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.

Putting a Face and a Price Tag on the Malpractice Issue for Emergency Medicine Physicians

They usually show up in jeans and a T-shirt, hand over an envelope, and with a little smirk say “I have a little present for the doctor.” So starts the arduous process of beginning a malpractice suit---a process that until very recently has been nameless and faceless, but in reality has implications far more serious than the financial statistics and physician manpower projections that have inundated newspapers and magazines. The fact is that our inability to negotiate an end to the “malpractice war” has been one more body blow to reversing the pessimism that exists among practicing physicians.

As an OB-GYN/dean who employs emergency physicians, I know all the statistics. I know that insurance companies are boosting rates partly to make up for price wars in the 1980s. I know that less than 2% of malpractice claims result in a winning verdict at trial. I know that one in twelve paid claims settles for a million dollars or more compared to one in fifty a decade ago. And I know that in the 2002 election, almost $8 million was contributed in lobbying efforts around malpractice, with the AMA and AHA leading the way on the providers side with 60% going to republicans, and the American Trial Lawyers Association infusing a bolus of money of which 90% went to democrats.

But there is a toll which belies those numbers. At my medical school which employed over 500 physicians and has a large emergency medicine department, we had been able to balance a budget despite a 60% increase in malpractice rates in the past 3 years. And while it is unfair that we have obstetricians and neurosurgeons that have bigger numbers on their malpractice insurance expense lines than their salary lines, that is only the tip of the iceberg. The real tragedy is in contemplating what could have been done with that “excess” money in a University that is proudly recovering. What research gains could have been made if we could have handed that to our excellent basic science chairs? What educational innovations could have been started with a little financial push? How might we have been able to help our faculty develop in a changing environment, if we had not had to hand more money over to a legal-insurance machine that seems to have a voracious and limitless appetite.

There is also a very personal toll. There is a piece of you that gets taken away when you get sued for malpractice. We do not live with a business mindset or a business ethic. It is why the best doctors sometimes are the worst allocators of resources. The best of us give care to each patient at the level we would a family member. And in some respects it’s what patients expect from us. In other words, people want managed care for everyone but themselves and their family. But WE as doctors have to live that paradox. Which is why that subpoena from the guy in the T-shirt is not really “the price of doing business” as the insurance companies might tell us. It is a dagger into the soul that separates the art of being a physician from the business of medicine, it is a factor in deteriorating personal relationships for physicians, and it is a symptom of the hidden curriculum that allows students to be more pessimistic after certain rotations than before they had the opportunity to interact with faculty.

So, what can we do? Having spent some time interacting with leaders on the state level through my role on the governor’s transition team, it is clearly time for a new approach. We need to stop the rhetoric around greedy lawyers and incompetent doctors. We need to tie malpractice reform to true quality improvements among hospitals and physician groups. Just as bond raters comment on the “financial health” of healthcare institutions, we should have impartial “quality raters” of health care institutions with a real commitment from the insurers and the legialature to provide malpractice relief for AAA rated institutions and physician groups. We need to make it easier rather than more difficult to “weed out” and retrain physicians that fall below minimum objective quality standards. And we need to in some way indemnify deans and chief quality officers from the fact that some of the same attornies that rail about physicians not policing themselves, will trip over themselves to file an antitrust claim when a doc is censured. And finally we need to ensure that payors stop talking about and actually implement “pay for performance” programs so that the best practices can be incentivized and encouraged.

Sounds like a difficult agenda. It is. But I for one would be willing to do whatever it takes if I could help prevent a young physicians from having to open up the envelope that says, “you have been sued…….”

Tips for those going to the Emergency Room...

Subject: EMERGENCY DEPARTMENT RULES"This is all so true!!" says Debra R., EMT/PCTRules for the Emergency Room:Here are some tips to those who may end up in an ER, be it yourself or a family member.

If it requires the ambulance team and entire truck crew of firefighters to transport you and safely place you on a hospital stretcher, it is time to go on a diet.

When you present to the triage nurse, do not tell him/her that your doctor called ahead. If you survey our waiting area, probably 50% of the people waiting said the same thing, and the other 50% use the ER as their regular doctor.

Never start out by saying, "I was searching the Internet . . . "

When asked how much you weigh, please do not give the "Deer-In-The-Headlights Look", and tell us you "really don't know". It's a simple question with a simple answer.

Just because you have a phone and know how to call 911, we are not impressed by your arrival on an ambulance stretcher. You had better be sick.

If you came escorted via EMS for multiple complaints that started more than one week ago and your entire family followed the ambulance to the hospital, you will be labeled a ninnie and treated like one, enjoy the waiting area with your family.

One complaint/ailment per visit, please.

Just because you came in on a ambulance, doesn't mean you're going home on one. You better start making arrangements, now. I am not driving you home, or figuring out how to get you home. Cab vouchers are not an option.

If you have one of these four, go to your own doctor in the morning: A Migraine; the Flu; a stomach virus; or a stuffy nose.

Do not ask us how long it will be. We don't know. I don't know what is coming through my door 30 seconds from now,so I sure as hell don't know when you're getting a room.

We have priorities. We understand that you have been waiting for two hours in the waiting room. If you don't want to wait, make an appointment with a doctor. The little old lady that just walked in looking OK to you is probably having a massive heart attack. That is why she goes first.

If your mother is a patient and we ask her a question, let her answer it.

If your child has a fever, you had damn well better give him Tylenol® before coming in. DO NOT let the fever remain high just so I will believe the child has a fever. Do you want your child to have a seizure? Do you?

If you are well enough to complain about the wait, you are well enough to go home.
Do not utter the words "it is in my chart", I don't have your chart, and I don't have the time to call and get it. Just tell me. It is faster.

We know how many times you've been to an ER. We can usually tell if you are faking it during the first 5 seconds of talking to you. Do not lie to us. If you lie about one thing, we will have to assume you are lying about everything. You don't want that.

If you have diabetes and do not control it, you are committing slow suicide.

If you are a female between 16 and 42 and your last period was between 28-35 days ago, please don't waste our time if you are here for Abdominal Pain & Vaginal bleeding. Guess what!!?? You got your period, again.

Do not bring your entire posse with you. One person at the bedside is all you need. It is really difficult to move around seven people who are in the way if you are really sick.

Every time I ask you a question, I learn more about what is wrong with you. I don't care if I asked you what day it is four different times. Each time I ask, it is for a reason. Just answer the questions, regardless whether you have answered them before.

If you want something, be nice. I will go out of my way to piss off rude people.

Our definition of sick is not your definition of sick. If a member of the ER staff says that someone is sick, it means that they are in the process of DYING. They have had a massive stroke, are bleeding out, having a heart attack, or have been shot. We don't consider a kidney stone, sick. Painful, yes. Sick, no.

At any given time, one nurse has four patients. One doctor has up to 15.

There is a law (similar to Murphy's) in the ER. If you have four patients: one of them will be sick (see above for definition); one of them will be whining constantly; one of them will be homeless; and one of them will a delightful patient. (don't be the whiner). Please.

If you see someone pushing a big cart down the hall at full speed and you hear bells going off, do not ask for a cup of coffee. Someone is dying, you inconsiderate a*****e. In the ER, bells don't ring for nothing. Sit down, shut up, and let us work.

If you can bi**h about the blood pressure cuff being too tight, or the IV hurting, you are not in that much pain.

Physicians and nurses are not waiters. We are not customer service representatives. This is not McDonald's®, and you very well may NOT have it your way. Our job is to save your life, or at least make you feel better. If you want a pillow, two blankets, and the lights dimmed, go to the Ramada®.

If you have any sort of stomach pain and you ask for something to eat, you are not sick.
Do not talk s**t about the other members of staff I work with. The doctor that you hate? I work with him every day, and I know that he knows what he is doing. I trust him a lot more that I trust you. I am not here to be your friend, and neither is he. I will tell him what you said, and we will laugh about it. If you want a buddy, go somewhere else.

If you are homeless, don't ask for a bus token or cab voucher to get home. It just confuses the staff.

Please don't tell us how to do our job. Do we go to your place of business and tell you how to do your job?

Please don't bring in a "show and tell". If you have to fish it out of the toilet, it's really not necessary to bring it in, we will take your word. If you did fish something out of the toilet, you may not use my pen.

"Scientific Jargon"by Dyrk Schingman, Oregon State University
"After several years of studying and hard work, I have finally learned scientific jargon.The following list of phrases and their definitions will help you to understand that mysterious language of science and medicine.

"IT HAS LONG BEEN KNOWN"... I didn't look up the original reference.

"A DEFINITE TREND IS EVIDENT"...These data are practically meaningless.

"WHILE IT HAS NOT BEEN POSSIBLE TO PROVIDE DEFINITE ANSWERS TO THE QUESTIONS,"... An unsuccessful experiment, but I still hope to get it published.

"THREE OF THE SAMPLES WERE CHOSEN FOR DETAILED STUDY"... The other results didn't make any sense.

"TYPICAL RESULTS ARE SHOWN"... This is the prettiest graph.

"THESE RESULTS WILL BE IN A SUBSEQUENT REPORT"... I might get around to this sometime, if pushed/funded.

"THE MOST RELIABLE RESULTS ARE OBTAINED BY JONES"... He was my graduate student; his grade depended on this.

"IN MY EXPERINCE"... once

"IN CASE AFTER CASE"... Twice

"IN A SERIES OF CASES"... Thrice

"IT IS BELIEVED THAT"... I think.

"IT IS GENERALLY BELIEVED THAT"... A couple of other guys think so too.

"CORRECT WITHIN AN ORDER OF MAGNITUDE"... Wrong.

"ACCORDING TO STATISTICAL ANALYSIS"... Rumor has it.

"A STATISTICALLY ORIENTED PROJETION OF THE SIGNIFICANCE OF THESE FINDINGS"... A wild guess.

"A CAREFUL ANALYSIS OF OBTAINABLE DATA"... Three pages of notes were obliterated when I knocked over a glass of beer.

"IT IS CLEAR THAT MUCH ADDITIONAL WORK WILL BE REQUIRED BEFORE A COMPLETE UNDERSTANDING OF THIS PHENOMENA OCCURS"... I don't understand it.

"AFTER ADDITIONAL STUDY BY MY COLLEAGUES"... They don't understand it either.

"THANKS ARE DUE TO JOE BLOTZ FOR ASSITANCE WITH THE EXPERIMENT AND TO ANDREASCHAEFFER FOR VALUABLE DISCUSSIONS"... Mr. Blotz did the work and Ms. Shaeffer explained to me what it meant.

"A HIGHLY SIGNIFICANT AREA FOR EXPLORATORY STUDY"... A totally useless topic selected by my committee.

"IT IS HOPED THAT THIS STUDY WILL STIMULATE FURTHER INVESTIGATION IN THIS FIELD"... I quit.

"This may be used or broadcast in any form as long as I receive credit.©Dyrk Schingman"as submitted by Tina Denetclaw, Pharm.D., BCPS

Happy and Safe New Year!!

Tis the season- too much alcohol, depression, suicide attempts, overdose, domestic disputes and car accidents/fatalities... Sounds like a very busy night at the E.D.! Sounds about right, but interestingly I found an article that says something different- According to Dan Romer, director of the Annenberg Adolescent Risk Communication Institute at the University of Pennsylvania, "deliberate self-harm" is actually much less frequent during the holidays. In this study, the used the admission records of 19,346 people in England and looked at daily rates of self-induced injury from 1976 to 2003. The conclusion? Between the dates of December 19-26 all levels were decreased and held this pattern through New Years. According to the article, even people with family problems were less inclined to attempt to hurt themselves during the holiday time. The feeling was that with extended family close, they feel less pressure. People are in the "spirit of giving" Hmmm... Maybe we should have more holiday time?! Despite what statistics/research may say, the holidays are not for everyone. We are all aware of the dangers on this Eve.... Hopefully yours is filled with joy and those wonderful New Years resolutions!
Wishing everyone a Happy, Healthy New Year!
Be Thankful and be safe! :)

As if Professionals in Emergency Medicine don't have enough to worry about!

If you ever want entertainment (or some real horror/night sweats/bad dreams) google "Patient Claims" and see what comes up!
An interesting claim about Dr. Adams and Ms. Lucas: a lipo-surgery patient who claims she met Dr. Adams while Bartending- he was her customer. According to her claim, Dr. Adams agreed to do lipo on Ms. Lucas's upper arms and abdomen, as she was an aspiring model and actress. According to Ms. Lucas, just as surgery was about to begin, Dr. Adams whispered in her ear "that he 'loved' her, that he was 'going to marry her." According to the law suit, Dr. Adams began making "house calls" shortly after the procedure, eventually taking her to dinner and drinking wine, while still heavily medicated. The plaintiff claims this is when Dr. Adams took her home and had sexual intercourse with her. Lucas claims this is when she became pregnant. According to the suit, Dr. Adams wanted to keep the baby and Ms. Lucas did not. According to the claim, Dr. Adams eventually referred Ms. Lucas to an OB/GYN who would end the pregnancy. Ms. Lucas also claimed that Dr. Adams "botched" her surgery and sued for sexual battery and malpractice. What in the world is happening???!!!! According to Wrong Diagnosis.com, the highest dollar payouts are often related to: misdiagnosis, failure to diagnose or delayed diagnosis of a severe medical condition. CALLING ALL EMERGENCY PHYSICIANS: DO YOU SEE THESE STATISTICS?! You are the ones who are blamed for this! Yes, you are overworked, understaffed, and a big part of your bonus is determained by how many patients you see per hour.... no sleep, not enough help, but when you make a mistake you get sued!! Between Physician/patient love-drama gone wild (which could be another blog) and issues such as patient safety, it's no more a question of "have you ever been sued?" It's more like: "When was the last claim filed against you and what was your involvement?"!! According to NCHS, data shows that in 2002, there were 33,051 deaths involving complications of medical or surgical care.

Emergency Medicine on Life Support

As we know, Emergency Medicine in the United States is in critical condition. Over-worked, under-paid, and under appreciated. Ambulances are turned away, patients are left waiting for hours and sometimes days. When they are finally seen internal pressure like lack of staffing combined with bonus structure such as RVU, makes getting these patients through as quickly as possible the priority vs. real patient-care. The result? Mistakes, Claims.... Patients and families left unhappy, suffering and physicians feeling like nothing can be done. What about reimbursement, overcrowding and lack of specialtists when they are needed most?
EMS, Specialtists and Emergency Physicians need to work as a team, Congress needs to ensure all emergency rooms are properly equipped and ready to handle whatever comes through the door. In 2003, emergency departments saw nearly 114 million patients - a 26 percent increase over the previous decade - but during the same 10 years the United States lost 703 hospitals and 425 emergency departments, one report noted.
Emergency departments are also playing key roles in disaster response, but in 2002 and 2003, emergency medical services received just 4 percent of the $3.38 billion doled out for emergency preparedness by the U.S. Department of Homeland Security.The reports urges Congress to allocate $50 million to reimburse hospitals for uncompensated emergency and trauma care and to increase funding to provide hospitals with resources needed to handle disaster situations.
Uninsured patients use the emergency departments as if they are walk-in clinics. With over 47 million uninsured people in the United States, where are they supposed to go? Instead of putting out these daily fires in the ED, we have got to create long-term solutions.