphotography.com. 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!
Oh
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.
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
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”.
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”.
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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?"