“Curmudge, other than giving your ancient brain its daily exercise, why are we writing another posting on Beeson’s Engaging Physicians (1)?”
“Because not everyone will read the book, Jaded Julie. I at least want to share with them a few of Beeson’s most important teachings. Perhaps we can do that with a quotation or two from each of the most critical chapters.”
“Have at it, Curmudge. I’ll just sit over here and take notes.”
Create and Communicate Organizational Vision and Goals
“Physicians care about clinical quality, practice efficiency, the quality and training of the nurses they work with, profitability, their reputation among patients, staff, and colleagues, their input on issues, appreciation for what they do, and responsiveness to practice concerns.”
“If leaders are unable to clearly communicate how an organizational effort will benefit physicians, then the strategy should be redesigned.”
“The leadership message to physicians should be: ‘Our goal is to eliminate barriers to care and to eliminate those things that waste your time.’”
Establishing Physician Confidence and Trust
“The importance of building trust with physicians cannot be overestimated.” “Trust in the leadership team precedes physician collaboration, participation, and alignment, and will be a vital element to the physician engagement process.”
Building Physician Leadership
“Perhaps the most important goal of physician leaders is to facilitate and execute the hospital’s transition from individual physician autonomy to system-based care delivery. System protocols, order sets, and evidence-based medicine outperform individual physician decision making in nearly all clinical circumstances.”
“Improving patient satisfaction and physician communication is the most common goal of a physician champion.” “Historically, physicians significantly underestimate the true impact of their own behavior on a nurse’s work experience.”
Training Physicians
“Leveraging the influence of the engaged physician who leads by example is perhaps the greatest catalyst of change in the behaviors of the healthcare workforce.”
“A physician’s technical ability to diagnose and treat a medical condition did not rank in the top six physician attributes that patients ranked as most important.” “In order for physicians to be successful, to grow business, to expand revenue, and to establish a reputation in the community, physicians must deliver the patient’s definition of a great physician.”
“Physicians are the smartest and best students in the world.”
“The reality is that trained, consistently executed communication behaviors will drive every measure of performance that physicians consider to be important—patient loyalty, malpractice risk, patient compliance, clinical outcomes, patient safety …and the quality of a physician’s work life.”
Physician Measurement and Balanced Scorecards
“If there is distrust, animosity, or significant ‘issues’ between leadership and physicians, then measuring and reporting physician performance will come under intense heat, protest, and rejection from physicians.”
Recognizing Physicians
“Recognition changes people, changes physicians, replicates behaviors, creates physician loyalty, and builds partnership and trust with a system and its leaders.”
“Curmudge, you didn’t include anything from Beeson’s discussion of AIDET* for physicians.” (*Acknowledge, Introduce, Duration, Explanation, Thank you.)
“I just assumed that everyone had read about AIDET in Studer’s book, Hardwiring Excellence (2). Which brings me to my final word about Engaging Physicians: READ THE BOOK.”
Affinity’s Kaizen Curmudgeon
(1) Beeson, Stephen C. Engaging Physicians: A Manual to Physician Partnership. (Fire Starter Publishing, 2009)
(2) Studer, Quint. Hardwiring Excellence. (Fire Starter Publishing, 2005)
Thursday, September 24, 2009
Thursday, September 17, 2009
Engaging Physicians--a Great Book
“Over the weekend, Jaded Julie, I read a great book. It’s called Engaging Physicians by Stephen C. Beeson (1). Remember when we talked about Physicians and Lean back on June 25, and I said that a hospital-wide Lean transformation must involve the physicians? Well, Beeson’s book goes into the subject much more deeply than the IHI white paper that I cited. This book was written principally for hospital administrators, while Beeson’s earlier book, Practicing Excellence: A Physician’s Manual to Exceptional Health Care (2), was written for the physicians themselves.”
“But Curmudge, how can you even comment about physicians? Without an MD after your name, your credibility with physicians is zilch.”
“I was an undergraduate with premeds, I later taught chemistry to premeds, and now I see doctors every day. All of that plus the fact that Beeson is a physician ought to raise my credibility to at least zilch-and-one-half.”
“Good luck, Curmudge. So if we acknowledge that physicians must be involved in a Lean transformation, why must so much ink be devoted to how we can make it happen?”
“Consider premeds and engineering students, Julie. The engineers’ grades can be B’s and they can be successful. The premeds must be sufficiently intense to earn A’s in order to get into medical school. In addition, the engineers learn about systems, collaborating with teams, and eventually working for an organization. In contrast, all the way through college, med school, and residency, physicians focus on developing their individual autonomy and personal responsibility for their patients. Systems and organizational issues—so critical in a Lean transformation—are rarely considered.”
“Curmudge, you sound as if you’ve known a few engineers over the years. Are there other ways that they differ from physicians?”
“It seems to me, Julie, that physicians are a bit more outgoing than engineers. The story goes that when you meet an engineer when walking down a hallway, he is always looking at his shoes. When you meet a doctor in the hallway, he is looking at your shoes.”
“You can’t say that, Curmudge! Somebody might be offended.”
“Okay. Sorry about that, physicians. How about this? Sometimes when you meet a physician in the hallway, he seems to have a ‘thousand-yard stare.’ I once met a guy with that appearance who was hiking down from the summit of Mount Rainier. He looked as if he had really been through the wringer.”
“That’s better, Curmudge. A physician might be thinking intently about his most recent or next patient. So what is your explanation…er, conjecture, Professor?”
“I once read that people can be changed by a significant emotional event—like marriage, motherhood, or in the present case, medical school and residency. My speculation is that med school transforms serious undergraduates into extremely intense practicing physicians.”
“Now I understand, Curmudge. That’s why Beeson wrote a whole book about how one should proceed to engage physicians in a hospital-wide renewal.”
Affinity’s Kaizen Curmudgeon
(1) Beeson, Stephen C. Engaging Physicians: A Manual to Physician Partnership. (Fire Starter Publishing, 2009)
(2) Beeson, Stephen C. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. (Fire Starter Publishing, 2006)
“But Curmudge, how can you even comment about physicians? Without an MD after your name, your credibility with physicians is zilch.”
“I was an undergraduate with premeds, I later taught chemistry to premeds, and now I see doctors every day. All of that plus the fact that Beeson is a physician ought to raise my credibility to at least zilch-and-one-half.”
“Good luck, Curmudge. So if we acknowledge that physicians must be involved in a Lean transformation, why must so much ink be devoted to how we can make it happen?”
“Consider premeds and engineering students, Julie. The engineers’ grades can be B’s and they can be successful. The premeds must be sufficiently intense to earn A’s in order to get into medical school. In addition, the engineers learn about systems, collaborating with teams, and eventually working for an organization. In contrast, all the way through college, med school, and residency, physicians focus on developing their individual autonomy and personal responsibility for their patients. Systems and organizational issues—so critical in a Lean transformation—are rarely considered.”
“Curmudge, you sound as if you’ve known a few engineers over the years. Are there other ways that they differ from physicians?”
“It seems to me, Julie, that physicians are a bit more outgoing than engineers. The story goes that when you meet an engineer when walking down a hallway, he is always looking at his shoes. When you meet a doctor in the hallway, he is looking at your shoes.”
“You can’t say that, Curmudge! Somebody might be offended.”
“Okay. Sorry about that, physicians. How about this? Sometimes when you meet a physician in the hallway, he seems to have a ‘thousand-yard stare.’ I once met a guy with that appearance who was hiking down from the summit of Mount Rainier. He looked as if he had really been through the wringer.”
“That’s better, Curmudge. A physician might be thinking intently about his most recent or next patient. So what is your explanation…er, conjecture, Professor?”
“I once read that people can be changed by a significant emotional event—like marriage, motherhood, or in the present case, medical school and residency. My speculation is that med school transforms serious undergraduates into extremely intense practicing physicians.”
“Now I understand, Curmudge. That’s why Beeson wrote a whole book about how one should proceed to engage physicians in a hospital-wide renewal.”
Affinity’s Kaizen Curmudgeon
(1) Beeson, Stephen C. Engaging Physicians: A Manual to Physician Partnership. (Fire Starter Publishing, 2009)
(2) Beeson, Stephen C. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. (Fire Starter Publishing, 2006)
Thursday, September 10, 2009
The Medical Home--Introduction
“Hey, Jaded Julie, let’s invent a model for personalized primary care.”
“We’re too late, Curmudge. It’s already been invented.”
“Let’s do it anyway. With your innate chutzpah and my propensity to pilfer paragraphs from publications (with proper citations), we can’t lose.”
“I’m with you Curmudge, and I’ll bring along my inborn audacity. Presumably, we’ll start by considering the patient’s needs, as the folks at the Mayo Clinic say, ‘The needs of the patient come first.’”
“That’s it, Julie. And one of the patient’s biggest needs is to be able to get into the office at a time that reflects the patient’s condition. If she is acutely ill, she wants to hear, ‘Come on over right now.’ If she is scheduling an annual physical, ‘sometime next month’ should be acceptable.”
“And just like when you were a child, Curmudge, you were certainly more at ease knowing everyone in the office and being able to spend whatever time was necessary with the doctor. I bet that’s still true, even for a senior citizen (actually, an old relic) like you.”
“Time with the doctor is a difficult issue, Julie, especially if the goal of our model clinic is personalized care. Fortunately, not every patient needs to see the doctor at every encounter with the clinic. We’ll discuss that more after we complete our list of basic criteria.”
“Coordination of care is another requirement to build into our model. It seemed to me that traditionally, after the primary care doc made a referral to a specialist, the patient-doctor relationship went from patient-primary care to patient-specialist. Sometimes the primary care doc might find himself/herself left out of the loop. The specialist might neglect to send a report; and if he did, the overworked primary care doc might not find time to read it.”
“Patient involvement in her own care is important, but she shouldn’t have to deal with the whole health care delivery system all by herself. That’s where our model clinic’s coordination of care capabilities can really help the patient.”
“Curmudge, a person with a chronic health condition cannot help but be involved in his/her own care. The newspapers remind us almost every day of the expense of these conditions and of the importance of controlling them by doing the right things at the right times. Our model clinic can help these people by monitoring their condition and reminding them when it is time for a specific test or exam.”
“Here’s another personalized care issue, Julie. In a big clinic or one connected to a hospital, a patient might have to go to different locations for different tests and procedures. It’s easy for the patient to feel ‘herded,’ and that’s what we want to avoid. Some place that I read about—perhaps Geisinger—assigns a guide to each patient. This would be a perfect duty for a volunteer with an outgoing personality.”
“Great idea, as long as the volunteer isn’t a curmudgeon. It would be better if everything could be done in the clinic exam room. This would include patient registration, nurse time, time with the physician, and scheduling the next appointment. Of course, this would require careful coordination.”
“I would call it choreography; but under any name, it’s a great idea. We’re already doing this in our pulmonary area. So Julie, we’ve put together our list of basic requirements, and we’ll talk in more detail about these in subsequent weeks. Do you think we should give our model clinic a name?”
“Of course. Let’s call it The Jaded Julie Primary Care Clinic.”
“(Now you know what I meant when I spoke of chutzpah.) Even though the name is not new, I think we should call it The Medical Home.”
Affinity’s Kaizen Curmudgeon
“We’re too late, Curmudge. It’s already been invented.”
“Let’s do it anyway. With your innate chutzpah and my propensity to pilfer paragraphs from publications (with proper citations), we can’t lose.”
“I’m with you Curmudge, and I’ll bring along my inborn audacity. Presumably, we’ll start by considering the patient’s needs, as the folks at the Mayo Clinic say, ‘The needs of the patient come first.’”
“That’s it, Julie. And one of the patient’s biggest needs is to be able to get into the office at a time that reflects the patient’s condition. If she is acutely ill, she wants to hear, ‘Come on over right now.’ If she is scheduling an annual physical, ‘sometime next month’ should be acceptable.”
“And just like when you were a child, Curmudge, you were certainly more at ease knowing everyone in the office and being able to spend whatever time was necessary with the doctor. I bet that’s still true, even for a senior citizen (actually, an old relic) like you.”
“Time with the doctor is a difficult issue, Julie, especially if the goal of our model clinic is personalized care. Fortunately, not every patient needs to see the doctor at every encounter with the clinic. We’ll discuss that more after we complete our list of basic criteria.”
“Coordination of care is another requirement to build into our model. It seemed to me that traditionally, after the primary care doc made a referral to a specialist, the patient-doctor relationship went from patient-primary care to patient-specialist. Sometimes the primary care doc might find himself/herself left out of the loop. The specialist might neglect to send a report; and if he did, the overworked primary care doc might not find time to read it.”
“Patient involvement in her own care is important, but she shouldn’t have to deal with the whole health care delivery system all by herself. That’s where our model clinic’s coordination of care capabilities can really help the patient.”
“Curmudge, a person with a chronic health condition cannot help but be involved in his/her own care. The newspapers remind us almost every day of the expense of these conditions and of the importance of controlling them by doing the right things at the right times. Our model clinic can help these people by monitoring their condition and reminding them when it is time for a specific test or exam.”
“Here’s another personalized care issue, Julie. In a big clinic or one connected to a hospital, a patient might have to go to different locations for different tests and procedures. It’s easy for the patient to feel ‘herded,’ and that’s what we want to avoid. Some place that I read about—perhaps Geisinger—assigns a guide to each patient. This would be a perfect duty for a volunteer with an outgoing personality.”
“Great idea, as long as the volunteer isn’t a curmudgeon. It would be better if everything could be done in the clinic exam room. This would include patient registration, nurse time, time with the physician, and scheduling the next appointment. Of course, this would require careful coordination.”
“I would call it choreography; but under any name, it’s a great idea. We’re already doing this in our pulmonary area. So Julie, we’ve put together our list of basic requirements, and we’ll talk in more detail about these in subsequent weeks. Do you think we should give our model clinic a name?”
“Of course. Let’s call it The Jaded Julie Primary Care Clinic.”
“(Now you know what I meant when I spoke of chutzpah.) Even though the name is not new, I think we should call it The Medical Home.”
Affinity’s Kaizen Curmudgeon
Thursday, September 3, 2009
The Evolution of Personalized Care
“In earlier conversations, Curmudge, you described family medicine in 1940 based on your personal experience. Back then, personalized care was the norm. Most docs were in solo practice with little or no supporting staff, they knew their patients well because they had delivered many of them, and they were willing to make house calls—sometimes in the middle of the night.”
“Seventy years ago, Jaded Julie, the financial side of solo practice was also pretty straightforward. Our family doctor’s patient load (panel) was kept low by the village’s low population. He charged what he felt was reasonable, my parents paid the bills, Dr. Arnold had a successful medical practice, and we enjoyed personalized care.”
“But now, Curmudge, a solo-practice doc is likely to be a preferred provider for an insurance company and he/she also has Medicare patients. Because of the level of reimbursements, his panel must expand to keep the practice viable. If the all-by-himself doc can’t expand his time to fit his panel and still get even a little sleep, there goes personalized care out the window.”
“That would seem be the case, Julie. In addition, think about how much more technically complex primary care has become. The advances in medicine itself are mind-boggling. Even small clinics have lab and radiology facilities, and the primary care docs have seemingly become the gateways to specialists for every disease, organ, and appendage. Then there are all of the externalities of health care delivery—insurance, Medicare, and regulations that change almost daily.”
“(Externality? I’m not sure what this is, but it sounds like more work.) You have described a rather unenviable plight for today’s primary care docs. So what, Ancient Oracle, do you suggest to get them out of it?”
“Suggest? No way! That’s beyond my salary grade. We must classify any statement that sounds like my judgment as pure conjecture. All I do is report what I find in the literature. Here’s an example, a Dr. Iliff, who sounded in 2003 as if he had done everything right in his solo practice (1). Seemingly everyone on his staff is a long-term employee: ‘My nurses have worked with me so long they know what I am going to say without my saying it.’ He has a long-time friend, a physician’s assistant, who also operates a solo practice; he helps smooth out the peaks in the doctor’s daily workload. Thus it would appear that the doctor has surrounded himself with surrogates who contribute greatly to his patients’ satisfaction. Perhaps we can call his practice ‘augmented solo.’”
“Curmudge, most docs that I know are, by nature, inclined to provide all of the personalized care that their patients desire. Their biggest constraint is lack of time. Dr. Iliff’s professional staff—because of their high quality and long service—make up for the doctor’s time limitation. But how does the doctor handle those externalities that you mentioned? Things like insurance, lab reports, reports from specialists, and Medicare?”
“He didn’t address many of these in his article, but he did emphasize that he limits his practice and keeps his office as simple as possible, with all records stored on site almost at arm’s reach. One might suspect that he has adequate—but minimal—clerical help who match the quality of the rest of his staff.”
“Well that’s one way to achieve personalized care. Are there others?”
“Sure thing, Julie. One is called ‘Concierge Medicine’ (Wikipedia calls this ‘Direct Care’). ‘Here are the basics: The patient pays an annual fee, ranging anywhere from $1500 to $10,000 a year for 24/7 access to her doctor. That means calls in the middle of the night, immediate, hour-long appointments, hospital visits, even house calls in some cases. Sometimes the fee includes appointment charges, but sometimes those are added on. Tests cost extra. Referrals get paid for separately’ (2). By significantly limiting his panel (100 to 1,000 patients), the physician is able to spend more time with each patient as needed. Typically, the concierge medicine practice does not become involved with insurance externalities; a patient with insurance handles that on his own.”
“I understand, Curmudge, that there are several business models for direct care.”
“One, apparently attractive to the uninsured, gets away from the pretentious connotation of ‘concierge’ by using the more descriptive term, ‘retainer practice.’ They charge $99 to join and then a flat monthly rate of $39 to $119 (3). Apparently however, retainer physicians are facing legal obstacles in some states (4). Primary care is certainly dynamic, Julie. Stay tuned for the latest news.”
“At your torpid tempo, Speedy, we could spend all year talking about primary care. When are we going to get to the medical home concept?”
“Never fear, Julie. The next time we talk about primary care, the medical home will be center stage.”
Affinity’s Kaizen Curmudgeon
(1)Iliff, D. Solo practice: the way of the future. http://www.aafp.org/fpm/20031000/23solo.html
(2)Trisha Torrey. Patient empowerment blog. http://patients.about.com/b/2008/03/21/your-doctor-on-call-247-for-a-price.htm
(3)Seattle doctors try flat-rate, no-limit primary care. (July 7, 2009)
http://www.medscape.com/viewarticle/705446
(4)Retainer physicians help uninsured but face legal obstacles. (June 4, 2009).
http://www.medscape.com/viewarticle/703900
“Seventy years ago, Jaded Julie, the financial side of solo practice was also pretty straightforward. Our family doctor’s patient load (panel) was kept low by the village’s low population. He charged what he felt was reasonable, my parents paid the bills, Dr. Arnold had a successful medical practice, and we enjoyed personalized care.”
“But now, Curmudge, a solo-practice doc is likely to be a preferred provider for an insurance company and he/she also has Medicare patients. Because of the level of reimbursements, his panel must expand to keep the practice viable. If the all-by-himself doc can’t expand his time to fit his panel and still get even a little sleep, there goes personalized care out the window.”
“That would seem be the case, Julie. In addition, think about how much more technically complex primary care has become. The advances in medicine itself are mind-boggling. Even small clinics have lab and radiology facilities, and the primary care docs have seemingly become the gateways to specialists for every disease, organ, and appendage. Then there are all of the externalities of health care delivery—insurance, Medicare, and regulations that change almost daily.”
“(Externality? I’m not sure what this is, but it sounds like more work.) You have described a rather unenviable plight for today’s primary care docs. So what, Ancient Oracle, do you suggest to get them out of it?”
“Suggest? No way! That’s beyond my salary grade. We must classify any statement that sounds like my judgment as pure conjecture. All I do is report what I find in the literature. Here’s an example, a Dr. Iliff, who sounded in 2003 as if he had done everything right in his solo practice (1). Seemingly everyone on his staff is a long-term employee: ‘My nurses have worked with me so long they know what I am going to say without my saying it.’ He has a long-time friend, a physician’s assistant, who also operates a solo practice; he helps smooth out the peaks in the doctor’s daily workload. Thus it would appear that the doctor has surrounded himself with surrogates who contribute greatly to his patients’ satisfaction. Perhaps we can call his practice ‘augmented solo.’”
“Curmudge, most docs that I know are, by nature, inclined to provide all of the personalized care that their patients desire. Their biggest constraint is lack of time. Dr. Iliff’s professional staff—because of their high quality and long service—make up for the doctor’s time limitation. But how does the doctor handle those externalities that you mentioned? Things like insurance, lab reports, reports from specialists, and Medicare?”
“He didn’t address many of these in his article, but he did emphasize that he limits his practice and keeps his office as simple as possible, with all records stored on site almost at arm’s reach. One might suspect that he has adequate—but minimal—clerical help who match the quality of the rest of his staff.”
“Well that’s one way to achieve personalized care. Are there others?”
“Sure thing, Julie. One is called ‘Concierge Medicine’ (Wikipedia calls this ‘Direct Care’). ‘Here are the basics: The patient pays an annual fee, ranging anywhere from $1500 to $10,000 a year for 24/7 access to her doctor. That means calls in the middle of the night, immediate, hour-long appointments, hospital visits, even house calls in some cases. Sometimes the fee includes appointment charges, but sometimes those are added on. Tests cost extra. Referrals get paid for separately’ (2). By significantly limiting his panel (100 to 1,000 patients), the physician is able to spend more time with each patient as needed. Typically, the concierge medicine practice does not become involved with insurance externalities; a patient with insurance handles that on his own.”
“I understand, Curmudge, that there are several business models for direct care.”
“One, apparently attractive to the uninsured, gets away from the pretentious connotation of ‘concierge’ by using the more descriptive term, ‘retainer practice.’ They charge $99 to join and then a flat monthly rate of $39 to $119 (3). Apparently however, retainer physicians are facing legal obstacles in some states (4). Primary care is certainly dynamic, Julie. Stay tuned for the latest news.”
“At your torpid tempo, Speedy, we could spend all year talking about primary care. When are we going to get to the medical home concept?”
“Never fear, Julie. The next time we talk about primary care, the medical home will be center stage.”
Affinity’s Kaizen Curmudgeon
(1)Iliff, D. Solo practice: the way of the future. http://www.aafp.org/fpm/20031000/23solo.html
(2)Trisha Torrey. Patient empowerment blog. http://patients.about.com/b/2008/03/21/your-doctor-on-call-247-for-a-price.htm
(3)Seattle doctors try flat-rate, no-limit primary care. (July 7, 2009)
http://www.medscape.com/viewarticle/705446
(4)Retainer physicians help uninsured but face legal obstacles. (June 4, 2009).
http://www.medscape.com/viewarticle/703900
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