![The 5 “A’s” of Surgical Practice
Available
Affable
Able
Approachable
Accountable
[Note were “Ability” is placed!!!]](https://image.slidesharecdn.com/practicemanagement-may2006-121026165644-phpapp02/85/Practice-management-may2006-7-320.jpg)
Practice management.may2006
- 1. How to Manage Your Practice Things You Never Are Told During Your Residency Steven M. Rudich, MD, PhD Associate Professor of Surgery Director, Liver Transplant Services University of Cincinnati College of Medicine
- 2. Myth (I) Since I am in academics, I do not need to worry about doing the “niceties” of dealing with referring doctors, as I would if I were in private practice
- 3. Myth (II) SinceI am the greatest surgeon since Michael DeBakey, patients are going to come from 100’s of miles to see me and referring doctors will not want any other surgeon to touch their patient
- 4. Myth (III) AsI need a crane to lift my CV, I will have the biggest _____ practice this side of the Atlantic Ocean
- 5. Fact Although you are a well-trained surgeon, remember: that just like a plumber or other tradesperson, you provide a service. If you make it (very) difficult for your customers (ie, referring docs) to deal with you, your business will suffer
- 6. Ultimate Truth Your “real” customer is the patient ALWAYS DO THE RIGHT THING, FOR THE RIGHT REASON, at THE RIGHT TIME – Learn from us, see our mistakes You would be surprised to see how often the right thing is not done: – It takes experience and learning the hard lessons to sometimes know what the “right” thing is
- 7. The 5 “A’s” of Surgical Practice Available Affable Able Approachable Accountable [Note were “Ability” is placed!!!]
- 8. What We Will Talk of: Letters/Notes/Documentation When/How to speak to your referring doctors (ie, your customers) We will go through the “process” from patient referral to the final (second) post- operative check and long-term follow-up
- 9. Patient Referral Who is your voice? How promptly do you return the initial call to you? – ASAP, even take the initial call from the OR. If the referring docs has to play too much phone tag with you, it will be easier to call someone else!!! Getting an appointment to see you: – Should benchmark for one week to see you Pre-visit triage: – Waiting to get ALL studies prior to initial visit vs seeing patient sooner without all data you can have Remember always: YOU ARE PROVIDING A SERVICE. THE EASIER AND MORE PLEASANT YOU MAKE THINGS FOR YOUR CUSTOMER BASE, THE MORE LIKELY YOUR CUSTOMERS ARE GOING TO WANT TO DEAL WITH YOU!!!
- 10. Categories of Letters Sent to Referring Doctors Initial consultation letter (note) Follow-up visit letter – Completion of work-up note – Pre-operative visit note First post-operative visit letter Second post-operative visit letter Subsequent visit/long-term follow-up visit letter
- 11. General Comments Concerning ALL Letters Sent to Referring Physicians (I) First name or Dr. ___ Time frame to benchmark to get the letter into the referring doc’s hands – One week from office visit to letter in referring doctor’s office Summary Tell them what a great job they did in recognizing this pathology/disease Tell them what a great job he/she did in working- up this patient prior to sending him/her to you
- 12. General Comments Concerning ALL Letters Sent to Referring Physicians (II) Always give your immediate contact information for them to reach you Always state in beginning of letter the purpose of the patient seeing you that day Try to remember to state in the letter the day and date of the office visit
- 13. Why Spend Time Dictating Well?? Colleagues and referring docs get the impression that you know what you are doing Expression of plan: – Work-up of disease – Operative plan Medical-legal issues Billing purposes – Review of systems, etc Remind you weeks/months/years from now your thoughts concerning the disease state, what you found, and why you did what you did Marketing: – You care enough and are thoughtful enough to delineate things
- 14. Issues Pertaining to Communicating with Referring Doctors Remember, chances are they are busier than you and they see more patients than you – Be patient and expect to play phone tag with them My rule: I try to reach the referring doc one time (for a particular thing); if I cannot reach him/her I leave a detailed message and request a call back. I do not re-call the doc for the same issue, unless it is an URGENT matter Always be as positive and upbeat as you can possibly be
- 15. “Appropriate” Times to Communicate with Your Referring Physicians Time of initial referral – Input and opinion from referring MD At completion of all pre-operative studies and the formulation of the “final” plan – Review briefly what YOU found during your work-up and how you are using this data to decide what to do Immediately following the operative event – Tell them what wonderful things you did to help their patient, and what a great job the doc did in recognizing the disease and starting an evaluation Following the first post-operative visit – Review pathology with doc; speak about other consultants needed (such as oncology, etc) and if the doc has a preference – Plan for who will take ownership of post-op surveillance studies Select times during long-term follow-up and surveillance of recurrent disease – At time of disease recurrence, make sure this is shared with the referring doc and they know that YOU were responsible for finding the new disease
- 16. What/When/How to Communicate with Patients and Families General issues: – Show pictures and radiographs – Plan for return to work – What to expect in terms of pain and how we are going to help you deal with that – Show where incisions will lay – Anticipated length of hospital stay – ALWAYS, ALWAYS ask your patient (and family) if they have further questions
- 17. “Milestones” in Communication with Patient and his/her Family First consult visit – Plan for work-up Final pre-op visit – Review all studies; final operative plan Day of surgery – Review with family what you saw, what you did First post-op day visit – Review with patient what you saw and what you did Day of discharge – Activity instruction, new medications First post-op visit – Review path, plan for surveillance Second post-op visit – Review plan for surveillance Subsequent follow-up visit
- 18. First New Patient Visit Always say “hi” and introduce yourself Always apologize for keeping your patient waiting Bring films in room to show the patient Have schematic drawings available to correlate radiology with “simple” picture as well as to use for showing operation you may be performing People do not like to feel as if you are rushing: template off an appropriate amount of time to spend with new referrals Always ask: whom do I need to thank for sending you to me and allowing me to be of help? Try NOT to be in scrubs
- 19. Initial History and Physical History of present illness: – When did you first notice this – What is different now that Dr. ___ sent you to see me? Radiology studies to date Other important studies already done as part of work-up Summary – Probably the most important part of dictation as you will be referencing back to this for future letters Niceties to include in your letter
- 20. Initial History and Physical Donot be afraid to say that you need to collect more data/do more tests prior to deciding what is best course of treatment
- 21. Initial History and Physical Patient: At end this first visit: – Give patient your business card – Ask if any further questions – Go over plan: what tests needed Referring doc: At end of initial visit: – Call to thank – Great job you did in recognizing the disease and starting work-up – Tell him what additional studies you need which he or his group can do – Give your initial thoughts and where you think work-up will go – If additional consultants are needed (ie cardiology clearance) ask if he has a preference or if you can arrange for such
- 22. Second Pre-operative Visit After all studies you initially ordered at time of first visit have been obtained After all other outside data (path, radiology) has been brought to you and reviewed After all results from outside consultants are made available to you Purpose of this visit: To relate to the patient your FINAL PLAN, in terms of what you are going to do
- 23. Second Pre-operative Visit Make sure you give ample time to ask questions Give patient an “out” and offer to obtain a second opinion on your plan Review anticipated hospital course, approximate time patient should expect to be hospitalized, time able to get to full activities, as well as back to work Review with patient plan to achieve analgesia
- 24. Second Pre-operative Visit Referring Physician Note Use your summary from initial consultation note to review course with patient PRIOR to you seeing him/her Next review ALL NEW STUDIES YOU OBTAINED as part of your work-up Re-do the summary including results from your work-up and how this changes the preliminary diagnosis Give a brief statement of YOUR opinion concerning how the “disease” should be treated Give a definitive statement on WHAT YOU PLAN TO ACCOMPLISH by surgery Niceties
- 25. In the Operating Room Bring films Bring your office chart!! – By definition, the best and most definitive note on that patient should be yours. – In case of some emergency, you want the best and most complete data on that patient in the OR with you. Try to see patient before they go to sleep. Of ALL THE STRANGERS in that room, the patient has at least seen you twice. That brings some element of security to them.
- 26. Operative Note Pre-op diagnosis Brief clinical history Post-op diagnosis – Use summary piece from second pre-op visit Procedure performed – What brought patient to OR? Surgeons Operative findings Anesthesia – What you found; what do want Fluids administrated to remember about this Drains operation weeks, months, years from now Complications – Cardiac events, Procedure in detail iatrogenic injuries – What you actually did in OR, in as much detail as you can stand Sponge, needle, instrument counts Patient disposition
- 27. Notes on Operative Notes Dictate the operation ASAP; as soon as you get back to your office – Delaying will only let you forget salient details which might be important BE HONEST. We all make mistakes. “Forgetting” to include something, like having to repair an iatrogenic injury, can have serious consequences for people managing your patient down the line Dictate your own operative report: – Billing purposes – Medical-legal purposes – Ability to better recall what you did later if you dictated the note yourself – Basis for your clinical research
- 28. What You Do Immediately Following Surgery Develop your own “ritual”: 1. Call referring doc from OR 2. Speak with family in waiting room 3. Go to office and dictate operative report 4. Give chart and films to your office staff 5. ?Speak to patient on your way home, after he/she has cleared effects of anesthesia 6. Send e-mail to your staff reminding of follow-up or other “different” things needed for surveillance based upon your operative findings and surgery a) Oncology consult, etc
- 29. First Post-Operative Visit • Go over surgery with patient: • You would be surprised how often people do not know what operation you performed on them • Review final pathology with patient: • It is reasonable to delay this first visit if the pathology is not back yet • Draw pictures of what you did during surgery, and findings • Describe to patient if you found anything different than expected and how that changed your pre-operative plans
- 30. Physical Examination at First Post-Operative Visit Examine incision Try to remove staples sooner than later, if medical feasible If place steri-strips on wound, remember to educate patient on when/how to remove these Remember, with few exceptions, if wound looks wrong, it probably is!! – Bite the bullet, and be aggressive with opening/packing wounds. You will rarely regret this.
- 31. Patient Education at First Post-Operative Visit Review medications. Make sure patient is back on all pre-op meds, as oftentimes things are lost in translation in the transition to outpatient Educate about analgesia: – Despite what you might think, most patients are under- medicated for fear of becoming a druggie, this is well known Review with patient plan to return to full activities, driving, as well as to work Review plan for disease management: – Future consultations, surveillance imaging, when to return to see PCP and/or referring physician
- 32. Letter to Referring Doctor Upon First Post-Operative Visit Sendout a “Packet” to all referring doctors, in which will be: – Operative report – Pathology report – Discharge summary – First post-operative visit letter
- 33. Letter to Referring Doctor Upon First Post-Operative Visit Start off letter by what brought patient to OR, and major findings of pre-op work-up Include operative findings (from your op note) Include post-op course (from your memory or from d/c summary) Include review of pathology (from path report which should be in your clinic chart by the time you see the patient) Include a review of pertinent laboratory data at time of discharge Include a brief summary of any post-op complications up until this first post-op visit
- 34. Letter to Referring Doctor Upon First Post-Operative Visit Finishthis letter with your opinion as to continued plans for the patient: – Radiographic surveillance – Colonoscopic surveillance – Referral for med/rad oncology – Laboratory surveillance – When you plan to see patient again
- 35. Phone Call to Referring Doctor Upon First Post-Operative Visit Remind doc of the patient – As, like you, they may not remember the patient off the top of their head Remind doc of what a great job they did in recognizing the disease, making the diagnosis, and starting the work-up Review the surgery you did, what you found, and how this is going to really help this patient Admit to any post-op complications and what YOU are doing to help in that regard Decide as to follow-up plans and who will be responsible for obtaining surveillance studies, obtaining consultants (onc, cardiology), etc Thank the doc for allowing you the privilege of being of help to their patient as well as to him/her If remotely true, tell the referring doc how easy the surgery was, and how you appreciate being able to work with him/her for the best possible care of his/her patient
- 36. Second Post-Operative Patient Visit Purpose: Give patient another chance to ask questions Another opportunity to provide education – Back to work, ADLs, etc Emphasize plan for follow-up and surveillance (which you will be organizing) Review plans for post-operative treatments done by other docs “Hand-off” patient’s care to next provider who will be running the show following successful surgery
- 37. Second Post-Operative Patient Visit End this visit with this: – “You know how to reach me for any problems whatsoever” – Make sure your staff has given patient 24 hour number as well as routine office number
- 38. Second Post-Operative Patient Visit Letter to Referring Doctor Purpose: – To review entire post-op course – Pin down responsibility for post-op surveillance studies – Make sure who is taking responsibility for post-op treatments/consultants No real need to make a phone call to referring doctor unless you really feel compelled to do such!
- 39. Final Thoughts You provide a service – ALWAYS REMEMBER WHO ARE YOUR CUSTOMERS Remember the FIVE “A’s” It is really a privilege to do what we do – Be grateful for what you have and what you have been given Do not just be a technician – To be called this, exclusive of other things, is an insult Judgment and clinical acumen makes you a surgeon, not being able to physically perform a particular operation Everything you do, from how you run your office, the clarity and thoughtfulness of your notes, to how your secretary answers your phones, reflects upon you and ultimately helps to decide the success of your practice.