Hundreds of Pearls from 40 Years in Practice

1. Hundreds of Pearls from 40 Years in Practice Robert Kotler, MD, FACS

2. "MEDICAL PRACTICE IS AN ART BASED UPON A SCIENCE" "We're here to train you how to treat patients, not just to operate on them.“ - Albert Andrews, Jr., MD, Professor and Chief, University of Illinois, 1972. "The secret of patient care is in the caring for the patient.” - Francis Peabody, Jr., MD, Harvard Medical School, 1929.

3. THE BASICS

4. YOU GAIN THE PATIENT’S CONFIDENCE BY YOUR APPEARANCE AND YOUR MANNER: • DRESS PROFESSIONALLY. • THANK THE PATIENT FOR COMING TO CONSULT WITH YOU. • BE HUMBLE. NEVER ARROGANT. • REMEMBER: “HE CURES MOST IN WHOM MOST ARE CONFIDENT.”

5. BEFORE ANY EXAM, WASH YOUR HANDS IN FULL VIEW OF THE PATIENT. • DON’T USE MEDICAL TERMS. HOW MANY PATIENTS KNOW WHAT THE WORDS “AESTHETIC” OR “NEOPLASM” MEAN? • SAY “ NO CANCER, I REPEAT NO CANCER” INSTEAD OF “ THE BIOPSY WAS BENIGN”

6. WHEN TREATING KIDS, YOU MUST WIN THEIR TRUST AND THE PARENT’S CONFIDENCE. • LET THE CHILD TOUCH AND FEEL THE SHINY INSTRUMENT. • TELL THEM IF YOU’RE GOING HURT THEM. • DISTRACT THEM WHILE YOU ARE INJECTING LOCAL. PLAY A GAME: WHO CAN COUNT TO 10 THE FASTEST?

7. AFTER SURGERY, YOU (NOT THE NURSE OR SECRETARY) SHOULD MEET WITH THE FAMILY OR FRIENDS • TELL THEM “EVERYTHING WENT WELL.” • IF THERE IS A PROBLEM, TELL THEM YOU WILL “DO EVERYTHING POSSIBLE TO TAKE CARE OF THE PROBLEM” • NEVER HIDE FROM A POOR RESULT.

8. ASK FOR A CONSULTATION OR A SECOND OPINION BEFORE THE FAMILY DOES. • GIVE SEVERAL CHOICES OF CONSULTANT. • IF IT IS ABOUT A PROBLEM OR COMPLICATION, MAKE SURE IT IS AT “NO COST” TO THE PATIENT. • PICK YOUR CONSULTANTS CAREFULLY. SOME KNOW HOW TO SPEAK TO PATIENTS BETTER THAN OTHERS • YOU NEED A CADRE OF ALLIES – ORAL SURGEONS, NEUROLOGISTS, DERMATOLOGISTS, ETC.

9. ALWAYS RECORD THE PATIENT’S HOME PHONE, CELL PHONE AND PHARMACY ON YOUR PDA OR POCKET DIARY. • CALL THE PATIENT THE NIGHT OF SURGERY. • PATIENTS ARE AMAZED, SURPRISED AND IMPRESSED.

10. YOUR OFFICE

11. RUNING ANY OFFICE IS CHALLENGING • HIRE ONLY THE BEST. EXPERIENCE IS IMPORTANT. SEE OUR TEN COMMANDMENTS OF EMPLOYERSHIP. • YOUR OFFICE MUST BE IMMACULATE AND NEAT. • STUDY YOUR DENTIST’S OFFICE AND PRACTICE. • DENTISTS RUN A TIGHT SHIP.

12. INVEST IN GOOD EQUIPMENT • HAVE AN INEXPENSIVE OFFICE OPERATING MICROSCOPE OR LOUPES. • FULL COMPUTERIZATION. • ARRAY OF TOP-QUALITY INSTRUMENTS FOR BIOPSY, MINOR PROCEDURES.

13. SURGERY-ONLY DAYS AND OFFICE-ONLY DAYS. • DON’T WATCH THE CLOCK IN SURGERY • WHY WORRY ABOUT AN OFFICE- FULL OF IRATE PATIENTS? • LEAVE SOME SPACE FOR ADD-ONS AND EMERGENCIES • IF NO SURGERY, DO OFFICE PAPERWORK OR TAKE YOUR KIDS TO DISNEYLAND

14. DO BIG, COMPLEX CASES EARLY IN THE WEEK. • THAT LEAVES SEVERAL WEEKDAYS TO HANDLE THE COMPLICATIONS, RIGHT? • SHORTER, SIMPLER CASES AT END OF WEEK

15. WATCH-WORDS • “DON’T EVEN TRUST YOUR MOTHER” (SOUND FAMILIAR?) • “TRUST BUT VERIFY.” • “WATCH YOUR NUMBERS.” • DETAILS MATTER.

16. HAVE AN OFFICE S.O.P.(STANDARD OPERATING PROCEDURE) MANUAL. “HOW WE RUN OUR PRACTICE.” • EVERYTHING IN WRITING. • THE STAFF MUST STUDY THE MANUAL. • INCLUDE EVERY OFFICE FORM.

17. HAVE PATIENTS COMPLETE QUESTIONNAIRES. SEPARATE QUESTIONNAIRES FOR VARIOUS TOPICS, E.G. • NASAL/SINUS QUESTIONNAIRE • FACIAL COSMETIC QUESTIONNAIRE • SKIN TREATMENT QUESTIONNAIRE SAVES YOUR TIME

18. BLOCK OUT TIMES FOR MEETINGS, VACATIONS EARLY IN THE YEAR. • DON’T MISS YOUR KIDS’ SOCCER GAMES. DO AN ANNUAL DAD’S OR MOM’S “DITCH DAY” AT DISNEYLAND. • FOCUS ON “COMPRESSING” THE YEAR’S WORK. DON’T LET WORK EXPAND TO FILL ALLOTTED TIME. • YOU NEED TO RE-CHARGE YOUR BATTERY.

19. TAKE YOUR STAFF TO DINNER OR LUNCH. • “GOOD AND WELFARE”. • YOU’LL LEARN A LOT.

20. HANDOUTS, HANDOUTS, HANDOUTS! • FOR PATIENTS, “EVERYTHING IN WRITING.” ALSO, AVAILABLE ONLINE. • PRE-OP AND POST-OP INSTRUCTION SHEETS • HAVE FAMILY/FRIEND REVIEW WHILE WAITING.

21. OPERATING ROOM

22. CHECK/CONFIRM ALL MEDICATIONS INJECTED INTO PATIENT. • HAVE THE ANESTHESIOLOGIST CHECK ALL MEDS TO BE INJECTED, INCLUDING LOCAL. • SAFER TO USE THE SAME MEDICATIONS ALL THE TIME. • YOUR PROTOCOL BOOK SHOULD LIST ALL MEDS TOPICAL OR INJECTED. RN MUST READ IT.

23. O.R. PROTOCOLS: “HOW I DO IT.” • LIST INSTRUMENTS, LOCAL ANESTHETICS, DRESSINGS, SUTURE PREFERENCES. • “EVERYTHING IN WRITING.” THIS WILL SAVE YOU TIME AND AGGRAVATION.

24. DEVELOP YOUR OPERATING ROOM TEAM. • SAME SURGICAL TECH, SAME CIRCULATOR, SAME ANESTHESIOLOGIST, SAME PACU NURSE. • STORE YOUR SUPPLIES IN DEDICATED SPACE.

25. PURCHASE YOUR OWN INSTRUMENT SETS. • DEVELOP SETS FOR YOUR MOST COMMON CASES, e.g. “NASAL- SINUS TRAY.” • SURGICAL INSTRUMENT COMPANY WILL PUT YOUR NAME ON THEM AND THE DATE OF PURCHASE, FREE. • ALWAYS HAVE ONLY YOUR ASSISTANT WASH AND PREPARE THE INSTRUMENTS. THEY WON’T GET “ LEGS”.

26. CONTINUING EDUCATION

27. VISIT OTHER SURGEONS IN BOTH THEIR OFFICE AND OPERATING ROOMS. • IN O.R., TAKE NOTES, DO NOT SPEAK UNLESS SPOKEN TO. • ALWAYS SEND A THANK-YOU NOTE AND A SMALL GIFT. • DO THE ABOVE AND YOU WILL ALWAYS BE WELCOMED BACK. • ASK FOR A COPY OF FORMS, HANDOUTS, ETC.

28. VISIT SPECIALTY HOSPITALS • MANHATTAN EYE, EAR, NOSE AND THROAT • MD ANDERSON

29. UNOFFICAL CONTINUING EDUCATION • TALK TO SURGICAL SUPPLY REPS • HAVE LUNCH WITH AN OLD PRO. THE MORE EXPERIENCE THEY HAVE, THE MORE EXPERIENCE TO SHARE.

30. BEWARE OF JOURNAL ARTICLES FEATURING “A NEW TECHNIQUE.” • CALL THE AUTHOR • SPEAK TO THE SURGEON WITH LONGEST EXPERIENCE • BEFORE YOU DO ONE, WATCH A SURGEON DO IT. • BE LEARY OF PROCEDURES WITH A SHORT HISTORY. • BETTER TO BET ON VETERAN PROCEDURES.

31. SUBSCRIBE TO MEDICAL PRACTICE NEWSLETTERS AND MAGAZINES. READ BOOKS ON MANAGEMENT • THE PHYSICIANS GUIDE TO THE BUSINESS OF MEDICINE, BY ROBERT W. KATZ, MS, CPA • SUCCESSFUL PRACTIC MANAGEMENT TECHNIQUES, BY GEORGE CONOMIKES • ON BECOMING A LEADER, BY WARREN BENNIS

32. KEEP UP WITH WHAT IS HAPPENING IN THE REST OF THE WORLD • WHAT HAPPENS IN THE WORLD- AT- LARGE WILL ALWAYS EFFECT YOU. • THE WALL STREET JOURNAL AND THE NEW YORK TIMES ARE THE TWO BEST PAPERS IN THE COUNTRY.

33. OFFICE CHARTS

34. DICTATE OR RECORD EVERYTHING INTO YOUR COMPUTER. EHRs ARE HERE TO STAY. • CONSULTATIONS, PROGRESS NOTES, TELEPHONE CONVERSATIONS, Rx PHONE-INS. • NOTHING MORE IMPRESSIVE TO ANOTHER DOCTOR -- OR A JURY -- THAN FIRST- CLASS RECORDS. • A QUALITY CHART IS A DIARY.

35. BE SURE TO HAVE COPIES OF ALL PRESCRIPTIONS IN THE CHART. • IF PHONING A PRESCRIPTION, COMPLETE A FORM AND PLACE INTO CHART. • OR, DICTATE A CHART NOTE, INCLUDE THE PHARMACY NUMBER AS WELL AS PRESCRIPTION DETAILS.

36. DOCUMENT ALL PATIENT TELEPHONE CONVERSATIONS IN THE CHART. • LIKEWISE FOR YOUR STAFF • “ MRS. SMITH ASKED ABOUT RUNNING A 10K RACE 2 DAYS AFTER SURGERY; ADVISED AGAINST. WAIT UNTIL 14 DAYS AFTER SURGERY.”

37. MAKE YOUR CHART NOTES VALUABLE. • STATE WHAT YOU’RE DOING AND WHY YOU’RE DOING IT. IF A PROBLEM, STATE WHY IT HAPPENED AND YOUR PLAN TO CORRECT. • TAKE PHOTOS TO DOCUMENT BOTH GOOD RESULTS AND COMPLICATIONS • RECORD PATIENT SENTIMENTS OBJECTIVELY

38. MISCELLANEOUS

39. FIND TOP QUALITY AND PATIENT-FRIENDLY RADIOLOGISTS AND LABS. • TIMELY AND ACCURATE REPORTS A MUST. • READ THEM YOURSELF. IF INCONSISTENT WITH CLINICAL DATA, CALL THE RADIOLOGIST OR PATHOLOGIST. • NO REPORTS SHOULD BE FILED WITHOUT YOUR INITIALING. NOTE WHAT YOU DID ABOUT THE RESULT AND WHO WAS NOTIFIED.

40. REGARDLESS OF YOUR PRACTICE SETTING, YOU NEED GOOD FINANCIAL ADVICE. • USE AN ACCOUNTANT WHO HAS GOOD BUSINESS SENSE WHO ISN’T JUST A BEAN-COUNTER. • A MEDICAL PRACTICE MANAGEMENT CONSULTANT IS YOUR BEST SINGLE SOURCE OF HELP. • FRIENDS WILL GIVE YOU UNBIASED ADVICE.

41. “DILUTE YOUR RESPONSIBILITY” - JOSEPH SCHIFF, MD • USE CONSULTANTS LIBERALLY. • A GP OR INTERNIST DOES THE PRE-OP H&P. NOT YOU • HAVE YOUR ANESTHESIOLOGIST INVOLVED BEFORE THE PROCEDURE IF NEEDED.

42. “YOU DO NOT HAVE TO GET A GREAT RESULT -- JUST DO NOT GET A BAD RESULT” - HOWARD DIAMOND, MD

43. “DON’T DO ANYBODY ANY FAVORS.” - MOREY PARKES, MD • DON’T CUT CORNERS TO INCREASE RISK TO PATIENT OR YOURSELF. • DON’T TRY TO “SAVE THE PATIENT MONEY” BY NOT DOING INDICATED TESTING.

44. “WHEN ALL GOES WELL, WE DON’T LEARN ANYTHING.” -ARTHUR DEBOER, MD • ALL SURGEONS MUST ACCEPT COMPLICATIONS. “STAND BEHIND YOUR WORK.” • JUST DON’T REPEAT THE SAME MISTAKE. • KEEP A FILE ON EACH PROCEDURE – MAKE NOTATIONS FOR “ NEXT CASE”

45. FAVORITE DO’S AND DON’TS

46. THE DON’TS • DON’T PROVIDE CURBSTONE PRESCRIPTIONS TO EMPLOYEES, FRIENDS, NURSES, YOUR CAR MECHANIC, ETC. • DON’T TREAT YOUR EMPLOYEES. REFER TO YOUR BEST COLLEAGUES. • DON’T REFILL RXs AD LIB. WRITE: “ NO REFILLS” • IF THE PATIENT IS STILL HAVING PAIN AFTER THE FIRST BATCH, WHY IS THAT? • SEE THE PATIENT WHEN PAIN IS NOT SUBSIDING AS ANTICIPATED.

47. DON’T DISPENSE PAIN PILLS, NARCOTICS, TRANQUILIZERS OR SLEEPING PILLS IN YOUR OFFICE. • YOU’RE NOT A PHARMACY. YOU DON’T HAVE A LICENSE FOR THAT. • YOU’RE SUBJECT TO AUDITS FROM MEDICARE AND OTHER BUREAUCRACIES. WHO NEEDS THAT? • BETTER IS TO HAVE A NEARBY PHARMACY FILL THE PRESCRIPTIONS AND DELIVER IT TO YOUR OFFICE PRE-OP.

48. DON’T DO ANYTHING YOU COULD NOT LATER DEFEND AS TOP-QUALITY MEDICINE. • NO “LONE RANGER”. STAY MAINSTREAM. • BEWARE EXPERIMENTAL TREATMENTS. • BEWARE SHORTCUTS.

49. DON’T TAKE CALL OR COVER FOR • COLLEAGUES YOU DO NOT KNOW, DO • NOT LIKE, OR DO NOT RESPECT.

50. DON’T TRY TO CHEAT INSURANCE COMPANIES. • THEY’RE SMARTER THAN YOU ARE. NASTIER, TOO. • THEY’LL REPORT YOU TO THE MEDIA OR MEDICAL BOARD. NEITHER WILL BE YOUR FRIEND. • “DOC, COULD YOU BILL THIS NOSE JOB TO MY INSURANCE COMPANY; I HAVE GREAT POLICY.” • HOW DO YOU KNOW THE “ PATIENT” IS NOT AN UNDERCOVER GOVERNMENT AGENT. OR, WORSE, a 60 MINUTESREPORTER?