J. Scott Litton, Jr, MD

Earlier this month, my family and I decided to take an early summer weekend trip to central Florida to visit our relatives. My two daughters had just finished the school year, and as promised to them if their grades were good, they were promised a trip to visit their aunt and uncle in sunny Florida. As we boarded the airplane for a direct flight, my children were very excited to be going away for a few days.

Shortly after the plane reached cruising altitude, I noticed a very obese woman sitting across the aisle from us seemed to not be feeling well. The person sitting beside the woman was using a magazine to try to calm her down by fanning her. I then noted the flight attendant going over to check on her. I heard the passenger beside the woman tell the attendant that she was not feeling well and thought she was going to pass out. At that time, I elected to make it known to the crew that I was a physician and was happy to check on her if needed. I was quickly given permission to assess the woman's condition.

The crew brought me a medical kit that consisted of a stethoscope and a blood pressure cuff. Unfortunately, the woman was very obese and the cuff was not large enough to get an accurate blood pressure measurement. As I questioned the woman about her condition, she informed me that she was short of breath and felt nauseated. I asked the crew to make oxygen available to the woman, thinking that she was possibly having a vasovagal episode. I continued to question the woman about her condition and it was at that time that she informed me that she felt a pressure in her abdomen moving into her chest. I quickly looked in the medical kit and found the routine medications that could be used for an ACLS emergency. I had nitroglycerin available, but since I was not able to get an accurate blood pressure and could only palpate a very weak and thready carotid pulse. I was fearful to use nitroglycerin.

I found a bottle of aspirin and gave a tablet to her and asked her to chew it up and swallow. Shortly before using the aspirin, she became very diaphoretic and clammy. She then told me that she was having a sharp pain in her chest and was feeling very nauseated and was about to vomit. At this point, I was very concerned regarding her condition and informed the crew that she needed to be transported to a hospital as quickly as possible. In just a few seconds, the plane changed course and we started our descent. Once we had landed, the EMS crew and police department awaited our arrival into the gate. I assisted the woman into a wheelchair and helped transport her off the plane.

Once she had left the plane, the crew came to me a few minutes later and informed me that she was on the way to the hospital and that her condition was stable. As we sat at the gate and awaited takeoff, I reflected on the recent events. The condition of the woman and the limited history I was able to obtain led me to conclude that she very likely had a myocardial infarction during our flight. I have been a physician for almost 13 years, and fortunately had never before been asked to provide emergency services to an ill person during a commercial flight. I am hopeful that she ended up doing well and that she was able to get to a hospital rather quickly after her condition became critical. It would not bother me at all if I am able to go another 13 years - and hopefully longer - before I have to act in a similar situation for an ill person during a family vacation.

In a situation such as this, I felt that I acted appropriately and assisted the woman to the best of my abilities with the limited equipment available on the airplane. In retrospect, it would have been nice to have had a larger blood pressure cuff, a pulse oximeter, and other equipment to more appropriately assess her condition. Unfortunately, I do not know the woman's name, nor do I know the final outcome of the events after she arrived at the hospital.

I am hopeful that she ended up doing well and hopeful that once her condition was treated that she was ultimately able to finish her trip to Florida.

Articles

As a physician, you are always on the job; even on your flight to a family vacation in Florida when a medical emergency occurs.

"Is There A Doctor On Board?" This Time, There Was

I finished residency almost 10 years ago. At that time, I was eager to enter my solo family medicine practice in my hometown in rural, southwestern Virginia. I had just completed a very rigorous residency program. My program was unopposed, and with the exception of the surgery residents in our hospital, the family practice residents ran the pediatrics, OB/GYN, and internal medicine services. When I trained, there were no weekly time limits on our participation in clinical activities. The time limits actually started the day after I finished my training. I barely missed it.

When I entered private practice, I was very nervous. With each patient I would see, day to day, I was able to reflect on a particular patient that I had treated in residency. "Read about your patients," was a very famous line from many of my attendings both in medical school and in residency. I completed board certification just after finishing residency and thought I was set to go.

Now 10 years have passed. I found myself with the task of having to take the certification exam, yet again. However, this time it was for re-certification. Needless to say, I was very nervous. Sure, I have been reading about my patients. I easily met the annual CME requirements year after year. I had completed each step of the maintenance of certification process for the American Board of Family Medicine (ABFM), for which my class was the first ones to enter. The question still remained: Had I done enough?

As I started to review and prepare for the upcoming exam, I asked myself numerous times: Had I been studious enough over the past 10 years? Many times I would come home after a hard day's work and simply crash. The daily readings were sometimes completed, but had I read enough? Had I prepared enough for the exam? As I took the re-certification exam, I was able to complete the test fortunately in much less time than what was allocated. As I drove home from the testing center, I was both relieved to have finished it and anxious to get my scores back. Just last week, I was thankful to find out that I had received a passing score.

I used a compilation of different study methods for the exam. In the months before the exam, I would quickly review the pertinent journal articles that related to patients I had encountered during each week. The practice questions on the ABFM website were also very useful. Probably the most useful method was to complete the American Academy of Family Physicians (AAFP) home study review course. I was able to watch review lectures on my iPad while exercising each day. My exam prep seemed to fit in easily with my daily schedule.

In the course of a typical year, many of us will receive advertisements in the mail for board prep courses. There are many online sites available that can prepare you for the exam as well. While I chose only the AAFP prep course, I think any review course would be helpful. For my particular practice, I treat mainly very healthy individuals that are very focused on keeping themselves well. With such a focused patient population, one is not exposed to the varied disease states that you would find during residency training. This is why a board review course is helpful. You are forced to relearn things that you have learned in the past and might not have thought about much during private practice. I have not delivered a baby since 2005 (in our hospital's emergency department while on call), therefore I had to refresh my memory regarding typical obstetrics ante partum and postpartum management. That is just one example to site.

The best advice I can give to a colleague looking to re-certify is to complete your daily reading. I was probably not as vigilant as I should have been over the past 10 years, but the next 10 will definitely be different. Read about disease types that you do not regularly treat on a daily basis. Get a good review course and start it a few years before you are due to re-certify so that the material you once learned can be easily recalled again. Continue to read about your patients. This is the best advice that I can pass along. I regularly teach medical students and residents, and this is my constant reminder to them. Read about your patients.

Many have debated the decision to be board certified, but the process of reviewing and refreshing ourselves regarding things we have once learned, and should not forget, is very helpful for allowing us to be well-rounded physicians. Do not overwhelm yourself with too many methods of review or too many courses. You can easily spend too much money and not be able to focus on the material at hand. The one review course and daily reading worked for me, and I think it will do well for you as well.
 

Many have debated maintenance of certification, but I think reviewing and refreshing ourselves allows us to be well-rounded physicians.

Advice for Physicians Preparing for Maintenance of Certification

It all started with the passage of the Affordable Care Act. From the time our lawmakers passed healthcare reform up until now, the landscape of medicine has been changing. Any physician can tell you that some changes were needed. The cost of healthcare has been increasing and far outpacing inflation for many years now. While the intent of the ACA was good, the aftershocks are changing the very way we practice medicine.

Small hospitals in rural areas will be the first ones to enact changes. Reimbursements are not increasing and the new penalties that hospitals across the nation face for readmissions within 30 days, the decreasing numbers of actual admissions, and the increasing numbers of outpatient observation admissions are forcing all facilities to lay off personnel and decrease services provided. Coupling this with the fact that fewer patients are coming to doctor's offices for services produces a very steep decline in revenue.

Our local small hospital is facing this very problem. In our small rural community, we have a higher than average number of Medicaid patients, a higher than average number of self-pay patients, and a lower than average percentage of patients with third-party insurance. Such changes have placed a sharp decrease in the hospital's operating budget and it is now faced with having to close the ICU and decrease the number of inpatient beds to account for the decreased patient demand.

Businesses are facing a similar problem. The sharp increases in insurance premiums are forcing employers to either decrease the benefits provided to their workers or increase the cost burden to workers by way of higher premiums and higher out-of-pocket copayments and deductibles. This reaction by small businesses has a direct negative effect on hospitals and medical practices, as many patients are either forgoing medical services or delaying services due to the higher cost on the employees.

With the passage of the healthcare reform law, Medicaid expansion has been stagnant as well. By avoiding Medicaid expansion, many low income families will find themselves with lesser than average paying policies and will also find it very difficult to identify physicians that are willing to accept the lower reimbursements for the services provided. My practice still accepts Medicaid payments for our existing patients, but the decreased reimbursements by the plans have forced my practice to be unable to accept new Medicaid patients for quite some time now.

The changes we are facing have produced a perfect storm for our healthcare industry. The sluggish economy is causing everyone to cut back on regular spending. This has a trickledown effect on medical practices and hospitals alike.

How are we to embrace the changes thus far and the ones that are still to come once the full effects of the ACA are felt in 2014? At this point, there is no clear answer to the problem and unfortunately the effects listed above will continue to occur as time passes on. Physicians are still faced with the challenge of not only providing the needed medical services to their patients, while still being faced with the ever-increasing costs of operating costs outpacing the flat increases of reimbursements for services provided.
 

Physicians will likely have a hard time embracing future changes under the Affordable Care Act as the current effects are less than desirable already.

Healthcare Reform is Changing the Landscape of Medicine

I often look back on my time in medical school. The first day of classes was basically an orientation time. We met our instructors and received handouts for the first-year courses. The day ended with a nice dinner at the dean's house for all first-year medical students. As we prepared to leave for the evening, the dean's words continue to echo in my mind. He said, "Everyone go home this evening and relax. Watch the sun go down and make your preparations for the next day to come, for this will be the last day that you will be completely up to date with nothing else pressing to do."

How true those words are from 1996. Time is by far the biggest enemy for the physician in clinical practice. How many of you go into work each day and struggle to complete patient care, complete administrative paperwork, return phone calls and messages from concerned patients, meet with hospital personnel regarding the newest changes to come, etc.? It seems as if there is just never enough time to get everything done each day.

Time management is one of the most critical areas that physicians attempt to manage. In terms of patient schedules, we try to schedule patients on our appointment list with enough time to carefully listen to each complaint and manage each issue needed. As patients come and go in the office, the issue of same-day, call-in patients always comes up. We try our best to see them as best we can and attempt to leave enough empty space in the daily schedule for such open access. However, the messages to be returned, tests and reports to review and follow up on, and employee management are all factored in to this block of time. How can one manage everything effectively and go home on time at quitting time?

The short answer to the concept of time management is that no one will ever get it right every time. We try to properly educate our patients regarding same-day call ins, message return, etc., and effectively prepare them for the amount of time that they should expect before their concern or problem is addressed. Nurses triage the incoming calls for same-day visits and patient concerns and those are handled in order of importance. Fortunately for my practice, we utilize a very robust EHR that provides an intra-office messaging system. As patients call in with concerns or questions, the nurse attaches their concern to a message and it is forwarded to me. I will answer such messages between patient visits and at lunch time so that the delay is as short as possible. We also utilize a patient portal that allows me to communicate with patients via secure electronic communication without the extra step of involving the nurse or medical assistant.

I very much try my best to leave the office on time each day. Of course the daily work is not complete when I leave, but of the work that is left to be completed, I can wrap it up at home after the kids have gone to bed and after I have spent quality time with my wife. Of course this extends the total duration of my awake time, but it allows me to get the day's work completed and finished each night before I go to bed. As I go into work the next day and the nurses and medical assistants review my message replies, they will joke with me and say, "...you were up pretty late working last night weren't you doctor?", as they are able to see the timestamp on the replies.

The take home message regarding time management is that we can never master our day completely. However, after physicians have been in clinical practice for a certain period of time, we are able to effectively grasp exactly how much work we can complete in a day and we adjust or tailor our schedule as needed.

I have colleagues that can see patients faster than me and have colleagues that see patients slower than me. Whatever your pace may be, adjust it so that you are able to complete each day's work within that day. Never get yourself into the bad habit of procrastination. Do your best to work hard and efficiently while you are at work and most importantly, do not take away time from your family on a routine basis.

As physicians, grasp how much work you can do in one day, adjust your schedule accordingly, and start fresh each new day.

How to Manage Time Efficiently as a Physician

In a busy medical office, each new day brings new challenges that must be addressed. There has never been a more daunting task the physician must face than to get his/her employees to work together as a team. In my office, I strive to encourage employees to work as a single unit, rather than the front-office staff versus the back-office staff. There are several ways this can be addressed and I will outline some of the ways I have handled it.

Nonclinical employees must realize that they are an important cog in the wheel of patient care. This concept has been stressed by me since day one of my practice. Even though the reception staff might not have an actual hand in providing care for the patient, I remind them that they are the first faces our patients see when they come to the office. A friendly smile and greeting is very important. Patients will not want to come back to an office where they do not feel welcome and this is so very important when the reception staff greets them or speaks to them on the phone. The reception staff understands that verifying demographic information, insurance information, etc., ensures that we will be able to contact the patient successfully when needed and also enables us to successfully bill for the services provided.

Cross training employees to help each other when needed is vital. In our practice, there are three providers and four nurses. The extra nurse is very helpful for administering allergy injections, fingerstick INR monitoring, and vaccine administration for walk-in patients. If the number of walk ins should be higher than normal, the other nurses will pitch in and help as needed. If there are no walk ins present and the waiting room is full of scheduled patients to be seen, the float nurse assists with obtaining vitals and rooming the patients. Each nurse also regularly reviews the intra-office messaging system and all are able to phone or contact patients by our online portal for delivery of instructions or results. The extra nurse has worked well for providing adequate coverage if one of the other nurses happens to be sick or off for a scheduled vacation. Each nurse knows that the others will help as needed and this has worked well thus far.

Schedule routine meetings with each group of employees at your medical practice. Have you ever had employees that seem to not be as efficient or as busy as you would like? There is no better method for encouraging better productivity than to regularly meet with each specific group of employees and review your expectations. This has worked well thus far with each group and during these meetings I allow the employees to have a brainstorming session for providing suggestions for improving work flow and efficiency.

Another method of measuring your employees' performance is to randomly poll your patients.

• Did receptionist Y ask for your demographic information?

• Was the office staff helpful for you today?

• Do you have any suggestions as to how we can improve the services provided to you?

Each recommendation listed is but one way to encourage your employees to work well as a unit. Remind them of how important they are. Remind them that they are doing a good job. Remind them that you could not provide the care to your patients without them. You will find that following some simple steps, as listed above, will motivate your employees to work even harder. The patients will see this and they will be pleased as well.

Members of your medical practice working together is vital to efficiently treat patients and have a successful office.

Getting Your Medical Practice Staff to Work as a Team

On any given day in a busy medical practice, we are all subject to ever-increasing demands for same day care, refilling medications, scheduling procedures, etc. Busy physicians in private practice must continue seeing patients on the schedule and at the same time, we must be aware of the above patient requests and ensure that our employees are all working together for the common good of patient care. How best to keep this cycle moving in an efficient manner is a very challenging task.

In my practice, I am the only physician and I have two nurse practitioners (NPs) that work for me. The nurse practitioners have their own panel of patients; however, this panel is considerably smaller than my panel of patients. As a result, I rely on the nurse practitioners to be available to see patients who call for same day service and acute illnesses. Not only must I continue to care for the patients on my schedule, but I must keep my schedule flexible so that I am available to discuss patient care with the NPs and see any patients that they require assistance with. For almost eight years now, this practice has worked very well and has produced a very high level of patient satisfaction. As patients exit the office, they are encouraged to go ahead and make an appointment for follow-up care. However, some patients are reluctant to do so and after many weeks of procrastination, when they call back for same day care this typically results in an encounter with the NPs.

Each nurse practitioner and myself have one licensed practical nurse (LPN) that works with us to assist with patient care. I have one float LPN that is available for administering vaccines for walk-ins, allergy injections for same day visits, and fingersticks for INR measurements. I try to keep the daily schedule from resulting in excessive work, not only for myself, but for the nurse practitioners as well. This careful work balance allows each of us to feel as if we are staying busy, but at the same time, prevents any one of us from feeling as if we are pulling more than our fair share of the workload. This careful balance has produced a very high level of job satisfaction not only for me, but for the nurse practitioners as well.

The nurses are encouraged to pitch in and help out their co-workers when the patient load starts to increase. Since the NPs have a lighter schedule than me, I am able to use one of their LPNs, or the float nurse to assist with patient care or other responsibilities. While one nurse is getting a patient ready for me, another nurse is filling out physical forms or possibly preparing vaccinations for administration. The nurses all work very well together and this sharing of job functions has also produced a very high job satisfaction rate for each of my employees.

One must not forget the increased strain and stress of the clerical staff. I have two front desk employees that are busy with patient registration, check in and checkout, scheduling of follow-up visits, and patient referrals. During times when the patients are all placed in their rooms, if any of the LPNs have any downtime, they assist the front desk staff with scheduling or referrals. This has worked very well with also producing a very high level of job satisfaction for the clerical staff. Whether the patient sees me or one of the nurse practitioners, the nurses and clerical staff all understand that each patient does not belong to just one provider, rather each patient belongs to and is the responsibility of the medical practice.

It is very important for the physician to ensure that each employee is working efficiently, but not overwhelmed by the current task(s) at hand. Operating a primary-care medical practice can be a very challenging but rewarding occupation. Taking time to understand the duties of each of your staff members and provide the appropriate back up when needed is crucial to operating an efficient practice. A practice that operates efficiently will result in timely patient care, effective patient care, and ultimately will result in the most coveted outcome for a medical practice - a positive word-of-mouth recommendation. Patients can very easily spot an employee that is not happy with his/her job. When your employees are working well together, patients will perceive this and ultimately your outcomes will be positive as well.

Taking time to understand the duties of your staff and provide the appropriate back up when needed is crucial to operating an efficient practice.