Deborah Winiger, MD

One of the main reasons I went into medicine was because I enjoy taking care of patients and building relationships.  It was a driving force into my decision to go into family medicine.  Over the years, I have developed wonderful relationships with many of my patients and families.  I had the honor of delivering babies for many years of my practice and formed bonds that have lasted for many years.

Watching children grow up and having the privilege of caring for two and three generations of families make coming to work every day worthwhile.

In this new era of medicine, patients are having to make choices about treatments based on costs - some are developing large debts to their physicians - and it has had an incredible impact on the relationship doctors have with their patients.  I try very hard to stay out of discussions of my patient bills, but invariably I get drawn in by my patients or my staff.  I have a wonderful staff that handles patient accounts so that I can spend my time taking care of patients but occasionally I have to get involved.

As such, I have learned about insurance policies than I ever want to know - patients often ask my opinions on which plan to choose, asking to explain their deductibles and discussing medications and cost.  Patients look to me and my staff to help them navigate the confusing world of insurance companies and requirements.  With all the changes, patients who have been used to paying only a copay or nothing don't understand deductibles, so we spend a great deal of time explaining them.

I think it is important for physicians to try to continue to build relationships with patients to generate loyalty.  It makes what we do more meaningful as well as decrease our malpractice risk when better bonds are formed.  With patients changing insurance often, their loyalty becomes more difficult to earn.  Patients are quick to change doctors for the smallest issue or just because of convenience making relationships more challenging.

We have to remember that patients go through difficult times both financially and emotionally and we need to be there for them even in troubled times.  We can be that calming influence in their lives even when make are lives difficult.  Hopefully we can focus on that when dealing with patient's financial and insurance issues.

I plan to continue to connect with my patients and enjoy being part of the lives and helping them to live healthy productive lives.  Hopefully our patients the effort we make despite the time and effort it takes to be a doctor in this changing healthcare environment.

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A lot stands in the way of a strong patient-doctor relationship these days, specifically the cost of care. But physicians must remain committed.

The Evolving Patient-Doctor Relationship is as Vital as Ever

2017 promises to be a unique and challenging year for physicians.  With the possible repeal of the Affordable Care Act, the start of implementation of the Medicare and CHIP Reauthorization Access (MACRA) Act, and continued push of value based payment systems there is a lot of uncertainty for physicians in independent practice.

Value-based care is a concept we all try to do for our patients, but never as a part of reimbursement.  The change from fee for service will be a significant adjustment for many practices.  Even though Medicare gave us a slight reprieve by allowing partial participation, it is still a difficult decision to decide whether to participate in MACRA or not..  Being part of an Accountable Care Organization (ACO) I have no choice, but hopefully the larger organization will be able to fare better in a system that so far isn't looking very favorable to small practices.  My goal is to stay active in my ACO board to be able to help navigate the process for the other physicians.

It will take a difficult balance to provide the personalized care my patients have grown accustomed to without being forced to make decisions for financial reasons. I also worry about getting lost in the sea of paperwork and regulations to document the care we provide.   Hopefully working as a team with my staff, with everyone working to the level of their degree to streamline work flow, will help the process.  Hopefully the EHR companies will continue to enhance systems and look for ways to be more interactive to share information.

With the current state of insurance shifting more of the burden of cost to the patient it's becoming more difficult to collect patient balances from patients who don't have the money.  Many of them also delay care and ration their medications due to cost.   This will likely only get worse in the upcoming year with increased premiums and companies shifting more cost to employees.  We can hope the new administration will help to move the needle the other way, but it will not be an easy job.

My goal for the new year is to continue to build my practice to maintain my independence in this changing environment.  The rewards and flexibility of independent practice are well worth it - the relations with my patients whom I have developed over my years in practice make every day worth going to work.  Hopefully that is what will keep us all going and as we have adapted to changes over the course of our careers.

Hopefully, I can share tips along the way. I welcome any suggestions from others on successful ways to survive in the new era of medicine.

Next year will be a challenging one for physicians for many reasons. This doctor is looking to survive in the new era of medicine. 

What Will 2017 Bring for Physicians?

I have been in solo practice for 15 years. I am proud that four of my seven staff members have been with me for more than 12 years and the others for more than two. I have worked hard to make my office environment conducive for my employees and make them want to stay. By creating a family atmosphere in the office and listening to my staff, we have created a welcoming environment.  New employees acclimate well and my patients can see the workings of the office and respect the efficiencies that a good staff creates.  It’s a thrill telling my new patients that my staff has been with me for many years.

From my staff’s point of view, they say they enjoy the working environment because of the consistency I create in my patient care. By following guidelines and creating protocols that we all follow, it makes it easy for my staff to know what I would want and even make decisions for me when I’m not there. I also support my staff by standing by them with my patients and not contradicting or questioning them in front of patients.

Even when a mistake is made I show my staff support and explain the situation to the patient. This way they have trust in me and how I handle situations. One of my nurses recently took a second job with another local physician and came back to tell me how she took the consistency in our office for granted and how it made her job enjoyable - her comment was that I “spoil my staff.”

I have tried hard to give raises every year if possible and also reward my part-time staff with paid days off, holiday pay and the flexibility to take time off and cover for each other. I do feel having part time staff can be a benefit - not only for the financial advantage, but the option of having coverage when others are out. By paying slightly higher salaries and offering some benefits, I can attract and keep better qualified staff who will stay and prevent turnover that costs a lot more than the small raises every year.

I am always trying to make changes to the workflow in the office to make everyone’s job easier. By listening to patient and staff suggestions, my practice continues to evolve and change and stay ahead of the trends in technology and practice management and by getting staff to buy in they are willing to learn new methods and make the practice better.

I’m proud that a lot of my staff members have been with me for more than 12 of my 15 years in solo practice. Here’s how I keep them with me. 

I’m Proud to Have a High Rate of Staff Retention

In 18 years of practice, I am proud of the fact that many families have been going to me for a long time, including multiple generations in some families.

In our training as family physicians, we are taught to build relationships with our patients. We want to take the time to get to know them as people and as part of a family and not just as a disease. These relationships can be developed by taking the time to sit down and listen to patients. I spend more time than many physicians to truly see patients and have found you can be profitable without seeing 30-40 patients/day. I have had many patients comment on the fact that I am always willing to listen to them and they appreciate that.

I also have a dedicated staff that has been with me for several years. They get to know my patients and the patients come to trust them and look for their advice. We work as a team whether my PA sees patients or they are seeing the nurse, I am in the background reviewing the encounters so that the next time I interact with the patient, I am aware of what has happened to them.

Taking the time to make notes regarding patients’ personal lives -vacations, weddings, family events and work changes, then asking about them on the next visit makes patients thinks you care. Many are amazed I remember – thank goodness for good notes! I learn a lot from my patients and enjoy sharing their lives.

We also try to be available for patients from having same -day appointments, early morning and late evening appointments to make it easier to be seen. I also have nurses that are available to triage patients daily. Patients feel better about their care if they can be seen and get their questions answered easily.

In this world of being expected to do more in less time and spend more time on the administrative work of patients, we have to remember the real reason we went into medicine and learn to slow down, listen and take time with our patients and they will come back and refer their friends and family.

In this era of added administrative work, it’s important to slow down and listen to your patients. That’s the key to retaining them. 

Looking at Patients as Family

It has been six months since what was supposed to be a disastrous change to ICD 10 occurred. I'm happy to say we are still in business and surviving.  Although no one looked forward to the change and dreaded what could have happened, it appears the delays allowed the insurance companies and EHR vendors to be well prepared and prevent delays. 

I didn’t do much preparation or learning of the new codes. My EHR vendor did a good job with an easy crosswalk program, allowing the entering of ICD-9 codes that displays choices in ICD-10.  It also featured a search function by diagnosis, which has overall worked well. It's sometimes not as easy as ICD-9 but we are learning as time goes along.  We still laugh when unusual choices pop up and can’t wait to pick the code for things like struck by turtle or pecked by chicken, initial encounter!

As of now we have had no coding issues with insurance companies questioning or denying claims due to coding.  Luckily in family practice there is a short list of common codes most often used, which we are have already begun to memorize. I know some specialties, like orthopedics and emergency medicine, have a larger set to choose from and need more specificity for coverage.  The next year will tell if insurance companies get more strict in code review and deny for lack so specificity. 

I had great concern over the last few years and discussed with many colleagues who were doing significant preparation with courses or flash cards. Luckily, my choice to rely on my EHR and other crosswalk programs has paid off.  They have worked fairly easily and only about once or twice a week do I struggle with unusual or vague diagnosis that are difficult to code. 

Overall ICD 10 has worked well, I'm still not sure it helps in the care of our patients or makes us better doctors, but at least it was a fairly smooth transition for us.

 practices family medicine at North Suburban Family Healthcare in Vernon Hill, Ill., and is a member of the 

This article was originally published in the April 2016 issue of

One Practice's ICD-10 Experiences at Six Months

Malpractice is a topic no one wants to discuss since it serves as an added stress and cost to medical practices. However, it is inherent in every physician's career. The thought of an agent of the court coming to your office with notification of a malpractice lawsuit is a nightmare for anyone. Practicing good medicine should be the best way to prevent a lawsuit but a few extra tips always help.

In my opinion, spending time with patients, taking the time to listen, and building relationships are the best way to prevent a lawsuit. You are less likely to miss an important detail, your patients feel cared for, and they are willing to believe that you tried your best - even if there is a bad outcome that is out of your control. This includes your staff who are front line to the patients and can make or break a patient's good opinion.

Another point I find helpful is to ask the patient what they are worried about when they present with multiple complaints. You can spend a great deal of time performing tests and follow up, when all the patient 

 is reassurance that they don't have a certain condition that a friend or family member told them about (one that likely isn't even in your differential diagnosis.)

Giving patients reassurance along with specific follow-up instructions if they don't improve is also important. Written instructions help the patient to understand and remember, and can also serve as documentation if there is ever a future recurrence.

I also find that if a patient insists on seeing a specialist or having a certain test done - even if you don't feel it is necessary - it is sometimes best to acquiesce and comply. You never want to hear a patient say later that they saw a specialist and she made a diagnosis that you missed (or refused to provide the referral.)

Discharging a patient from your practice can also be difficult; even when a patient is noncompliant or does not pay his bills. This must be done correctly by giving the patient 30 days of care and making sure there isn't some other issue that you are not aware of. Not having all the facts prior to patient dismissal may cause a lawsuit to be filed.

Also, you should choose your words wisely. Sometimes saying too much, even if you are trying to be helpful, can be a problem. Be cautious when interacting with patients outside of the office - at the store or a restaurant for instance. I had a case where I saw a patient in a setting outside the office and she mentioned some health issues she was experiencing. I just listened and acknowledged the issues. But, low and behold, this conversation was mentioned in a malpractice case she later filed! Luckily it was dropped right away. Be forewarned: These casual conversations can be construed as advice or an opinion and may be used against you.

Finally, trusting your instincts is important. If you think there is something wrong, even though your tests don't prove it, pursue the issue further until you make a diagnosis. Instinct rarely fails us.

, practices family medicine at North Suburban Family Healthcare in Vernon Hill, Ill., and is a member of the 

How do you help prevent a lawsuit against you and your practice? 

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This article originally appeared in the March 2014 issue of 

Deborah Winiger, MD, says spending time with patients, taking the time to listen, and building relationships are the best ways to prevent a lawsuit.