Developing a Web presence is a popular way to create visibility and market your practice. Seventy percent of better-performing practices have a Web site to market their practice, according to Performance and Practices of Successful Medical Groups: 2010 Report Based on 2009 Data. To supplement your Web site, social media channels, such as Facebook, Twitter and LinkedIn, are free, easy to set up and offer an opportunity to connect with patients outside of the office.

Here are some do’s and don’ts for expanding your practice’s online presence:

Do provide answers to common patient questions in social media posts. If you’re an orthopedic practice, post answers to questions such as, “How much work will I need to take off after ACL surgery?” or, if you’re a family medicine practice, “When is the best time to get a flu shot?”

Don’t let all staff have access to your social media channels. Elect one person to manage the posts and respond to any questions received to ensure a consistent voice. Post regularly and respond quickly.

Do use social media channels to alert your patients of news in the practice. Do you now accept credit card payments? Did one of your nurses reach his or her 10-year anniversary? Share it on social media.

Don’t “friend” patients or accept friendship requests from patients on your personal social media accounts. Your staff may have close relationships with certain patients, but it’s best to separate staff members' personal lives from their work relationships.

Do understand the needs of your patients. If you regularly conduct patient satisfaction surveys, ask your patients whether they would like to see the practice on social media and how they would benefit from it.

Don’t ever post identifying information about patients online. If a patient asks a question via social media about prescription refills, appointments or medical history, send them a private message and ask them to call the office or send the office an e-mail via an encrypted e-mail exchange.

Source: article courtesy from MGMA

The race among hospitals to hire local physicians is heating up, even though the consequences for the cost and quality of health care are still unclear.

The trend isn’t new, but hospitals in metropolitan areas across the country are quickening their pace, “driven largely by hospitals’ quest to increase market share and revenue,” according a study released today by the Center for Studying Health System Change,  a nonprofit think tank in Washington D.C.

Hospitals argue that employing more physicians helps them improve the quality of care they deliver through better coordination of care, and even lowering costs by avoiding repeat tests and procedures. It’s also part of their efforts to prepare for expected Medicare payment reforms initiated as part of the health overhaul, including accountable care organizations and bundled-payment models.

But the trend could also increase costs, the study finds.  Hospitals usually offer their doctors productivity-based compensation, which can mean more testing and procedures. Physicians interviewed as part of the study “noted that employed physicians face pressure from hospitals to order more expensive testing alternatives.”

The rates for procedures performed in hospital settings can also be higher. Hospitals tend to have more clout with insurers, particularly those that employ large groups of doctors and are able to negotiate higher payment rates. In addition, hospitals can charge facility fees even for outpatient services and locations. That can result in higher costs both for insurers and for patients, who may end up with higher deductible and coinsurance costs. Medicare also pays a substantially higher rate for visits to offices that are part of a hospital, even if they’re not located on a hospital campus.

In addition, coordinating care is difficult, even within a single hospital system, and “does not occur automatically once physicians become employees,” the study reports

On the other hand, the study adds that one potential benefit of physician-hospital alignment is that it may allow better access for low-income patients to employed specialists who would might not otherwise accept Medicaid.

In 2009, half of new doctors were hired by hospitals, according to the Medical Group Management Association, a professional organization for physician practices. And a 2009 report by the American Medical Association found that one in six doctors works for a hospital.

Source: original article courtesy of physiciansnews.com

Although unexpected by some, it appears the iPad is not only leading the tablet charge, but in computing, in general. One of the first mass-produced modern tablet computers, Apple’s iPad boasts great design and durability, a long battery life, and a iOS developer platform that’s helping the tablet lead the way into the next generation of computer technology.

Physicians and medical professionals have been some of the earliest adopters and strongest supporters of the iPad, and many electronic medical record (EMR) vendors are responding to the increased demand by producing solutions that are iPad-compatible.

Medical software vendors are approaching iPad solutions in various ways, but the development efforts can be summarized into these three options:

(1) Native iPad EMRs. These solutions have been developed specifically for the iPad and its iOS operating system. They take full advantage of the operating system and iPad user interface. The downside is that they are limited in terms of availability – so you only have a few robust choices if you want a native iPad EMR.

Many of these iPad apps are really great software applications. One solution, Dr. Chrono, allows physicians to easily pull up previous history charts and electronically send prescriptions to pharmacies. Nimble, another native iPad EMR, includes a module that allows physicians to display medical images and actually mark on them via the touchscreen interface – an intuitive and useful application that is the type of design that we’ll most likely see in other, future touchscreen-compatible EMRs.

These applications are new, meaning they lack many of the complex feature sets that on-premise or web-based EMR solutions offer. It will take some time for these systems to develop the full functionality of the more traditional systems. They most certainly will, but they simply don’t have all that the other systems can offer today.

(2) Remote access EMRs. Many software vendors are porting their native EMR solutions to the iPad by the means of remote access utilities, such as Citrix. The benefit is that most systems can be ported to the iPad using this technology. The drawback, however, is that this approach is simply creating a “window” via the iPad to access these on-premise EMRs. Physicians invested in the iPad because of its operating system and design, which is lost in these remote access ports.

Because remote access EMRs require some IT resources to host the system, this isn’t the best solution for physicians that are looking to eliminate server or hosting responsibilities.

(3) Web-based EMRs. These EMRs are some of the most popular solutions for doctors seeking HITECH Act incentive funds. In addition, there are a large amount of solutions from software vendors offered in a web-based, software-as-as-service model. With many solutions to pick from, physicians can select the system that best fits their budgeting and practice needs. Web-based EMRs run through the physician’s web browser, and many solutions are optimized for Apple’s Safari. That’s perfect for the iPad, as Safari is the native iPad Internet browser.

These systems do have their drawbacks when used on the iPad, though. The performance of web-based EMRs on the iPad will largely depend on your Internet connection – so an excellent WiFi network is essential. In addition, since these systems were created with a keyboard and mouse in mind, tablet use many be hindered at times, especially when manual key entry is required.

So what are physicians’ options? Today, most vendors offer some sort of remote access option for their EHR solutions. Look for many of these to offer more iPad-centric solutions as the platform gains more and more physician and industry support.

For more information on the iPad EMR options check out: iPad EMR Apps | A Guide to Electronic Medical Records. In the guide, we took a look at the top ten EMR solutions (in terms of market share), and put together a list of their iPad EMR offerings.

Allscripts (Allscripts Remote). Through Allscript’s propietary web services technology (UAI), the Appscripts EMR can be accessed via the iPad.

eClinicalWorks (iClickDoc). The eClinicalWorks reseller easeMD offers a remote access application.

Eclipsys (Sunrise Mobile MD). Sunrise Mobile MD allows remote access to the Sunrise hospital EHR. Note: Eclipsys is now a part of Allscripts.

Epic (Canto). Little is known about the Epic iPad app. The system has three stars and 13 reviews in iTunes.

GE Centricity. GE just launched their native iPad application. The app is a free download for all of GE’s web-based EMR clients.

Greenway Medical (PrimeMobile). The system provides remote access to Greenway’s PrimeSUITE EHR. The native application is available to Greenway customers, and offers a 30-day trial of the software.

NextGen (NextGen Mobile). NextGen’s mobile EHR software works on all Apple devices, Blackberries, and some Android systems.

Practice Fusion. Physicians can log into Practice Fusion on the iPad via the third-party app, LogMeIn.

Sage Intergy. The Intergy EHR solution can be accessed via remote access applications.

SOAPware. Physicians can use third-party applications such as Jaadu or LogMeIn applications to access SOAPware.

Source: article by Houston Neal, courtesy of physiciansnews.com

Being a physician is rewarding — but it can take a toll on your personal life. There may be no way to avoid that entirely, but here are some of the best ways to release a little steam to avoid total burnout.

1. Practice smart scheduling. Chances are there are certain times of the year when your waiting room is oozing with patients (and other times when it isn't). "Many practices have natural cyclicality," explains healthcare consultant Laurie Morgan of consulting firm Capko & Co. If possible, book your schedule to allow more meaningful time off during low-volume periods — rather than being "trapped" in the office with a light schedule for the full week.

2. Start a hobby. Making time for outside endeavors is often linked with professional satisfaction. So if you enjoy writing, for example, consider creating your own blog, or contributing to another medical blog. Or take a recreational class on something totally unrelated to medicine at your local college.

3. Volunteer. For many physicians, giving back to the community is a great source of satisfaction. Give one day a month to a free clinic in your community — or if you're really adventurous, consider using some vacation time to volunteer with a group like Remote Area Medical, which provides medical care to people in remote areas around the world.

4. Make time for yoga or exercise. You already know that exercise boosts your mood, improves your sleep, and helps you stay trim. Yet, according to the Centers for Disease Control and Prevention, just 35 percent of adults ages 18 and older engage in regular leisure-time physical activity. If you don't have time to attend an hour-long boot camp class or train for a marathon, waking up just 30 minutes earlier to play a yoga DVD or take a jog on the treadmill (or around the block) does the trick.

5. Read something nonmedical. Even if you love catching up on ICD-10 code updates and EHR guidelines during your break (or the Practice Notes blog at PhysiciansPractice.com), sometimes getting your head away from thoughts of patients and medical terms is good for your health. Just 10 minutes with a sensational tabloid or a chapter in the latest mystery novel can provide a mental break that'll leave you feeling refreshed.

6. Break for an occasional sweet treat. We don't recommend gorging on candy every time you're stressed. But sometimes it helps to keep your desk drawer stocked with chocolate for a little pick-me-up when the going gets tough, suggests Jennifer Frank, a blogger for Practice Notes. Or, have the local ice-cream store that caters parties visit your office on a predetermined date and time for an end-of-the-day treat, suggests MGMA consultant Rosemarie Nelson.

7. Make time for family. Those who feel the most burned-out tend to be those whose lives are out of balance. To avoid the resentment over an all-work-no-play life, Frank suggests playing with your kids on a daily basis. For physicians with adolescents and teenagers, schedule time for a game of catch or making dinner as a family.

8. Go for a walk during the day. Many physicians say they don't have time to fit a regular exercise program into their busy schedules. But most everyone has time to take a 10-minute walk once a day. If you're just too busy to take that lunchtime stroll, follow the Mayo Clinic's advice and take a 30-minute walk after work to blow off steam. Just remember: Making patient rounds doesn't count!

9. Delegate tasks. Sometimes burnout is a simple case of a physician taking on too many responsibilities. To make your life more manageable, Nelson suggests taking time to delegate tasks that don't require your talents/skills in the clinical area as well as the management arena. This will allow you to spend more time focusing on patient care.

source: article courtesy of Marisa Torrieri at physicianspractice.com

Another female physician had a brilliant idea recently. She wanted to get some of the other women physicians together to talk and have dinner. No spouses, no kids, no drug rep, no lecture. Just women with similar interests, similar problems, similar dreams, and similar backgrounds.

But who knew how similar our backgrounds were? It just so happened that the one and only Caucasian, U.S.-raised woman who made it to dinner had to leave early as she was on call. That left four of us. Four women from four different countries and four different religions. And yet, as we regaled each other with tales of our med-school lives, we discovered how alike we are. And how alike the healthcare is in our home countries, and how very different it is compared with the United States.

We all had stories of our Robin Hood days. Our hospitals couldn't supply things for free. There was no insurance. Patients needed to supply their own meds, IV lines, syringes. And since many could not, especially on an emergent basis, those who afford to do so got the "Wish List.” Families of women in labor were usually willing and able to go to the local pharmacy to buy things. So while she probably didn't need more than one pack of sutures for her episiotomy, they usually ended up buying two, plus two IV catheters, a vial of antibiotics, and various and sundry supplies. These we would keep for the trauma patients, who usually arrived alone or carried in by their drunken friends. Or for the man with bowel obstruction from a tumor that was probably unresectable.

We recalled those days of having to have patients' family members donate blood. It didn't matter if they were a match. But for every unit transfused, we needed a unit back. One woman remembered a patient in the burn unit who had been there for weeks. He needed so many transfusions, they ran out of family members. And during trauma surgery, who had literally run from OR to the blood bank and back to fetch blood? Oh, yeah, that was us.

We remembered the goiters the size of heads, the ulcerated breast cancer, and the death from stupid things like gastroenteritis. All from lack of preventive care. Because patients need to chose between feeding their family and paying for a check-up.

And we relived those fulfilling moments. The profuse thanks. The potful of food, in lieu of payment. The bucket of mussels or the basket of eggs as a token of gratitude. The half dozen children named after us because we assisted in their deliveries.

And we compared it to life here in the United States. Where patients complain that the hospital bed isn't comfortable or the hospital food doesn't taste good. Where the woman in her BMW carrying her Gucci purse asks "What did I pay a $50 copay for?!" when she doesn't want to hear it really isn't her thyroid making her fat. Where there is Medicaid and Charity Care and PADD. Where you can get antibiotics for free at the supermarket.

Anyone who complains about our healthcare system should spend a year or two in a third world country ER.

Source: article courtesy of Melissa Young, MD physicianspractice.com

President Obama and congressional leaders announced an agreement Sunday night to avert financial default. While this is good news to the majority of the nation, it may not be the best compromise to physicians who see Medicare patients.

The proposed deal, which the House and Senate are expected to vote on by end of day today (August, 1) calls for spending cuts in two stages.

Stage one would call for immediate spending cuts of almost $1 trillion over a decade.

Stage two is most relevant to physicians. A specially-appointed 12-member Congressional committee would be charged with coming up with a recommendation for $1.5 trillion in deficit reductions by the end of November.

Those recommendations, which could include cuts to Medicare and Medicaid, would be put to a Congressional vote before the end of the year.

There is a catch (dubbed "the trigger mechanism"). If the committee does not reach an agreement or if its recommendations are rejected by the house or senate, automatic cuts of $1.2 trillion would be applied in across-the-board spending. These cuts would go into effect in 2013.

“To hold us all accountable for making these reforms, tough cuts that both parties would find objectionable would automatically go into effect if we don’t act,” Obama said during a press conference Sunday night.

Medicaid would be exempt from these cuts. However, Medicare cuts would be on the table. These cuts would take the form of reduced payments to physicians and insurance companies, not to Medicare beneficiary programs.

Essentially, providers would bear the brunt of the Medicare cuts. And let's not forget that there is a 30% cut looming as of Jan. 1, 2012 thanks to the sustainable growth rate (SGR) formula for physician reimbursements in the Medicare program. Congress delayed acting on that until this December.

“Despite what some in my own party have argued, I believe that we need to make some modest adjustments to programs like Medicare to ensure that they're still around for future generations,” Obama said.

With economic pressures on physicians mounting and regulatory incentives to affiliate with larger entities expanding, an increasing number of physicians are becoming employees of larger medical groups or health care systems. Restrictive covenants are becoming a mainstay of physician employment agreements. While the American Medical Association Council of Ethical and Judicial Affairs has found them to “disrupt continuity of care, and potentially deprive the public of medical services”, it has found them “unethical” only if they are “excessive in geographic scope or duration … or if they fail to make reasonable accommodation of patients’ choice of physician.” At least eight states have invalidated restrictive covenants, including three that have specifically enacted statutes banning them; however, courts in New Jersey and Pennsylvania have upheld them as recently as 2005.

Restrictive covenants never benefit employees and in an ideal world, you would want to delete them entirely from your employment contract. However, in most cases, this cannot be achieved; therefore, if you are becoming an employee in Pennsylvania or New Jersey, you might benefit from some helpful pointers about how to negotiate restrictive covenants.

What is a Restrictive Covenant?

A restrictive covenant is a provision in an employment or purchase agreement that prohibits you from practicing medicine within a certain geographic area for a specified amount of time. Restrictive covenants are designed to protect the economic interest of your employer who is assumed to have spent time and money training you, introducing you to its patients and sharing confidential information to you.

Pennsylvania and New Jersey Law.

Both Pennsylvania and New Jersey recognize the validity of restrictive covenants under certain conditions. In Community Hospital Group, Inc. v. Jay More, M.D., 183 N.J. 36, 869 A.2d 884 (NJ 2005), Dr. More, a neurosurgeon, left his employment at Community Hospital Group and joined a neurosurgery practice within the geographic area and time restricted by the restrictive covenant in his employment contract. The New Jersey Supreme Court concluded that a physician’s employer had a protectable interest in “protecting the investment in the training of a physician” in addition to traditionally recognized interests in confidential business information and affirmed the contract’s 2 year time period restriction; however, it “bluelined” the agreement, that is, it modified the agreement, to reduce the 30 mile geographic restriction so that Dr. More would be permitted to cover the Somerset Hospital emergency room that relied on his coverage to be able to provide neurosurgery services to its patients, thus protecting what the court viewed as the public interest.

The Pennsylvania Superior Court in Wellspan Health vs. Bayliss, 869 A. 2d 884(PA Super 2008) agreed that physician restrictive covenants are permissible and enjoined Dr. Bayliss, a perinatologist, from practicing in Adams and York counties where Wellspan drew many of its patients since it concluded that a patient referral base was a legitimate interest of Wellspan; however, it “bluelined” the restrictive covenant to permit Dr. Bayliss to practice in Lancaster County because Wellspan didn’t compete with him in Lancaster County for maternal-fetal patients; thus, Wellspan did not have a legitimate business interest in preventing Dr. Bayliss from practicing in Lancaster County.

The bottom line is that, in Pennsylvania and New Jersey, restrictive covenants are likely to withstand judicial challenge if they protect a legitimate business interest of the employer, they don’t unduly harm the employed physician, they are “reasonable” in geographic scope and duration, and their enforcement won’t harm the public. However, many of the restrictive covenants proposed by employers arguably fail to satisfy these requirements and therein lies the negotiating opportunity.

Legitimate Business Interest of Employer/Scope of Practice.  Most restrictive covenants include some variation of language that restricts the employed physician from “directly or indirectly, as an employee, employer, contractor, consultant, agent, principal, shareholder, corporate officer, director, or in any other individual or representative capacity, engage or participate in any business or practice” that competes with the employer.  Since protecting the employer’s legitimate business interest is at the core of the restrictive covenant, the first question to ask is what kind of business opportunities would “compete” with your employer?

Not every form of medical practice or facility in which you might practice post-employment is likely to compete with your employer. For example, if, as an anesthesiologist you are employed by an anesthesiology group that limits its practice to hospital settings, you can argue that the group should not be able to prevent you from practicing at an outpatient pain clinic within the restricted area after you leave the practice. If you are a pulmonologist who is employed by a hospitalist group, the group arguably does not have a legitimate reason to prevent you from opening a general pulmonology practice within the restricted area. Thus, one approach is to list in the agreement the types of facilities that the employer considers to be a competitive threat.

Another approach is to carve out certain types of facilities that don’t threaten your employer’s business. For example, if you are employed by a pediatric practice that provides outpatient care primarily, you should be able to practice as a facility-based pediatrician. If you are employed by an internal medicine group that provides outpatient and hospital inpatient services only, you should be able to become the medical director of a nursing home in the restricted area. You might also identify in the agreement specific institutions at which you would be permitted to work.

Another approach is to propose, as the perinatologist defendant successfully argued in Wellspan, that your employer’s legitimate business interest does not extend to geographic areas from which it draws no patients. This might mean limiting the mileage restriction, the applicable counties, or some other geographic delineation in the restrictive covenant.

Geographic scope. Restrictive covenants address geographic limitations in many ways: they might set a mileage radius from: 1) a group’s primary office; 2) each of the group’s offices; 3) each of the group’s offices currently existing or developed in the future; or 4) each of the hospitals or other facilities at which any member of the group practices. Or, rather than a mileage restriction, the restriction might be defined by counties.

The first step is to map out the circumference of the restriction and note the medical facilities that are located within the proposed restricted area. Are there certain facilities or practices that you think you might want to join if this particular employment arrangement doesn’t work out? Note where these facilities or practices are located in relation to the proposed restricted area. For example, an employer might impose a 10 mile restriction from its primary office at 100 Montgomery Ave. in Ardmore, PA. If the facilities at which you might want to work post-employment are located 8 miles from the employer’s primary office, try to reduce the geographic scope to 7 miles.

Once the restrictive covenant is measured from more than one central point, for example, from all of the practice’s offices, the geographic restriction is increased exponentially. Thus, you should try to limit the restriction either to the practice’s principal office or to those offices or hospitals in which you primarily practiced as an employee within the last 12 months of your employment. Be especially careful about agreeing to be restricted from practicing within a certain number of miles from the employer’s future offices since introduces a degree of uncertainty that makes it difficult for you to evaluate the impact of the restriction.

What might be considered a “reasonable” geographic restriction in a rural area may not be considered “reasonable” in an urban area. Thus, while a Pennsylvania court upheld a 50 mile restriction in rural Pennsylvania in Geisinger Clinic v. DiCuccio, 414 Pa. Super. 85, 606 A.2d 509, 518 (1992), it is unlikely that such an expansive restricted area would be considered reasonable in an urban setting.

Time. Most physician contracts restrict physicians from competing during the term of their employment and for one to two years thereafter; under most circumstances, this restriction would probably withstand a court challenge. However, if you have a one year contract, it might not be reasonable for the employer to impose a restrictive covenant that is longer than your initial agreement. Also, if you leave the practice within a short period of time, that is, before you’ve received the benefit of being trained by the employer, the restrictive covenant should not apply at all. You can argue for “tiered” applicability, that is, if you leave during the first year (especially if you are new to the area or just finishing your residency so that your ability to develop a significant practice within the first year is limited), no restrictive covenant should apply. If you leave during the second year, a one year restriction should apply; the two year restriction should apply only if you have been employed for at least 2 years by the employer imposing the restriction.

Triggers. One point that many physicians fail to consider in negotiating restrictive covenants is the circumstances under which the restrictive covenant is triggered.  It is arguably fair for the restrictive covenant to apply if: 1) the employed physician leaves without cause (thus arguably “leaving the employer in the lurch”); or 2) the employer terminates the physician with cause (other than alleged physician incompetence) since the physician may have been able to prevent her termination.

However, if the employed physician leaves due to the employer’s breach of the agreement, the restrictive covenant should not apply. (This means that you also have to pay attention to the contract’s termination provisions since many physician agreements fail to include a provision permitting the physician to terminate for cause, a necessary prerequisite to invoking this trigger.)

Similarly, if the employer terminates the physician for no reason, e.g. the employer overestimated its patient volume, the physician should not be penalized by being subject to a restrictive covenant.  Finally, if the employer terminates the physician because the employer alleges that the physician was incompetent, no restrictive covenant should apply because an “incompetent” physician presumably cannot be a competitive threat to the employer.

In addition, restrictive covenant should not apply if the employer ceases to provide the type of specialized services that the physician provides. For example, if a hospital discontinues its obstetrics services, the employed obstetrician-gynecologist should be able to practice obstetrics anywhere without being subject to a restrictive covenant.

Public Interest. In contrast to the American Medical Association, the American Bar Association has a longstanding rule prohibiting restrictive covenants in lawyers’ contracts, concluding that they inappropriately intrude upon the lawyer-client relationship and restrict the public’s right to choose an attorney. Several commentators have argued that the public’s right to choose a physician is at least as important as the public’s right to choose an attorney. However, while judges see themselves as appropriate arbiters of lawyers’ rights, they have usually deferred to the AMA’s judgment about what is ethical for physicians.

Nevertheless, in deciding whether a restrictive covenant is enforceable, courts invariably consider whether enforcement of the restrictive covenant is likely to injure the public. The More court specifically reduced the mileage restriction in Dr. More’s restrictive covenant precisely because his skills as a neurosurgeon were needed to provide coverage in a particular hospital’s emergency room. In an earlier Pennsylvania case, New Castle Orthopedic Assoc. v. Burns, 481 Pa. 460, 469, 392 A.2d 1383, 1387 (1978), the Pennsylvania Supreme Court reversed the grant of a preliminary injunction that would have prevented an orthopedic surgeon from practicing within a certain geographic area because it concluded that there was a shortage of orthopedic specialists in the geographic area; the orthopedic surgeon was permitted to practice in the restricted area to avoid harm to the public.  Considering the great weight often given to potential public harm by courts, you might be able to negotiate the complete elimination of a restrictive covenant if you are practicing in a rural area with a shortage of physicians in your specialty.

Restrictive Covenants and Recruitment Agreements. If your compensation in your employment agreement with a medical practice is subsidized under a recruitment agreement with a local hospital, the restrictive covenant must comply with the Stark law. Under an older version of the Stark Law, a medical practice could not include a restrictive covenant in its employment agreement with a physician whose compensation was subsidized by a local hospital. However, after 2007, this requirement was modified, so that restrictions are now permitted provided that they do not unreasonably restrict the physician’s ability to practice in the geographic area served by the hospital. Failure to comply with state law would be considered evidence that the restrictive covenant is not “reasonable.”

Liquidated Damages. An increasingly number of restrictive covenants include liquidated damages clauses. These clauses permit the physician to “buy her way out of the restrictive covenant.” The amount required to be paid should relate to the costs incurred by the employer in terms of patients lost due to the physician’s departure and recruitment and training of a replacement physician. One possible way of calculating these damages is to relate them to the physician’s annual compensation while she was an employee.

Consideration.  Restrictive covenants are valid only if they are part of another agreement, e.g. a purchase agreement or an employment agreement, because they must be accompanied by adequate consideration, i.e. payment. Generally, the salary offered by the employer in the initial employment agreement is considered adequate consideration. However, if an employer subsequently tries to add a restrictive covenant to an employment agreement, it will not be upheld unless the employer provides additional payment to the employee.

Dispute Resolution. Litigation is expensive and time-consuming. It is generally in all of the parties’ interests to expedite the resolution of disputes involving restrictive covenants. The American Health Lawyer Association has dispute resolution services that include both mediation and arbitration. Starting with mediation in these types of disputes often means a faster and more equitable resolution.

Original article courtesy of Martha Swartz, M.S.S., J.D. at physiciannews.com.

The numbers are daunting. Consider these statistics from the Association of American Medical Colleges graduate questionnaire and try not to glaze over and fall off your chair in a fit of depression:

The average educational debt of indebted graduates of the class of 2009 is $156,456.

79 percent of graduates have debt of at least $100,000.

58 percent of graduates have debt of at least $150,000.

Has it always been this way? No. Medical education debt has increased, and is driven by rising tuition, according to the American Medical Association. AAMC data concurs, showing that median private medical school tuition and fees increased by 50 percent (in real dollars) in the 20 years between 1984 and 2004. Median public medical school tuition and fees increased by 133 percent over the same time period, according to the AAMC.

How Bad Is It?

The good news, if there is any, is that nephrology fellows may have slightly less debt than trainees in other fields, according to Mark G. Parker, MD, director of the Division of Nephrology and Transplantation Program, and director of the Nephrology Fellowship Program at Maine Medical Center.

In 2009, Parker worked with colleagues at several institutions and the American Society of Nephrology to survey the current renal fellow ASN membership and learned that, for instance, only 4.9 percent of fellows had an educational debt burden of greater than $200,000, whereas it was reported in the New England Journal of Medicine earlier that year that nearly 25 percent of U.S. medical graduates report this level of debt burden, Parker said.

“And while 38.4 percent of fellows described little or no educational debt, over 30 percent still described indebtedness in the range of $50,000 to $200,000,” Parker said. “The reasons for this distribution are uncertain, but it’s notable that currently only 40 percent of nephrology fellows are U.S. medical graduates and the nature of a young adult’s financial obligations obviously must, to some degree, reflect socioeconomic background and resources during one’s academic years. Interestingly, when asked why they chose nephrology as a career, only 1 percent of fellows cited ‘earning potential.’”

Parker is not certain that the stress of educational debt or the strategies for managing debt are different for nephrologists than they are for any other young professionals. “In the tenuous economic environment of recent years, I think it may be sensible to utilize the services of a reputable professional financial advisor in order to help one’s short- and long-term personal finance strategies,” Parker said. “Certainly, it should be a high priority to have a plan to pay down one’s pre-existing indebtedness before the additional financial obligations of life (mortgages, cars, children, unanticipated crises, etc.) accumulate. It is clear that ‘credit’ will no longer be extended as liberally as in years past, and that is probably a good thing, but it forces young people embarking on careers and starting families to have a more realistic and prudent approach to ownership and their general purchasing power.”

Consequences

Okay, medical fellows owe a lot of money. But are there ramifications beyond having to wrangle spending the first few years after gradation? Yes, according to Dr. Adam Weinstein, a nephrologist at The Kidney Health Center of Maryland.

“Having student debt is a huge stress for all physicians, nephrologists included,” Weinstein said. “For those of us that have decided to pursue subspecialty fellowships, the delay in loan repayment can mean hundreds to thousands in deferred interest payments. With between $150,000 to $250,000 in debt, on average, it is like starting your first job with a mortgage payment on top of having delayed your life, family, a real mortgage payment and other asset accumulation (think retirement savings, equity in other investments, etc.).”

Whether debt affects where nephrologists decide to work is debatable. According to Weinstein, heavy debt motivates young nephrologists to aim for a lucrative job, which generally requires moving to a densely populated area.

“More importantly, physicians often think of choosing to sub-specialize based on differences in pay,” he said. “For instance, for an extra two to four years of training beyond the three years of internal medicine residency, your salary may go up by 15 percent to 40 percent, sometimes more. Despite the delay in debt repayment, this is a strong incentive to not stay in general internal medicine. Especially since the work-life is not all that different amongst the various internal medicine subspecialties.”

Martin Osinski, president of NephrologyUSA, in Miami, Fla., said numerous factors influence the choice of where a nephrologist ends up working. The vast majority of nephrology fellows Osinski has worked with over the years have not used debt repayment as a motivating factor in choosing a position, Osinski said.

“I believe the fact that the majority of physicians coming out of nephrology fellowships not being U.S. medical school graduates have played a key role in that fact,” he added. “Unless someone feels tremendous stress from the debt and goes out looking specifically for lucrative practices in order to pay them off (I have seen a few), I think most U.S. grad fellows look at the long-term picture, practice potential, place to live, opportunities for spouse and children and time to partnership as more important than how quickly they get their debt paid off.”

Parker agrees. As a fellowship training program director he has advised graduating fellows about the job market for more than 10 years, and does not think educational indebtedness plays a large role in where nephrologists work, either geographically or in terms of practice style.

“Historically, I think that a proportion of trainees have gravitated to private practice for multiple reasons, with higher earning potential being only one contributing factor,” Parker said. “If anything, the choice of work environment is often determined by other factors—for example, many international medical graduates choose positions that will allow them to fulfill specific visa requirements, in turn presenting the opportunity to remain in the U.S. long-term.

Original article courtesy of Michelle Beaver at renalbusiness.com

Premedical students are, understandably, focused on getting into medical school. They shadow physicians and have an idea of what being a physician is like.  However, many don’t have an understanding of what life at medical school is like.

Medical school is a place in which you will grow as a person and as a professional. You will be challenged to study more than you thought possible and pick yourself up when you fall down.  The massive amounts of knowledge you need to learn in a short period of time makes medical school one of the most challenging professional schools out there.

I like to think of medical school as a roller coaster. Each medical student who enters is happy and even eager to study but as the months drag on, the studying gets old and you say to yourself, “I cannot wait until all this studying is over!“

As a new physician, I have experienced the sleeplessness, the long arduous hours of studying, the multiple stops at Starbucks and more.  Here’s my overview of the realities of attending medical school.

Types of Schools

Two types of medical schools exist: Allopathic Medical Schools and Osteopathic Medical Schools.  Allopathic medical schools confer an M.D. degree and Osteopathic medical schools confer a D.O. degree.  Both schools train its students to become fully licensed to practice medicine and prescribe medications. Both doctors see patients and become investigators of the body as they try to find out why their patients are sick.

What’s the difference? Osteopathic Physicians learn osteopathic manipulative treatment, using their hands to help diagnose and treat different diseases.

Class Structure

The typical medical school focuses on a combination of lectures and problem-based learning modules. Imagine sitting in class, listening to lectures, taking notes and then taking Scantron or even computerized tests. This is the standard way in which medical school builds and tests your knowledge. In fact, medical school literally feeds your brain with first, basic sciences and then, clinical knowledge.

The problem-based learning method consists of a group of med students working together to solve a patient case. For example, you are presented with a hypothetical 45 year old man with a history of heart disease and high cholesterol. He travels from New York to California on a business trip. Upon landing he experiences excruciating right leg pain. Problem-based learning focuses on exploring this case and diagnosing this patient. A physician-moderator typically sits in to guide and create the dynamic of the group.

Schools may have a traditional or system-based curriculum.  A systems-based curriculum means that all your classes are divided up by body system. For example: Month one may be about the cardiovascular system, month two may be about the gastrointestinal system and month three may be about the reproductive system and so on.

Classes

YEAR 1

Your MS-1 (Medical Student 1) year will be your most difficult year of med school.  Year one of medical school consists of mostly basic sciences courses, which means LOTS of memorization. I detail the major classes below, but medical school also consists of medical ethics courses, OSCEs in which you learn the physical exam and more. OSCEs refer to Objective Structured Clinical Exams in which you are presented with various hypothetical patient scenarios. An actor portrays a patient with a certain clinical disease and you are expected to obtain a thorough medical history and physical examination in the allotted time period.

GROSS ANATOMY

In year one, you are presented with one of the most challenging medical school classes known to humankind: gross anatomy. For many of you, gross anatomy conjures up images of cadavers and the smell of formaldehyde. Gross anatomy has two components: lecture and lab. Lecture is typically lasts for an hour while lab is typically about four to five hours long.

Different medical schools structure their gross anatomy courses differently: Some medical schools have gross anatomy every day while other medical schools opt to hold the course three times a week. The course itself can last three months to one year.

Here, you will learn the wonders of the human body from the cranial nerves, brachial plexus and mediastinum to the femur, humerus and orbicularis oculi muscle in your eye. I’m not gonna lie, gross anatomy is a tough class. You have to keep up with the reading or else you will be behind. Study in groups if you like learning with a group of people.

HISTOLOGY

Histology is the study of cells in the human body. This, too, consists of a lecture and lab component. Oftentimes, you will take histology and gross anatomy together, especially if your medical school is systems-based.  Lab consists of looking at slides in the microscope. I loved histology but didn’t appreciate gross anatomy until I was done with it!

PATHOLOGY

Ever watch Dr. G Medical Examiner? Pathology class in medical school is similar to pathology seen on Dr. G Medical Examiner. You look at histology slides of, for example, an infarcted heart (heart attack) and know by inspection that it is a damaged heart. This, like histology and gross anatomy, consists of lecture and lab.

BIOCHEMISTRY

Biochemistry is similar to organic chemistry but better. Don’t panic, you don’t have to distill any liquids in lab or draw any funny structures as this class is primarily lecture-based. You may have to memorize the Kreb’s cycle and glycolysis cycle.

YEAR 2

Year two of medical school is typically clinical-based. Here you will learn a handful of the diseases you will encounter in the hospital, such as:

Myocardial infarction (heart attack)

Pulmonary embolism (blood clot in the lungs)

DVT (deep vein thrombosis )–blood clot in the leg

Rheumatoid arthritis

Congestive heart failure

and the list goes on (and on and on…).

This is when medical school turns to real medicine.

YEAR 3

Year three consists of clinical rotations. Here you will become part of the medical team. A medical team typically consists of an attending (senior doctor), residents (doctors-in-training) and interns (first year residents). As a medical student, you are at the bottom of the totem pole. Some doctors will make that well-known while others are very nice.

You will rotate through the many clinical specialties of medicine, such as Internal Medicine (adult medicine), pediatrics, ob/gyn, psychiatry, etc. Here, you will get a taste of what kind of doctor you will become.

Your team will grade you on your performance during your rotation. As with any work environment, this can be a bit biased. However, national tests are administered at the end of your rotations. Some medical schools require you to pass this exam to receive a grade at the end of your clinical rotations. Sometimes, the percentage grade is even factored into your final rotation grades.

YEAR 4

Year four of medical school is much like year three but a bit more specialized. You can delve into the specialties of medicine even more. For example, if you liked internal medicine, you can elect to do a gastroenterology, cardiology or rheumatology rotation. Grading is the same as in year three.

So this piece hopefully gave you a good overview of the nuts and bolts of medical school. Congratulations on your recent admission – or good luck with your applications – and best wishes for your future plans!

Original article courtesy of Dr. Lisabetta Divita at studentdoctor.net

In 2007, my wife opened a private medical practice, Brazosport Urology, in our hometown of Lake Jackson, Texas. While my background has been in IT, her clinic quickly became our family business and I took on the role as practice manager. It was quite the ideal set up — she could spend time thinking about her patients while I spent my time running the business end. After a while it was clear that we needed to move all of business items — from billing to prescriptions — to an electronic system.

From my previous experience working in enterprise IT environments, I felt I was in a better position than most practice managers. I understood the costs and commitment involved in maintaining an on-premises system, and I knew what to expect during the selection process. After getting referrals and doing my initial research, I determined that moving toward a cloud-based system would be best for our growing practice. The price quotes on a standalone system and time and resources involved in managing a SQL server, backup, desktop clients, and everything in between that goes into managing a server in-house was just not the best choice for us.

Obviously, hospitals and large managed health care centers have the resources to implement some of the larger, more legacy-based systems — but more importantly, they have a need for these types of systems. Think of it this way, it would be like giving a small business owner an IBM mainframe to run their business. They don’t really need it or want it and they can’t maintain it. It’s daunting, and because of this I saw that many of our counterparts were putting off moving to an EHR system. It’s not that they don’t see the benefit, or want to take advantage of the government incentives, it’s more the fear of undertaking such a big project that they know nothing about.

Even with my technological background, we still needed a less complex, shorter learning curve, yet strong application for our mid-tier practice. Looking at our list of desires and needs, we quickly realized that one issue that we wanted resolved with our EHR system was the inefficiencies of paper/phone/fax-based prescribing and prescription filling. Our staff would routinely spend extended periods of time on hold with or contacting pharmacies regarding particular scripts and physical proximity to patients.

Many patients — feeling the economic pinch — would request less expensive alternatives to their regularly prescribed meds, something that also required tedious formulary research and verification. And filling or refilling scripts on nights and weekends was always a time-draining experience. Additionally, all of these inefficiencies precluded our practices’ ability to focus on expanding the patient panel and ensuring the highest quality customer service possible. With our location, word-of-mouth is key, so we try to make sure everyone leaves here with something good to say about us.

The process of finding the right EHR system isn’t always easy no matter what your background, and we even switched systems after just six months with the one I initially selected. But in the end, it was worth it. An unexpected benefit of finding the right EHR was its impact on our quality of life — both at the office and away. Both our doctors and staff have seen a boost in productivity provided by the system; not only are they working more efficiently, but they are freed from menial tasks and able to focus on issues that directly impact the growth and success of our practice. We’ve found that we can do some things that used to take up to 30 minutes in less than a minute, and that frees all of us up for more satisfying, strategic revenue-generating and value-creating activities, such as customer service or prospecting — which goes directly to our bottom line.

Original article courtesy of Derrick Berger at physicianpractice.com