Jordan Rosenfeld

Collecting from patients is not an easy job, but there are ways to handle it in an efficient and compassionate manner. We talk to experts on how to prevent payment delinquencies and how to handle them when they occur.

Before physicians worry about collecting delinquent payments, there are several strategies to ensure collections take place up front. “Patients are consumers and they need to be treated like consumers,” according to Noel Felipe, senior vice president and revenue cycle practice leader at Firstsource, a company based in Columbus, Ohio, that offers digital solutions in the health care space. “Consumers make decisions about where they shop and what they pay. They make value judgments based on their perceived value of a product or ease of consuming that product. The health care industry has to migrate to that type of mentality.”

This means making payment as simple and efficient as purchasing a product on Amazon, utilizing technology so patients can pay by phone or iPad, steering clear of too much technical jargon and having a comprehensive patient portal. “Your patient portal should allow them to make payments, to establish payment plans,” he adds.

Additionally, he urges physicians to take some payment up front. “You should collect 100% of your copays at the time of service. Your chances of collecting money go down post-service by 54%.”

The only exception to taking payment up front may be in a practice that includes services such as labs or X-rays, according to Lillian Phelps, senior director for product management at Availity, a health information network in Jacksonville, Florida. “Maybe collecting payment is better on the back end in that case, because you don’t know if they have to get a lab drawn or an X-ray,” she says.

Payment plans and options are an effective way of getting patients to pay, Phelps says. “You should come up with a financial clearance policy that sets dollar thresholds and time frames. You might even look at the relationship you have with the patient — if this has been your patient for 10 or 15 years, and he’s never had a financial collection, there should be some sort of consideration for their history.”

Any form of collections is improved by including digital means of paying, says Phelps. “Are you sending your statements digitally? Do the statements have a link to pay the bill? Folks don’t go to the post office (much) anymore,” she says. “Being able to offer digital or mobile payment options is a great place to ensure the bill is paid.”

Having a digital means of paying also increases the likelihood of patients making some payment rather than none, Felipe points out. “If I owe my physician 500 bucks and I go onto the portal and I have no choice but to pay 500 bucks or leave, and I can’t afford it, I’m going to exit out. But if I have payment terms, I’m going to pay what I can pay.”

Beyond simply making easy payment options available, Felipe encourages physicians to utilize propensity-to-pay analytics to drill down and figure out the demographic of a practice. “It’s easy to collect from people with high ability and high desire — those are automatic,” he says. “The people with low desire and high ability, you’re going to have to work at a bit. Propensity-to-pay modeling to help you understand where to place your expectations is critical in a successful physician practice.”

This sort of analysis can circumvent delinquencies by allowing the physician to preemptively offer financial resources and support to those patients most likely to have trouble paying, according to Srulik Dvorsky, cofounder and CEO of TailorMed, a health care IT company for health care providers and pharmacies in New York City.

“Instead of waiting for patients to experience financial distress or have a bill be written off, if you have the technology that can screen for patients based on their out-of-pocket responsibility, you can come to those patients as early as their diagnosis or registration and offer assistance programs,” Dvorsky says.

Additionally, remember that not every patient will engage in the same way, so pick the right strategy for the right demographic, Felipe says. “Baby boomers will not respond to text messages, but millennials will. Millennials will not talk to you on the phone and they don’t really care to look at email. So, if you want to collect more money, you have to pick the right engagement strategies for your patients.” He recommends having software that uses algorithms to predict engagement behaviors.

Physicians who utilize software and technology of this sort have an advantage in collections. “I think physician practices are in a very unique and enviable position where they can predict pretty closely what the patient should owe, and I think that conversation should happen either at the time of service or before service,” Felipe says.

When a balance is outstanding, Felipe advises that physicians should not be the ones to raise this issue directly with patients. “This is a relationship that doesn’t need to be strained over financial dialogue,” he says. He gives the example of how most dental practices work. After your oral examination, the dentist comes in to tell you what services you will need, and the billing staff member talks to you about the money.

He recommends having a financial counselor of some form on staff — this could be your billing person, a care coordinator, or another front office employee. This person can direct the patient to philanthropic organizations and resource documents such as those already prepared by the Centers for Medicare and Medicaid Services.

“You don’t have to recreate the wheel with resources,” says Gloriann Sordo, J.D., a principal at AdviCare, a company in Lakeland, Florida, that handles clinical denials for hospitals. She also encourages physicians, or their billing staff, to ask insurers what resources they have for patients. “I believe the payers should be doing more in trying to help patients understand what their responsibility is.”

Additionally, this person can help patients review and understand their insurer’s explanation of benefits, says Sordo. “Patients assume it’s their physician’s office that is responsible for their balance, rather than the insurer,” she says.

Sordo emphasizes the importance of helping patients understand the role the insurer plays in their care, since they may deem something not medically necessary. “It’s important to help patients understand it is not an arbitrary decision your physician’s office is making on what to charge you.”

Sometimes the simplest steps can ensure the most efficient collections. Phelps urges physicians to make sure their front desk and billing staffs are collecting basic but crucial information. “Make sure you have a copy of their card. Get the ABCs down and run patient eligibility,” Phelps says. “Ask for the money up front.”

Phelps also recommends preparing ahead for each day by running all patients’ eligibility and benefits the night before. “Doing that work the night before makes your check-in process go more smoothly and gives you the opportunity to accurately calculate what their cost share would be once they’ve done their visit.”

Phelps says, “At the end of the day I tend to believe that people want to pay their part and they want to have the opportunity to do so. But sometimes they need education.”

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Handling patient collections

If medical practice staff desire to improve their career skills, they will likely need to have a conversation with their boss, often the practice manager.  Together, they’ll need to explore opportunities to advance to a new role, take time off to pursue improvements, or ask for reimbursement of costs.

Wendy Terwelp, a career coach who works with healthcare professionals of all kinds and founder of Opportunity Knocks of Wisconsin, recommends medical professional staff frame the conversation around the employer’s return on investment.

“If they can leverage the conversation into how it will benefit the practice, that’s going to help them get reimbursed or sponsored to attend a conference,” she says. “Operational efficiencies can turn things around and increase profit, so if they can learn better ways to implement different technology, that can help.”

If the boss is a particularly challenging person, or if dollars are tight, Terwelp says staff should make the case that healthcare changes rapidly, especially with technology. New skills can help a practice avoid so many hassles. Training can improve procedures and documentation, which helps avoid lawsuits. That, in turn, can improve compliance with the joint commission.

And if employers still aren’t convinced, show them the research. For example, a 2010 study in the 

 points out that the payoff for better trained staff manifests in better employee retention, staff morale, practice efficiency, job competency, and patient satisfaction.

But approaching these conversations can mean walking a fine line between sounding self-serving and making a case for how individual professional development can benefit the practice.

If this is a nerve-wracking prospect, Carol Aiken, CMM CPAR, clinical operations administrator of Smith Family Clinic for Genomic Medicine in Huntsville, Ala., advises staff to look at the situation from the administrator’s point of view. Aiken, a practice manager with more than 30 years of experience in hiring and running a medical practice, says she keeps a keen eye on those motivated employees.

“I’m never going to look at anybody for advancement opportunity unless they have been self-motivated to present an opportunity to me for consideration,” she says. “I always tell younger people don’t be arrogant and think that you know it all, but also don’t shy away from the discussion. Maybe there is no real opportunity for improvement today but let your employer know ‘I want to be as valuable to you as I can.’”

Aiken says improving skills is a win-win for both parties. When staff let employers know in a concise and succinct way they would like feedback, that shows they are serious about their job. That can lead to further discussions about opportunities for advancement, too.

However, professional development is ultimately an investment in the future, so if a boss isn’t supportive, Terwelp says it may be worth trying to find another job where advancement is possible. “If you’re not growing, then you’re not moving forward.”

Tips for medical practice staff to broach the conversation of mid-career professional development with their employers.

How to talk to the boss about career advancement

Discussions about professional development tend to focus on medical practice staff entering the field, who have much to learn, and those at the end of their careers, who have much to teach. There’s an assumption that individuals learn as they go, but there can be several years, even decades, where it can feel like they’re just plugging away.

Christopher Lee, MPH, CPHQ, clinical solutions marketing manager for Family Health Centers of San Diego, finds that once practices hire qualified personnel, many small practices do not necessarily invest in further development of their staff-to their own detriment. “Many of them are just humming along doing the same things they’ve always been doing,” he says, adding that makes it even more important for staff to advance their own career. “[Career advancement] is something people have to take the initiative to do.”

Professional development is important to medical practice staff at all stages of their careers. However, mid-career development may be especially important for those staff who are ready to advance their skill set to maintain peak performance, increase earnings, improve their marketability, or prepare for a job transition. This development can reinvigorate daily work and drive staff forward, but it can also be overwhelming. Here are six ways medical practice staff can advance their careers.

Wendy Terwelp, a career coach who works with healthcare professionals of all kinds and founder of Opportunity Knocks of Wisconsin, says staff should not wait for practice managers and other bosses to green light their professional development-even if there is no or limited financial support. “If you don’t continue your training and professional development, that hurts your career more than anything else,” she says.

She says medical practice staff should start by identifying their skills gap. She suggests staff ask their bosses what areas in the practice are currently unfulfilled or need improvement. In some skill sets, such as medical billing or coding, it may make sense to pursue a higher certification or a next level course.

Carol Aiken, CMM CPAR, clinical operations administrator of Smith Family Clinic for Genomic Medicine in Huntsville, Ala., has seen the difference training makes in her more than 30 years of practice administration. “It’s very difficult to work in a medical office and just learn on the job,” she says.

It’s important to have a career advancement goal in mind, says Andrea Clement, the Atlanta-based director of communications for The Medicus Firm, a national healthcare recruiting firm. “What skills do you want to add-and why? What new role are you aiming for?”

Clement recommends practice staff who are not sure what would make sense in terms of career advancement talk to their supervisors to see what opportunities may be available and what they might need to do to qualify for them.

Assessment tools can help staff identify the next likely area of focus or advancement, many of which are often offered through professional medical associations, certification programs, or courses in a given skill set.

Once staff have a sense of their goals, experts agree that staff should mine professional medical associations for helpful resources. Clement says there are associations for nearly every medical office role, including coders, billers, nurse managers, case managers, patient advocates, and more.

There’s the AAPC, National Association for Medical Staff Services (NAMSS), the American Association of Medical Colleges (AAMC), the American Health Information Management Association (AHIMA), and any of the professional organizations that doctors and nurses belong to, such as the American Medical Association (AMA) and the Medical Group Management Association (MGMA), among others.

Most associations offer industry information, career advice, trend updates, and job boards. Professional associations often host conferences with expert speaker panels, mentorship connections, continuing education, and networking opportunities.

Lee says he’s benefited from the professional associations by learning about staffing trends, upcoming policy announcements, and reimbursement changes. He has also seen career planning courses and mock interviews offered at association meetings and conferences.

An additional benefit of professional associations is the chance to meet and develop a relationship with a mentor in an area that medical practice staff hope to either break into or develop their skills toward.

Mentorship is important, Lee says, because “you don’t know what you don’t know.” When trying to improve upon one’s skills or make a career change, he says, people tend to come with a lot of assumptions of how they think the process works, though not all of them are correct. Mentors can steer staff in the right direction and help accelerate the learning process.

Professional memberships also open the door to another key strategy for career advancement: networking.

Lee says through an association he participates in, he was able to ask a chief administrative officer of a large hospital about transitioning into hospital business strategy. The executive told Lee how to get started and helped connect Lee with someone in the organization. Without the help of the officer, he doubts he would’ve gotten a call back.

Building a network is an ongoing process and can require a bit of input before yielding results. However, 

 have found that many career opportunities arise from 

, so it’s important to keep meeting people and keep in touch.

“Ideally, networking should be an ongoing mindset and approach, not just a one-time push when you’re in need,” Clement says.

Aiken says she encourages administrators and office managers to allow their employees to network. She regularly receives calls from fellow practice managers and their employees asking questions about issues ranging from Medicare initiatives to coding questions. “I’m telling you, healthcare can’t survive if we don’t network,” she insists.

Sometimes the best career move for medical practice staff is to take additional courses, whether in person or online. Clement knows it can be challenging to make the decision to sacrifice the money and time in order to fulfill this goal, so she recommends asking a series of questions before taking the leap into further schooling. These questions include:

Am I choosing the right degree to further my health career goals?

What type of instruction does the program offer?

What kind of help and support will I have?

How much will it cost, and how will I pay for it?

Will my new degree prepare me for career advancement?

Will my degree be respected by my employers?

However you go about improving your skills, Terwelp says career advancement is a necessary part of working in the ever-evolving medical field. “You have to be on top of your game in the medical profession so that you can [continue to] accommodate the rapid changes. You’ve got to own your career.”

Stepping back for perspective in the middle of your career can unveil fresh insights and help plan future accomplishments. Here are six ways for medical practice staff to advance their careers.

Mid-career development for medical practice staff

Offering benefits to employees is a necessary part of staying competitive and encouraging employee retention. A 

 (SHRM) found that the number two reason employees leave a workplace after seeking better pay, is for better benefits.

Additionally, the individual market for health insurance since the passage of the Affordable Care Act has become “a field of land mines,” says Adam Hyers, owner and president of Hyers and Associates, Inc., a Columbus, Ohio-based independent insurance agency that works with numerous healthcare providers across the country. “It’s a fool’s errand to send your employees out on the individual market where the networks are very restrictive and the costs are very high.”

However, every practice has to find the right balance of offered benefits to keep a healthy margin. The 

2017 Kaiser Family Foundation Employer Health Benefits Survey

 showed that on average, organizations offering health benefits paid as much as $5,900 per year per individual covered, and $13,400 for family coverage. These costs add up in practices with numerous employees.

Experts suggest practices review their benefits annually and survey employees before making any major changes to benefits, but to also be proactive in seeking opportunities for cost savings.

In the current health insurance landscape, in which the Trump administration has been seeking legal workarounds to the Affordable Care Act in lieu of a failed repeal, it may be especially useful to review benefits more than once a year, says Arthur Tacchino, JD, chief innovation officer at Sync Stream Solutions, a New Orleans, La.-based consulting firm that helps employers understand and manage health benefits.

“Things are always changing, so re-evaluating benefits is a really good idea because a better option might have come along or have been created that [employers] might not be aware of,” he says

However, physicians and practice administrators need to be aware that some new options may not be as good as advertised. One such area, billed as cheaper for employers and individuals, are short-term or “mini” medical plans, which might only cover an individual for three months to 12 months, Tacchino explains.

Jonathan Gruber, PhD, professor of economics at MIT, in Cambridge, Mass., who has expertise in employee benefits, calls these plans “terrible.

“They’re not real insurance,” he warns. “Some people are going to be fooled into thinking they have insurance when they don’t, and it will pull healthy people out of the pool and raise the premiums for everyone else.”

Additionally, while not new, multiple employer welfare arrangements, which allow smaller practices to band together and buy health insurance as a larger group, are becoming more popular in the face of the high cost of steeper health insurance costs, according to Ty Reid, director of worksite benefits with the O’Neill Group, an insurance broker of employee benefits, in Wadsworth, Ohio.

“Smaller practices are starting to contract healthcare in the way much larger organizations do through risk sharing agreements,” Reid explains.

Gruber feels the most effective way that physicians can save money is to be “more aggressive in shopping across insurers.” He sees employers saving a lot of money by narrowing the networks of the plans they offer to their employees. “Employers don’t need to cut benefits, just cut out high priced providers that aren’t much better than any other providers,” he says.

He says it’s common for physicians to see a name they’re familiar with, such as Blue Cross, and sign up purely because of the name recognition, “but they don’t shop around or realize there are better options out there. It’s worth a day and a half to sit down and shop the options,” he insists.

Whether a practice is engaging in an annual review of benefits, or financial concerns drive a need for a change, practices should attempt to forecast the costs of offering different levels of benefits packages, either through available tools, such as online analysis toolkits or with the help of a financial advisor who can run the numbers under multiple scenarios.

Forecasting costs help a practice come up with benefits options, such as tiers of coverage based on employee classifications, says Tacchino. The higher the tier, the more expensive the premium is likely to be, for the employee, but there may be fewer out-of-pocket expenses.

Another area of cost savings could come from changing the percentage the employer pays for the plan. If a practice is already paying 80 percent of benefits, dropping that contribution to 60 percent, for example, could result in significant savings, Tacchino recommends.

Of course, this must be done with a clear understanding of the legal and regulatory considerations about how much an employee is allowed to pay for the benefits a practice offers. “If the plan you’re offering is not affordable, you may be subject to penalties under the law,” Tacchino says. And it could also affect morale among practice employees.

He strongly recommends having a financial advisor or human resources expert who understands the legal particulars about employee benefits weigh in as providers make decisions about changing benefits.

Additionally, Hyers recommends keeping an eye on employees who might be eligible for Medicare in the near future.

“Even if they’re not retiring, you want them to be investigating their Medicare options, with or without a broker,” he says. “A lot of people can mess up their Medicare enrollment by not understanding the deadlines and rules.”

Reid says it’s also important for practices to keep in mind that the average employee’s literacy about their own benefits tends to be low.

“Medical practices are focusing on the employee experience. Rather than potentially adding or dropping certain benefits, the focus has shifted to improving the way they are communicated,” he explains.

Practices are turning to concierge services, coaching, and decision-making support tools such as apps for smartphones or tablets, such as PolicyGenius, which helps consumers understand the ins and outs of health insurance, defines terms, and the details of their specific plans to help employees find the best and most efficient ways to receive care.

“After all, benefits are only as valuable as what you get out of them,” Reid says. “So it’s becoming less about which benefits to offer, and more about using the ones they have more effectively.”

Many practices opt to survey their employees to make sure that the benefits are covering the things that employees actually want, according to Hyers.

“Sometimes you can get pretty good tips as to what’s bothering people, he says. “There’s competition out there for employees and you’ll see a lot of people leave groups out of frustration from poor benefits.”

However, he cautions that survey questions must be carefully crafted so as not to get employees’ hopes up for benefits a practice does not intend to offer.

The SHRM employee benefits report echoes this, stating, “Be mindful that conducting a survey will set up employee expectations that benefits may change or be improved. Therefore an organization should have a clear purpose and a plan of action based on the survey results.”

And when rolling out new benefits packages, Joe Weinlick, chief marketing officer of Nexxt, a workforce recruiting company, encourages providers to be as transparent as possible about reasons for the change. “With premiums rising in recent years it’s very hard to convey to employees that the reason they may have to pay more, or that benefits are getting worse, is external to the company,” Weinlick says.

If a practice has done its homework, surveying employees and forecasting costs, picked a new set of benefits to unroll, Weinlick urges thoughtfulness in laying this out for employees. Changes to benefits can be stressful and often require provider changes.

Just rolling out changes, particularly if costs are going up for employees, without much warning, “leaves a bad taste in employees’ mouths,” Weinlick says.

Weinlick says results of a 2018 internal survey from Nexxt’s database of 2,403 employees in the healthcare industry the survey revealed that “medical and dental was critical,” followed by vision.

Retirement plans are often popular, Weinlick says, but not always an option for employers−due to costs−so he sees employers offering professional and career development resources, as well as “wellness benefits,” in the form of resources and information. The SHRM employee benefits report shows that employers were most likely to have increased wellness benefits over any others in 2016, as a way of making up for gaps in medical, dental, and vision benefits.

The number one benefit after medical coverage that employees want is schedule flexibility, Weinlick shares. This may be a way to keep employees happy without offering too wide a panel of benefits. “People want the ability to be able to fit their private life into their work life,” he says, to take time off for family time and even their own medical appointments.

This could come in the form of vacation days off, or other forms of paid time off, as well as allowing an employee to work part-time hours. He’s even heard of companies that offer loan reimbursement programs for employees with student loans, as an incentive for younger employees who might not need as comprehensive health benefits, or for older employees who are trying to increase their education.

In trying to strike the right balance between retaining employees and keeping a happy bottom line, the expert consensus is to review benefits annually with an open mind toward change.

“A once a year review of benefits can save you a lot of money,” Gruber says.

An annual review of benefits each year might be able to save a practice a lot of money, experts say.

Benefits review: how to better your practice

Physicians have long relied upon checklists to provide proper medical care to patients for everything from diagnosis to preparation for surgery. Can this same tool be used to improve patients' emotional care and connection with physicians? Experts echo emerging research that say yes.

"For physicians, checklists should be seen as a convenience both for the provider and their patients," says Doug Levy, JD, a consultant on physician communications, who formerly taught a course called Foundations of Patient Care at the University of California at San Francisco Medical School.

Any tool that fosters improved physician-patient communication can go a long way toward helping patients regulate their emotions, better understand medical information, and allow physicians to better assess their patients' needs and expectations, according to 

"Patients reporting good communication with their doctor are more likely to be satisfied with their care, and especially to share pertinent information for accurate diagnosis of their problems, follow advice, and adhere to the prescribed treatment," the authors write.

Research of this nature convinced the team at Hawaii Pacific Health in 2016 to initiate a checklist of steps for physicians to perform during every office or hospital visit, with the goal of improving patients' emotional well-being, and to encourage deeper trust between physicians and patients.

From a template, physicians identified items they already practiced, and then had to choose two more from the checklist to add to their own. These ranged from clearing their minds of distractions in order to be present, to listening to the patient for several minutes without interrupting. The result of this change in practice was a more than 20 percent improvement on a physician communication score within a year of implementation.

While the idea of a checklist may sound like an additional task to add to a physician's already full day, many doctors already have an informal process in place and it's a matter of making it more overt and consistent.

For Karen Sibert, MD, president of the California Society of Anesthesiologists and an associate clinical professor of anesthesiology at UCLA Health, the idea of this kind of patient well-being checklist is a no-brainer. She's long followed a mental list designed to do just this.

"I have a consistent approach in my mind that has these steps I repeat," she says. Sibert says she believes strongly in a quality personal interaction because "it's so critical to the patients having confidence in you, what you're going to do for them, and feeling comfortable with it."

She always begins by addressing her patients formally and establishing herself as a physician in her introduction, which creates "an atmosphere of clear communication" that includes being respectful to the patient. She emphasizes that it's important to ask questions in the interaction rather than just reading from a chart.

After decades of practice, Sibert is keenly aware that she has "roughly 10 minutes to make the patient feel as though they want to put their life in my hands."

This also includes what might seem like a small or superficial detail, but is part of a larger ritual of preparation: "My residents often comment that the last thing they see me do before I go see a patient is put on lipstick." She says it's all part of presenting herself to the patient in a certain light. "No patient wants to see a physician who looks haggard and cross," she says.

For physicians who don't already engage in such ritual behaviors with their patients, Sibert agrees that a checklist is a good idea, though "it really needs to be tailored to the situation and shouldn't come off just like reciting the phone book," she urges.

As it is, EHRs have contributed to physicians doing more work on their computers facing away from patients, so a good list should eventually become integrated into a physician's routine and allow for more engagement with the patient.

Levy points out, "There is an element of patient care that is like customer service. And consistency is one of the most important reasons that people give when they say they come back to the same store."

Similarly he's seen a lot of feedback that "patients really dislike being asked the same information over and over again, and they 'like to count on consistency between physicians as well, so that one experience is as good as the next. "

Levy feels that if physicians can look at adding a checklist in as a way of "making it so your patients have a consistent experience not only every time they're with you but every time they're with your colleagues, you'll find your practice will run better."

There are a myriad of small ways where checklists allow for standardizing practices that can help prevent missteps.

Additionally, from clerical issues, to physicians reviewing and adding to a medical history before and after a patient encounter, checklists help them do things in a logical sequence, and confirm that the task was done, Levy says. "It also is a backstop against innocent oversights as well as any urge by a harried provider to skip over a step."

Of course, he acknowledges that the term "checklist" can be an obstacle because it sounds administrative, but he urges physicians and medical systems to remember that a checklist "is about making the physician-patient experience and the care that physicians are delivering work better." Levy encourages any practice or hospital setting to be sensitive to its audience and use the right semantics when introducing the checklist concept.

A good checklist should help create connections between physicians and patients, which should not be complicated, according to Somaia Arafa, MD, a former pathologist who now runs a physician coaching consultancy in Cleveland, Ohio.

Start by practicing empathy, she encourages. "Empathy is a tuning fork," Arafa says. Pay attention to "what [patients are] saying but also what they're not saying." This means slowing down so you can pick up on body language cues, facial expressions, tone of voice.

Sibert echoes this approach. She recalls a time when a patient was projecting a lot of negative emotion onto her. She could have simply chalked this up to anxiety over the impending surgery, but she probed more deeply. "It turned out the patient's husband had died three days earlier." Sibert says it's always worth it to ask what else is going on.

Arafa adds, "By intentionally listening deeply and actively to what patients are saying and not saying, physicians lessen the chances of any errors and/or miscommunications."

Another consideration for a practice adding a checklist is to try to "steer clear of jargon and high-level medical terminology that patients won't understand," Arafa says. This increases the likelihood that patients will understand what you're telling them, and reduce feelings of distance between physician and patient.

All of Arafa's suggestions can be summed up as: "Be fully present with patients. Listen deeply without judgments or interruptions, so they feel understood and acknowledged."

This is what she calls "mindful attention," which slows down the communication enough for the physician to observe any concern or confusion that the patient might be experiencing.

How do you get physicians who are already overburdened by administrative tasks and heavy panels to consider adding one more thing to their plates?

"What's key is helping show them that you're not adding something new, you're just organizing what they're already doing," Levy insists.

Most physicians already have an informal routine or set of procedures to connect with patients, but making it more formal can help to ensure consistency and improve patient outcomes.

Levy also adds, "It's really important to show [physicians] the benefits" before rolling out checklists." Levy said that while at UCSF "publishing all the data internally had a positive impact on the departments, which implemented better procedures as a result."

Peter J. Pronovost, MD, senior vice president for patient safety and quality for Johns Hopkins Medicine and director of the Armstrong Institute for Patient Safety can vouch for this. He was part of a national program 20 years ago to create a checklist to reduce infections that were killing more people than cancer using evidence-based guidelines. The checklist spread widely among physicians across the U.S., and easily preventable infections decreased 80 percent nationwide.

While that checklist was designed to help prevent a medical condition, it led to behavioral changes in both physicians and patients and cemented his belief in the power of checklists. The biggest lesson he learned in the process was that you can't standardize a checklist.

When they encouraged physicians to "make it better, make it your own, improve upon it," Pronovost explains, they found that physicians were more likely to use it. "We have to get out of the mindset of scaling and imposing interventions on [physicians and] practices, and be much more in the mindset of co-creating."

Just as the goal of better communication between physicians and patients is to build trust that leads to better health outcomes, Pronovost says he lives by the phrase, "change progresses at the speed of trust, and trust grows when we do things with rather than to others."

He says the best way to get any physician to implement a checklist of this kind is by respecting doctors' wisdom. "They have to be implemented in a way that's done 

 the physicians rather than to the physicians," Pronovost says.

Physicians implement checklists when they are providing clinical care for patients - but what about emotional support?

Implementing Patient Communication Checklists

Even as physicians are busier than ever, some with exceedingly heavy panels, the Association of American Medical Colleges (AAMC) has alarmingly 

 that physician demand will exceed supply by 2030. AAMC, a Washington, D.C.-based non-profit focused on medical research and education, predicts shortages in primary care between 61,700 and 94,700 physicians by 2025, and as high as 60,300 for non-primary care specialties.

Jason Farr, a Texas-based recruiter with The Medicus Firm, a national physician recruiting firm, remembers hearing about a physician shortage coming over a decade ago, centered around primary care and rural areas. "Fast-forward here we are a decade later and it is as real as can be," he says.

There are a number of reasons for this shortage, ranging from baby boomer aged physicians facing retirement, as well as an influx of patients aging and needing more medical care. Millennial physicians are more concerned about the 

 than their older counterparts, leading them to work fewer hours, and many physicians are burning out due to technology and regulatory burdens. Here, experts weigh possible solutions to handle the shortage.

One answer to this physician shortfall might appear to be solved by an increase in medical school enrollment. However, training programs for residents and fellows haven't expanded at the same rate, creating a bottleneck in the residency pipeline. According to an 

 by AAMC, first-year enrollment at U.S. medical schools has increased by 28 percent since 2002. "The real chokehold is in the residency programs," says Fred Jacobs, MD, JD, New Jersey-based executive vice president of St. George's University School of Medicine and former commissioner of New Jersey Health and Senior Services.

Indeed, in 2017, there were a record-breaking 35,969 U.S. and international medical school students and graduates competing for only 31,757 positions, according to the 

, a shortfall of over 4000 residents-to-be.

"We have a shortage of physicians but a surplus of talent," Farr says.

Funding for residents is expensive, as well, and most hospitals and medical groups do not have extra funds to pay for them or they go way over budget in order to do so. In 1997, Congress capped the amount of funds for Medicare support for graduate medical education (GME) "at how many residents you were training at the end of 1996," says Len Marquez, Senior Director of Government Relations and Legislative Advocacy at AAMC. This has contributed to the slowdown in the number of medical residents who can enter the workforce. "If Medicare funding isn't expanded to include more GME positions, then there is no other viable source," Jacobs says.

The AAMC is sponsoring legislation that seeks to raise these caps. Two bipartisan bills have been introduced in 

, Marquez says, that would "over a five-year window, increase the number of Medicare supported GME residency positions by 3000 between 2019 and 2023, with a total of 15,000." This would help with the shortfall, he says.

While the bills are no quick fix since "it's difficult to move legislation right now that costs the federal government money," Marquez says, he's hopeful about the bipartisan support they're gaining and are continuing to educate. "Because it's not like in 2030 Congress can say we need additional physicians and just flip the switch."

Some institutions are creating their own medical-school-to-residency pathways, such as Kaiser Permanente, an Oakland, Calif.-based managed care company, which currently trains 600 residents annually and 

provides continuing medical education (CME)

Senior Program Integration Manager for the newly forming Kaiser Permanente School of Medicine, Aldina Washington, MBA, says by email, "We are currently in the very preliminary stages of developing the school, starting with establishing an organizational structure and beginning the accreditation process."

Farr says it's the beginning of a process that he expects will grow as hospital systems and medical groups become desperate to fill physician gaps. "They're just going to start saying 'we're going to train ourselves,'" he says.

For medical school graduates who are ready to go but lack a residency spot, Arkansas, Kansas, Missouri and Utah have passed legislation to provide provisional licenses to some of these medical school graduates who have not been able to find a residency spot. However, there’s a condition. "With these provisional licenses they can practice primary care under the medical license of another physician, but it has to be in a medically underserved area," Farr explains. He calls this "one of the most creative solutions that I've heard. It's addressing an untapped pool of candidates." 

Midwestern states may also start to fall in line with this approach, says Dave Lenihan, PhD, JD, President of Ponce Health Science University in Puerto Rico, and President and CEO of Tiber Health, a medical education company developing new curriculum and analytics strategies. However, he feels that adding incentive for newly graduated physicians to take residencies in underserved parts of the country requires reducing the cost of medical education.

"If we want to put new physicians in rural America, we can't have students with a quarter million dollars in debt," Lenihan says.

One solution he proposes is to change the way medical education is delivered, thus reducing its cost, as they do at Tiber.

The cost of a new medical school can range between $150 to over $600 million in development costs. This includes building and curriculum design. When a new campus is opened, a significant amount of money goes towards curriculum development, he explains. 

Tiber uses a standardized curriculum so that the costs of development are minimal. The cost of the faculty is spread across many more students. Because the curriculum is already developed with world-class faculty and approved to a Gold Standard, the proposed new school can open in a significantly reduced period of time.”

At Ponce they also offer a "flipped classroom" approach - in which students listen to their lectures offline, out of the classroom, and use class time to go over clinical cases. "You don't need all that brick and mortar -that's not what's required to train these future doctors."

One of the quicker solutions to get more patients served may be to train more physician assistants (PAs). There are already nearly 

 practicing PAs in the US, according to the 

. PAs are not required to do three to seven years of residency training; they only require a one year rotation, which could make them available to the workforce quicker than physicians.

Physician extenders "can help one physician care for more than one patient at a time," says Karen Sibert, MD, President of the California Society of Anesthesiologists and a professor at UCLA. In her field, physician anesthesiologists rely on the support of advanced practice practitioners and assistants - either certified registered nurse anesthetists (CRNA) or certified anesthesiologist assistants (CAA). "They are exactly analogous to what PAs are for a primary doctor or surgeon," she explains. They are trained in a medical, not nursing, model, and work directly under the supervision of physician anesthesiologists. The CAAs, she says, "provide an opportunity for the physician anesthesiologist to focus on emergencies and saving lives, and not some of the lower level tasks such as initial screening and paperwork."

This speaks to many physician frustrations with doing work that doesn't make the best use of their talents. "There are days where, here I am with a lot of experience and higher education, and I'm pushing a stretcher down the hall for lack of somebody else to do it," Sibert says. She does not consider herself above the work, but says "it's really not an effective use of society's resources."

While physicians have mixed feelings about technology - and much frustration with the increased burdens of their EHRs - technology is expanding, and may be able to alleviate some of the burdens of the physician shortage. Particularly in the arena of telehealth, where physicians can schedule virtual visits with patients where the patient doesn't have to come into the office.

"If you're talking about a family medicine physician being able to manage a panel of 5000 patients who can then, with some technology, ramp up to 7500 patients, that's huge," Farr says.

Jeff Barson, a Utah-based healthcare consultant in virtual care, medical education, and artificial intelligence, goes so far as to suggest that technology is the only way to meet patient demand. "There is no capability to solve the problems coming around the scalability of delivery of care with human labor," he says. Trying to add more physicians, he feels, is a losing battle. "The reason it's not possible, is it's not working now. The United States has the best delivery of healthcare available and still it is far short of where the actual need is."

He believes that artificial intelligence (AI) algorithms will shift the roles of physicians from a "knowledge-based role into more of a skills role." There will be less reason to memorize information in the same way anymore because all of that information will be available in an AI-driven database that can not only bring up the information at a moment's notice, but help in diagnosis. Skills around the decision-making process will still be needed," he says, but it could make it possible for fewer physicians to do more work with less effort.

Farr points out that many institutions could encourage physicians to push off retirement by modifying their hours. "Rather than allowing them to go from full-time to zero and leave a hole, think about a creative way to keep retiring physicians on staff." If two physicians go to half time instead of leaving, "you can cut your loss by fifty percent," says Farr.

Medical groups and hospitals will most likely have to rely upon a combination of solutions. Whatever methods they choose, Lenihan concludes, "We have to fix this now otherwise we'll be in a giant mess in ten years."

There is a shortfall of physicians in the field - here are a few potential ways to keep up with increasing demand. 