Monday, March 31, 2008

Experience from the outside-

Anyone who reads this blog on a regular basis, knows I have not posted for a while- I have been quite busy, but check back occassionally and discovered an e-mail from an internist stating "Dear Doc,It's not called the American Trial Lawyers' Association anymore. It's been renamed the American Association for Justice. Is that hilarious?" Brian McCarty is an internist who has a website and I actually found it quite interesting! Below is something I pulled from the home page... Thanks, Brian!!
Posted 3-22-08
Doctor, before you performed the autopsy, did you check the pulse?
Did you check for breathing?
So, it is possible that the patient was alive when you began the autopsy?
Well, let me put it this way. The man's brain was sitting in a jar on my desk. But I guess it's possible he could have been alive and practicing law somewhere.

So how are those statistics?
So many reports/studies, etc. has gone into figuring out why it's such a difficult task- Everyone tries to find solutions, everyone has answers and thinks they know the "real" issues. As you will see, below, I have found yet another source defining those issues- This came from The Hospital & Health System Association of Pennsylvania. While all of this information seems very accurate, I would LOVE to know why we can't come up with reasonable solutions- across the board.

Many Roles and Responsibilities
The hospital emergency department is the first place that people turn to when they
have an injury or illness that needs immediate attention. It also provides much of
the medical care for patients without medical insurance, or for patients whose
physicians are unavailable evenings and weekends. Emergency departments are safety nets for those with
behavioral health problems, a safe haven for communities in times of disaster, and many are designated trauma
centers prepared to treat the most serious and complex health care emergencies.
• The number of visits to
emergency departments has
increased nationwide by 28
percent. However, the number of
emergency departments available
to meet health care needs has
declined, with 437 emergency
departments ceasing operations
nationally during the past 10 years
(1997‐ 2006).
• In Pennsylvania, the number of
emergency visits increased by
more than 21 percent, while the
number of available emergency
departments decreased by 17
Emergency Care Trends Strain
the System
• Emergency departments are used more frequently than physician offices by Medicaid, self‐pay, and charity care
• People without health insurance access the emergency department for health care and they often wait until
they are very sick before turning to the emergency department for help.
• Elderly patients with worsening chronic conditions use the emergency department because of ongoing needs.
• Driven by the closure of state psychiatric hospitals, a decline in inpatient psychiatric beds, and low
reimbursement rates for mental health services, a growing number of seriously mentally ill patients are going to
emergency departments.
• The growing threat of a disease outbreak or terrorist attack raises public expectations of the role of emergency departments in their community.

Over the weekend I had my own ED experience and it was not pretty. Since I write about how people abuse the emergency department, I think it has almost been dangerous for my loved ones- I don't react. So... maybe some of you have experienced this:
daughter: "Mommy, my stomach is KILLING me"
me: "you will be fine- do you have a test tomorrow?"
daughter: "MOM, NO- I really don't feel well!"
me: "well, you will have to tough it out- I don't feel well either, but I still have to work- you are going to school tomorrow! You better go to bed. Sleep will help."

Later in the evening, she starts vomiting GREEN BILE and it goes on for HOURS- I am now absolutely CONVINCED that it's food poisoning- She had Salmon earlier in the evening and I am convinced it was a bad piece of fish. I encourage her to "puke" thinking she is going to have a rough couple of days, but will be fine-
2:00AM- daughter " I AM GOING TO DIE- DO something MOMMY"
me "I am begging you.... pleaseeeeee let me sleep- just for two hours! If you want me to be there for you tomorrow, I NEED to sleep"
3:00AM I begin to realize this must be more than food poisoning- She is becoming dehydrated and I am feeling like an ass-
4:00AM I finally decide to take her to the local emergency room- (where I don't know ANYONE)
5:00AM get to the ED, go to Triage and there is absolutely ZERO waiting!!!! I was BEYOND impressed! I was planning on coming directly home once this was over and blogging EVERYWHERE about how SUPER this hospital was!!!
6:00AM- waiting in room for an hour, daughter still in horrific pain, FINALLY Dr. #$%^&* enters the room- Checks her belly, orders Ultra Sound- (pain in upper right quad, no fever) Orders Morphine for pain- it doesn't help. We move on to Dilaudid- finally SOME relief.
10:00AM- (have not seen Dr. since initial visit at 6am) Ultra sound is neg. He decides to order CT Scan- tells me he doesn't really think anything will come back- but you know, "just to be safe" we should do it.
She starts to drink contrast- 12pm- FINALLY go to CT Scan- 1:00 DO OVER... not enough in her system... more contrast- more waiting-
I could continue on and on... bottom line- It took this emergency dept. sixteen hours to figure out that my daughter needed and emergency appendectomy. She finally went to surgery at 10PM- and was FINALLY in a room at 1am.
Of course I must add- my daughter's VERY first words after arriving to her room post op
"AND YOU THOUGHT I WAS FAKING IT" Was she trying to do me in for good?!!!!! AHHH!! Anyway- After ALL of the time spent working in Emergency Depts, with ALL kinds of medical staff, was THIS my PUNISHMENT?! Even as I write this blog, I am dreaming of the words I will write to hospital administration-
I guess I need to take people more seriously vs. dismissing every ache and pain- we could have been in BIG trouble!!! I am sure she will NEVER let me live this one down!!!

Wednesday, February 20, 2008

Doctor? Doctor? PA’s can now be called Doctor

Is this right answer for the workforce shortage in EM? Keep your eyes open as new developments unfold. This may be the solution that face rural ED’s and difficult to staff locations where malpractice is still an issue. It is unlikely to think that resident education will be effected but as usual instead of focusing on our issues we will waste endless energy in discussions about purity. Is purity the issue or is treating the masses that flock to our door our mission? As a specialty we will debate and never decide, post in our camps but I welcome all with open arms who want treat the growing number of patients with narcopenia, the febrile Tylenol deficient babies, and the non-ambulatory elders who have lived too long because of science.

Please note new classification for emergency med and orthop PAs
An article posted in Advance for Physicians says: There's a new PA degree in town, and its name is "Doctor."
The U.S. Army and Baylor University have created the first clinical doctorate degree for PAs. Army PAs will receive a doctor of science physician assistant (DScPA) degree after successfully completing an 18-month residency in emergency medicine at Brooke Army Medical Center at Fort Sam Houston in San Antonio.
The first four DScPAs will graduate in a few weeks, followed by a fifth in early 2008. Eight more Army PAs began the 18-month program in July 2007, and 10 are scheduled to start in July 2008.
"The Army needs more emergency-medicine-trained, trauma-trained PAs for the battlefield," says Maj. Leonard Gruppo, MPAS, PA-C, who is the director of postgraduate education for the U.S. Army. "It was difficult for us to ask PAs to go through 18 months of incredibly rigorous, demanding training and then give them a certificate, as was done with our previous 12-month residency upon which this is based, and is done with almost all postgraduate (PA) residencies.
"We wanted to recognize their training and expertise, and there is no other way to do it right now. There is no board certification for advanced (PA) training or specialty certification (for PAs). There's no way to recognize advanced training in a way other people (outside the PA profession) would understand. We feel that the training is doctorate-level. When we compared (the PA doctorate program) to (doctorate programs for) other professions such as pharmacy or physical therapy, it compared favorably. This (PA doctorate training) is even more robust than many other (doctorate) programs."
The Army conceived of a PA clinical doctorate program in 1999 and began development of the initial program in earnest in 2003. The Army plans to convert all of its PA residencies in emergency medicine and orthopedics to doctorate programs, Gruppo says.
In addition to being the appropriate degree for advanced clinical training, these PA clinical doctorate degrees should also be a strong incentive for PAs to remain in the military and possibly for civilian PAs to consider military service, Gruppo says. The Army needs a large number of well-trained and experienced PAs to care for soldiers injured in combat.
"We did a study of Army PAs and two-thirds of the respondents said that the availability of these (doctorate-level PA) programs would significantly affect their decisions to stay on active duty," Gruppo says. "That's a pretty enthusiastic response."

Sunday, February 17, 2008

ED Management- Interesting recent article...

I am always searching for recent information on patient claims, statistics, etc. and stumbled upon this article. The numbers were a bit surprising- 22,000 preventable deaths directly related to pneumonia and heart attacks??? As it turns out, seems that documentation may be the real issue. I understand RVU and I understand the need to move patients through the ED as quickly as possible, but isn't there a better way? The numbers are frightening- screaming patient claims!! Who is managing your documentation? With the shortage of emergency physicians, the pressure to move patients up or out (see Movin' Meat) combined with paperwork, documentation WHY do so many people who are clearly NOT ill visit the ED?! Don't they know?? They are putting themselves at greater risk visiting the ED vs. ignoring their ear aches, stuffy noses and headaches!! Maybe we should send out e-mail blasts to everyone with some statistics, urging them to eat chicken soup and visit their family doc.

Study Claims EDs Fall Short on Pneumonia and Heart Care
ED Management
January 18, 2008
According to a new study by Johns Hopkins researchers, Emergency Department (ED) managers and their staffs are doing a poor job of treating pneumonia and heart attack patients.
In fact, the authors of the Academic Emergency Medicine article say that as many as 22,000 preventable deaths occur each year in the United States because EDs across the country aren’t meeting national goals.The researchers looked at the records of 1,492 heart attack and 3,955 pneumonia patients treated at 544 EDs between 1998 and 2004.
They found that only 40% of eligible heart attack patients received recommended aspirin therapy, and only 17% received recommended beta-blocker treatment; and among pneumonia patients, only 69% received recommended antibiotics, and 46% had blood oxygen levels assessed, as recommended by the American Thoracic Society.
However, ED observers assert that these numbers paint an inaccurate picture of care given in EDs, and that by and large it is poor documentation—not poor care—that caused the statistics to appear so disappointing.
“Once core measures started to be introduced, CMS (Centers for Medicare & Medicaid Services) would come to us an ask why we were not giving aspirin (to heart attack victims),” said Kevin Klauer, DO, FACEP, director of quality and clinical education and the Center for Emergency Medical Education with Emergency Medicine Physicians (EMP), a Canton, OH-based provider of emergency medical services.
“We discovered that in every hospital, there was some component of sampling that was to blame,” he added. “For example, EMS might have already given the patient aspirin, or they had taken it before arrival and the chart abstractor either didn’t know to check that or just didn’t do it.”
Certainly, some areas are documented better than others, says the study’s principal investigator, Julius Cuong Pham, MD, an assistant professor in the Department of Emergency Medicine at Johns Hopkins University School of Medicine, Baltimore, and a practicing emergency physician.
“But if a patient gets an aspirin, the medical record is a legal document,” Pham said, “so if you give someone aspirin you had better be sure you document it—the same thing with beta-blockers.”
For other variables, such as pulse oximetry, Pham concedes that the physician could just measure it, determine it is normal and not write that down. “What percentage (of reported errors) is due to documentation? We don’t know,” he said.
Klauer’s own documentation, he said, shows good compliance when it comes to aspirin. “Two years ago, we went to physicians checking charts and came up with different numbers than the hospital (was reporting),” he said. “We have physician reviewers review their peers’ charts. They know to look in a specific part of the chart.”
The numbers for all of his practice have been about 99%, with beta-blockers at 96% to 97%, Klauer said. “We have a quality director at every site. These statistics are measured quarterly and annually and compared to the other facilities, and the doctors are partially compensated on that basis,” he said.
This incentive-based compensation plan puts a certain portion of the physician pay at risk, and of that portion, 5% to10% is assigned to quality, Klauer said. Pham and Klauer agree the most controversial measure involves antibiotics. Pham said, “There’s a lot of controversy in the ED as the whether four hours (from admission) is appropriate, versus six or eight hours.”
There isn’t a single piece of controlled literature that assigns a specific time, Klauer said. “So, we may appear to not be in compliance because of flawed parameters, but we certainly won’t let our doctors practice bad medicine.”
Pham and his colleagues recommend the creation of systems in the ED to minimize whatever lapses in care are occurring. “Standardized protocols are shown in the literature to be effective,” he said. “For example, every patient with acute MI or chest pain gets aspirin and beta-blockers as part of their care unless it is contraindicated.” The nurse should serve as a check and balance by ensuring the doctors are following the protocol.
There may even be a role for IT, Pham said. “If you have a diagnosis of heart attack and you are about to log off without giving aspirin, a red flag may pop up. This takes the individual caregiver out of the equation,” he said. “The ED is very hectic, and it is not unreasonable to forget something. We need some warning feedback.”
Any performance feedback should be easily visualized, Pham added. “It could be a blinking light on the computer screen, a red flag on a chart. The bottom line is, these errors are likely lead to patient harm and death, and whatever we can do to improve on that will affect the health of patients.”
Klauer said, “If patients are getting aspirin 44% of the time, we are doing them a huge disservice, but I don’t believe that is happening.”

Wednesday, February 6, 2008

Walmart Solution to Patient Communication

Since when has a solution to one of our most difficult challenges been as simple as a trip to Wal-Mart? Ask and I will tell you a fascinating story about the Patient Communication Board and how it improved the customer service comments and made the concept of informing patients a teamwork process.

The problem we were facing was not new to ED or the culture of medicine. Our patient satisfaction was great except our survey tool highlighted that our patients felt uninformed and that the physicians and nurse didn’t spend enough time in the room. We decided to put a dry erase board and a marker in each of our patient rooms and call the process a “Patient Communication Board”. Each shift the nurse who has been assigned that room writes his or her name and the physicians name on the board. Throughout the course of the visit, the patient is updated by writing information about pending lab studies, test results, expected time of admission or disposition. This process takes about an extra 3-5 minutes of nursing, doctor or ED tech time. The cost of a board and markers is about eleven dollars per room.

The initial ED physician and nurse complaint phase about the new process lasted several months. We continued to stress a culture change around the importance of patient communication. After the process became second nature, we found that our patients were writing in the survey comment section that they felt they understood their diagnosis and the physicians and nurses were working together to keep them in the loop. Our surveys were being returned with compliments that identified the physician and nurse. This allowed us to reward specific individuals for their exceptional patient care.

Another unexpected benefit was a decrease in communication stress between the physicians and nurses. The updated Patient Communication board allows our doctor to walk into the room get information without having to locate the chart or the nurse. This increased foot traffic into the patient’s room improved the patient’s sense of well being. Overall this program was a success for our staff and the patients.
Low cost problem solving, culture change, and better patient care can start during a simple trip to Wal-Mart!

Monday, February 4, 2008

Physicians Practice Articles : Should You Outsource?

An interesting article about outsourcing by Physicians Practice-
Should You Outsource?
Getting Help Out of HouseBy Gregory Mertz
Few family physicians would argue that managing the business of medicine is more challenging now than ever before. Practice revenue is flat, or in some markets, declining; practice expenses, such as staff salaries and malpractice premiums, continue to grow; and the burden of government regulations, such as HIPAA, CLIA, and OSHA, are more onerous than ever.
Most physicians have a team of trusted advisers, such as an attorney, an accountant, and an investment counselor, who regularly assist them with personal and business issues. Yet when it comes to running the day-to-day aspects of their medical practices, physicians depend heavily on their own skills to make key decisions. But increasing business demands may well exceed the desire, available time, or the ability of many physicians in their part-time role as owner/manager of their practice, even with the assistance of an office manager or administrator.
To respond to this gap, more practices are electing to contract for management services with outside organizations, such as management services organizations (MSOs) and local consulting firms. How can you decide if such an arrangement can benefit your practice?
What to outsource
Contracting for management and support services is not a new concept for the healthcare industry; hospitals have been doing it for years, for services that range from placement of the CEO to food service and janitorial management. Medical practices now have a growing menu of service options as well.
Not all practices can benefit from outsourcing, and not all services need to be outsourced. The first step is to decide what aspects of your practice, if any, are good candidates for outsourcing. The services mentioned below are not the only ones available for outsourcing, but they are the most common for physician practices. Use the following questions to help focus your thinking. If you answer "yes" to most of the questions, it will be worth considering outsourcing.
Billing• Is your overall collection rate declining? • Are your accounts receivable (A/R) too high?• Are you experiencing an increased number of denied claims?• Are you facing a major investment in new hardware or software?• Are you finding that the number of staff needed to get the job done is growing?• Is turnover requiring too much time and attention?
Payroll• Are you concerned that payroll information will be shared with staff members who don't need to know? • Are you unable or unwilling to spend the time, or add the staff, to manage payroll internally?• Are you routinely paying penalties associated with late tax deposits or periodic reports?• Would you like to have access to more advanced payroll services, such as direct deposit?
Management• Are you unable to find the right person to help manage the business?• Do practice demands keep you from monitoring your manager's performance?• Do you have the sense that the staff is running the practice - not you?• Do you periodically need access to higher level advice than your current management can provide?• Are you planning to expand or contract the practice?• Do you have multiple people performing tasks that could be handled by a single, more experienced manager?• Do you feel that your practice's cost structure is too high, but you can't determine what to do to resolve those concerns?
Information technology (IT)• Have your data needs exceeded your capabilities?• Are you unaware of solutions that may improve practice performance?• Are the growing costs and hassles associated with routine upgrades a growing concern?• Are hardware problems causing disruption in practice operations?
How outsourced services work
Once you have decided to outsource part of your business, it's important to find the best possible contract. Costs and terms vary widely based on what you want done, but here are some general guidelines.
Billing — While some billing firms provide a "one-size-fits-all" approach, many are offering options that allow practice staff to perform some of the tasks and permit physicians to access data and reports online. This flexibility can be an important feature for more sophisticated practices.
Most billing service companies charge a percentage of the funds that they collect on behalf of the client practice. Fees are affected by the size of each claim, the number of monthly claims, the scope of tasks provided, and the payer mix.
Be sure to talk about performance standards in your contract with a billing service. Fees should be tied to collection percentages and days in accounts receivable. Processing electronic claims or providing patient statements may cost more. Some firms may offer additional services such as coding education, or provide you with access to their software for appointments and reporting.
Payroll — Many firms provide routine payroll services that include generating paychecks, direct deposit, preparing routine payroll tax filings, and annual employee statements (W-2s and 1099s). Many now accept direct downloads from practice accounting systems such as Peachtree, QuickBooks, and others.
Larger practices can also get time clocks that are directly integrated with the payroll system.
For smaller practices, outsourcing payroll can help you address privacy concerns. You don't want staff members to know what others (or the physicians) earn. It usually costs more to outsource payroll than to handle it internally, but the hassle factor is lower. Pricing typically includes a minimum charge per payroll plus a per-check fee. Direct deposit options add to the cost. Generally, the vendor automatically transfers money from the practice's checking account to cover the payroll, tax deposits, and vendor fees.
General management — You can select any number of management options, from a monthly visit from an experienced practice management professional to a full-time on-site manager who is actually on the payroll of a management firm. Fees are typically tied to some form of cost-plus approach using the salary of the manager as the base for the computation. If you already employ a manager, but need support from someone more experienced, consider a monthly retainer that would include a minimum number of hours of support.
Outsourcing practice management can also provide your practice with access to specialized professionals such as certified professional coders and billing experts.
If you decide to outsource these services, be sure to check references to find out if client financial performance improved as a result of their efforts and if the advice the clients received was beneficial and realistic.
Information technology — If you don't want the headache or capital costs of buying and maintaining new software systems, a growing number of practices are turning to application service providers (ASPs). These vendors charge a monthly access fee, typically tied to the number of users, which allows the practice to use the software via the Internet. The vendor maintains the database and the typical tasks, such as server maintenance and daily backups, are no longer your practice's to handle. You'll still need someone on staff, however, to keep your tablet PCs, laptops, wireless network, and other practice-owned equipment running smoothly.
Outsourcing IT may seem more attractive as the deadline for compliance with the HIPAA security rule approaches in April 2005. The rule requires system backup and disaster recovery, password protection, and encryption.
Apart from ASPs, practices also are using IT consultants on an hourly or retainer basis. Some vendors sell time blocks, which include prepaid hours of effort. While the cost per hour decreases with the size of the block, be sure not to overbuy.
Making a decision
The critical points that must be considered in making the decision between internal and outsourced are price, accountability, and flexibility.
Are you willing to pay more for better results? For example, the practice might be spending 5 percent of its revenue on its billing operation, but its collection rate may be 4 percent below what is typical for the specialty. Spending a few more dollars on a billing service may result in far more revenue. Typically, any outsourced service will cost you as much, if not more, than it would if handled internally. You need to see enhanced performance or cost savings to make it worthwhile.
When evaluating price quotes from various vendors, practices can use data published by the Medical Group Management Association (MGMA), that indicate the cost for various practice operations on a dollars-per-physician basis. You should be able to duplicate the service internally for the amount shown on the MGMA report. The Cost Survey: 2003 Report Based on 2002 Data can be ordered directly from MGMA.
In addition to making sure you get a fair price, you'll want to make sure that you get what you pay for. Some questions to ask vendors include: • What information will be provided to the practice leadership? • What assurances will the vendor offer related to performance, and what standards will they use as a measure? • What termination options are available if performance is not as expected?• Will the vendor modify their service to match the way that the physicians want their practice to operate?• How frequently will your practice have access to senior consultants or managers?
Identifying vendors
You can find potential partners by asking other physicians whom they use. Also try an Internet search, your professional society (many have a screening program for vendors, such as FP Assist, sponsored by the American Academy of Family Physicians), or firms that you encounter as exhibitors at professional meetings. Often medical supply, pharmaceutical, or banking representatives, your attorney or accountant could be excellent resources for recommendations.
Some services require knowledge of your specialty; others are generic to medical practices. A billing company should have a list of practices in your specialty that have used their service; management firms can be more general but should have experience with practices of your size and understand your budgetary constraints.
Keep in mind that the decision to outsource aspects of practice operations is not final. Evaluate vendor performance, and if you're convinced that you could do better, you can always elect to bring the services back in-house. Be sure, however, that you have had a frank discussion with your vendor about your concerns before terminating a relationship. Frequently, problems are a result of incomplete information. You're busy, and once you outsource tasks, you may pay less attention to operational details — but in the long run, it is still your practice.
Greg Mertz can be reached at
This article originally appeared in the November/December 2003 issue of Physicians Practice.

Thursday, January 24, 2008


Reflections from Martin Luther King Celebration and the need to recognize there is still a lot of unfinished work to eliminate health care disparities.

….on this special day when many in America pause to celebrate the life and explore the dream of The Reverend Dr. Martin Luther King, I am honored to be in the presence of one whose primary mission or may I say, whose dream, as Surgeon General was to assure that we, Americans of color—the Negro, the Latino, the Asian, and Hispanic—and the people indigenous to America—the Mexican, Navaho, Dakota, Cheyenne, and other native peoples stayed healthy long enough to dream and work for the promise inherent in the philosophy of Dr. King—that all men are created equal and have the inalienable right to life, liberty, and the pursuit of happiness. As an Emergency Room doctor who was fortunate to study and learn under some gifted urban E.R. doctors, I have seen almost everyway medial care in this digital age can save lives and everyway humans can die; whether by gun, knife, drug, car or neglect. I have seen how poverty kills. I have also seen how poverty challenges faith, hope and love to kill dreams. As Zora Neal Hurston, a medically-neglected queen of the Harlem Renaissance wrote “there is something about poverty that smells like death… dead dreams dropping off the heart like leaves in a dry season, and rotting around the feet.” Hurston died destitute in poverty from complications of hypertensive heart disease—a stroke caused by untreated high blood pressure. Therefore, Dr. Satcher, on this day that we commemorate the life of a man whose voice and vision filled the emptiness in so many souls with hope and reason, I salute you and thank you for your public service and unselfish commitment to eradicating racial and ethnic disparities in access to health care. I thank Dr. Sathcher for working to rid our communities of Newports, Winstons, Camels, Virginia Slims and the Marlboro man, and obesity; and for being one of the first in this Country who preached violence as a public health issue to mostly unhearing ears. I commend you for your selfless dedication to public health.
The meanings of the Martin Luther King, Jr. Holiday were eloquently phrased by Dr. King’s widow. Mrs. King wrote, among other things, that the King Holiday “is a day of interracial and intercultural cooperation and sharing. No other day of the year brings so many peoples from different cultural backgrounds together in such a vibrant spirit of brother and sisterhood. Whether you are African American, Hispanic or Native American, whether you are Caucasian or Asian American, you are part of the great dream Martin Luther King, Jr. had for America. This is not a black holiday; it is a peoples’ holiday. And it is the young people of all races and religions who hold the key to the fulfillment of his dream.” That is why I cherish the King Holiday. It is our yearly reminder that all people have the right to dream and that we should not be afraid to dream. But if we fail to set goals at every step and reassess and change what needs to be changed, if we fail to cherish ourselves and other, even those who make life difficult, and if we are diverted by the dreamless critics who discourage, our dreams will remain what they are. The King Holiday is a reminder of our potential and our responsibility to self and community.
Dr. King’s was a man of genuine wisdom and I am truly grateful because my brothers and I are the realities—the consequences of his dreams. I am grateful for the sparkle of my grandmother’s eyes when we graduated from college. I am thankful for the joy of my grandmother and parents when my brother and I were accepted into and graduated from medical schools and their celebration when we matched into the residency programs of our choice. These accomplishments of Green Streeter’s are the outcome of dreams inspired by Dr. King’s selflessness advocacy for equality and his dedication to us as a people. My grandmother Mazie and my parents truly believed in Dr. King’s dream and I am proud to say that my brothers and I gave and, hopefully, will continue to give life to the dream.
Inherent in Dr. King’s philosophy is the truth that life is not about circumstances—it is about choices and what we think. We can all dream but like someone wrote “we are what we think… all that we are arises with our thoughts, we make our world… what we think we become. Our potential is infinite; if we think we can do it, we can; we must live up to potential. Dr. King showed us the way and I pray many will be willing to walk it. Explore the world, live, love and cherish people, and let your life be an adventure, mistakes and all—and also as Langston Hughes reflected, “hold fast to dreams” let them become your reality.

Monday, January 7, 2008

What They Don’t Teach You in Business School

“I want to fly out to Louisiana and help.” That was the first instinct of hundreds of our faculty and many of our emergency medicine physicians at the University of South Florida as Katrina struck the Gulf Coast a few years ago. And despite pleas that volunteers should work through organized venues, many did go out on their own and satisfy a need that exists in all physicians and scientists—helping one patient at a time. Fast forward a few days to a call I received from one of my business colleagues that the power brokers in the New Orleans region were planning the rebuilding of New Orleans, a project to make the city more attractive to tourists and more “profitable” to those involved.

Never was the dichotomy between my physician mind and my MBA mind clearer. Former Gov. Richard Lamm of Colorado said it well when he stated, “American medicine is practiced one patient at a time. What makes a person a wonderful practitioner by definition makes them a poor allocator of resources.” So is that it? Should we feel comfortable training the next generation of physicians and nurses in a virtual business vacuum, secure that we are protecting them from the “dark side” of the business of healthcare?

Almost 10 years ago I embarked on a project to examine the medical mind vs. the business mind. It involved interviews and case studies with several hundred medical students, residents, and academic and private physicians, with similar studies for MBA students, men and women in business, and MBA professors. Our data accentuates a gulf between physicians and MBAs. In one case study, participants needed to question the “rules” and be creative in order to come up with a win-win scenario. Of the physician group, 87 percent “blindly followed the rules” and preferred the more mainstream “win-lose” strategy. For the MBAs, only 18 percent fell into that trap.

What we found is that even conservative academicians recognize the need for changes in the way we educate and select physicians. Some key issues:

► Are GPAs and MCATs still the “gold standard” for predicting success in a future where the differential diagnosis is as close as your palm (electronic or anatomic)? Simply put: Would a candidate with a 3.2 GPA and 26 in her MCATs, with superb communication skills, coordination proven on her simulation tests, and a finely tuned eye as evidenced by her fine-arts college minor be a better practitioner in the information world of 2020 than a candidate selected by traditional means?

► We can no longer relegate the real-world curriculum to a few “business” courses. Leadership in medicine is not about teaching “Excel for Dummies.” Instead, there was unanimity in our findings that there is no optimistic future in academic medicine without training physician scientists who understand collaborative negotiations, small and large group communications, making patients happy, running an effective meeting, and how to be an individual in an organization. When we taught these skills to residents, their optimism about the future of medicine increased, along with their desire to be creative.

► Professionalism is not just a competency for academic physicians; it is our lifeblood. As a dean who has had the honor of presiding over two medical schools, neither of which owns a hospital, I am convinced that uncompromising dedication to the principles of professionalism that are unique to academic health care allows us to train our future generation with the tools of the business world without being lost to “the dark side.”

As an MD-MBA, I am caught between a love of academic health care and a stark realization of the business imperative. My Wharton professors used to preach the importance of “getting back to business basics” during periods of stress. In reality, nothing could be further from the truth. Spreadsheets don’t solve these challenges. Our ability to succeed gets down to people, or what my business colleagues call “human assets.” Further, our ability to maximize those assets depends on leadership—defined as creativity, communication, negotiation and team building. We can ill afford to not teach our emergency medicine residents and students leadership in the business world while preserving what made them interested in medicine. And while integrity and professionalism will predicate our success in a new future, those attributes will never show up on any spreadsheet.