Tailoring New Physicians to Fit Your Practice

April 2001 Table of Contents

Find out how one group created an orientation program that assimilates new doctors more quickly and creates an increased sense of loyalty.

Randall Grimshaw, MD

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The online version of this article incorporates material not included in the print version.

In the traditional model of physician orientation, the established physician introduces the eager, young physician to his or her nurse, points out the new physician's three exam rooms and lets him or her know about the established physician's upcoming two-week vacation in Europe. The hope is that when the established physician returns, the new physician will know how to find the emergency room, be familiar with the local specialists and understand the peculiarities of the office staff. All this accomplished without a lot of pesky questions for the senior doc, right?

Well, the problem with this - and similar orientation models that assume a new physician can immediately jump in and be successful - is that they don't quite work. Instead, it takes longer for new physicians to become oriented to the practice and, thus, longer to feel like an integral part of the practice.

At Austin Regional Clinic (ARC), the multispecialty group I work for, this is something we learned the hard way - and something that made us rethink how we integrate new physicians into our practice. Our clinic has 125 providers, 50 of whom are family physicians, but this program could easily be adopted by a practice of any size with any specialty focus.

Time for a change

Although the "traditional" orientation program at ARC was less draconian than the model described in the introduction, it was still unstructured beyond two days of introductions and meetings with human resources, quality assurance, information technology and credentialing, among others. Subsequently, the clinic manager and the new physician's nurse played large roles in setting up the new physician's schedule, which didn't encourage the physician to take charge of his or her practice and productivity. Instead, it created a passive attitude from the new physician toward the practice.

KEY POINTS:

This group's orientation program sets a visit-frequency target for new physicians: 25 visits per day within the first seven to eight weeks.
Physicians' coding and documentation are reviewed after one and four months of employment as part of the program.
New physicians receive guidance through a mentoring program and short vignettes about various practice management issues.

When we started to see a growing decline in finances, morale, loyalty and buy-in -- and a sharp increase in physician turnover - senior leaders determined that we needed to expedite the assimilation of new physicians. I was tapped to develop a new orientation and integration program.

The old orientation program didn't encourage the physician to take charge of his or her practice and productivity.

Improving new-physician orientation

The goals we established for our new program were to accelerate the new physicians' gradual increase of visit volume, optimize their coding and documentation and instill in them a sense of group loyalty and recognition of the benefits of shareholder status. This involved making changes in the new-physician scheduling system, putting more emphasis on coding and documentation accuracy, developing a "chief orientation" to highlight citizenship and benefits issues, and providing more advice and assistance - in the form of mentoring and practice-management tips -- to the new physicians. We began by reorganizing the administrative portion of the orientation to allow the physicians to see patients on their first two afternoons instead of devoting their entire first two days to orientation. Then we rolled out the components of the new program.

Scheduling. The biggest change we made to the scheduling system was to set visit-frequency goals. In our old program, the new physicians weren't building volume quickly enough, partly because we had not set any targets for them (i.e., see X number of patients by Y date). In our new program, the new physicians' schedules initially allow 30 minutes per visit, which gives them time to become familiar with the use of our billing system, referral network, medical records format, etc. Then, we work with them to gradually increase their visit frequency to 25 visits per day (21 15-minute visits and four 30-minute physicals) within the first seven to eight weeks.

Practice Management Pearls

Some of this material is not included in the print version of this article.

As part of the new orientation and integration program at Austin Regional Clinic (ARC), the physicians developed single-page, practice management pearls to advise new physicians and increase consistency in the clinic. They chose the topics of the pearls based on which subjects prompted the most questions, problems or complaints from new physicians in the past. Here is the complete list of pearls offered at ARC:

Angry patients
Charting
Coding
Discharging patients from the clinic
Manipulative patients
Patients with lists
Phone-message management
Physicals
Physician-patient communication
Poor outcomes and unexpected deaths
Procedures
Referring patients to the after-hours clinic
Refills
Same-day appointments
Specialty phone advice
Utilization management
Workers' compensation

This article features four selected pearls ("Physician-Patient Communication" and "Patients With Lists" in the print and online versions of the article and "Refills" and "The Angry Patient" in the online version of the article only). All four of these pearls can be downloaded as one Microsoft Word file.

We also try to help our new physicians build a loyal patient base by emphasizing same-day appointment availability. Although the number of same-day appointment slots a physician can have varies greatly by the physician, the clinic and even the time of year, we suggest that new physicians try to have between 30 percent and 70 percent of their total daily or weekly appointment slots available for same-day appointments when they begin.

Coding and documentation. New physicians tend to undervalue their efforts. Our group has always done an extensive coding review approximately three to four months after a new physician starts. Now, I also provide an informal assessment approximately one month after a new physician joins our group. I choose to do these assessments myself, but they could be well handled by a nonphysician coding expert.

Chief orientation. To highlight the importance of citizenship and benefits issues, we decided to handle these issues separately from the rest of the orientation with each group of new physicians. We call this part of the program "chief orientation," because it is led by our group's department chiefs. Our goals are to decrease the number of misunderstandings, improve practice consistency and foster some positive peer pressure among the new physicians. The chief orientations also give our new physicians a chance to develop some camaraderie and realize that settling in to a new practice is a challenge for everyone.

The two-hour chief orientations are held at one of the chiefs' homes. We discuss such issues as provider support, hours, sick days, call, triage, professional courtesy and vacation benefits, among other things. We also take this opportunity to explain the benefits of shareholder status and invite discussion.

Mentoring. New physicians have always asked established physicians for advice. We decided to incorporate a more formal mentoring system into our orientation to ensure that new physicians have the opportunity to talk to physicians in other groups.

Our 'pearls' are intended to enhance consistency within the department and impart the wisdom of the ages on practice management issues.

We identify and recruit specific mentors for new physicians prior to their arrival. Ideally, the mentors are positive role models from a different clinic site who are in their first two to three years of practice. They're asked to be available by phone and to meet occasionally with the new physicians in nonclinical settings, for example, by going out to dinner together.

In addition to the formal mentoring system, we encourage the department chief, clinic manager and administrative representatives to make scheduled contact with the new physicians through phone calls or drop-by visits at lunch to provide reinforcement and positive feedback.

Practice management tips. Another way we offer advice to our new physicians is with our new practice management tips, or "pearls." These single-page pearls are intended to enhance consistency within the department and impart the wisdom of the ages on such practice management issues as handling patients with long lists, physician-patient communication, refills and angry patients. After writing the pearls, I circulated them to the entire department for peer review before implementing them in our new orientation program. Although developed specifically with our clinic in mind, most of the pearls could easily be adapted to fit any type of practice. [For more about the pearls and to view some samples, see page 40.]

Early results

We only have initial impressions of the impact of our new orientation and integration program since we've just recently implemented it. However, so far we've generally seen positive results with each change:

Visit volume is on pace or exceeding our goals in all cases.
Productivity per provider is dramatically better than a year and a half ago.
As we expected, coding reviews have shown a tendency to undercode, but there is enthusiasm for improvement; and documentation has been complete.
The chief orientations have been well received and have generated some good discussions.
Physicians are resuming shareholder equity buy-ins.
The mentoring has worked well, although inevitably there's been some variation in the extent of the mentors' help. Some mentors have been great, taking the new physicians out to lunch or dinner once or twice, some just call to make themselves available and, unfortunately, some volunteer but don't follow through.
Just about all the responses to the practice management pearls have been positive. In fact, the internal medicine (IM) chief now gives copies of the pearls to the new IM physicians too.
Morale is significantly improved.
An unofficial, informal survey of the new physicians first oriented with this program indicated satisfaction with the process, awareness of the program's goals and a sense of control over their schedules and practices.

All four of these pearls can be downloaded as one Microsft Word file. ( 307 KB).

Practice Management Pearls

Physician-Patient Communication

Occasionally, patient complaints are rooted in a general dissatisfaction with the experience of an office visit. These complaints transcend whether the patient got well, or even whether the physician was on time. They might arise because the patient left the exam room feeling as if he or she had not been properly heard or that the physician didn't properly explain things to the patient. Comments such as, "She didn't listen to my explanation," or, "He barely looked at the rash," signal deficiencies in the physician-patient relationship for that interaction.

The "happy glow"

We've all seen the patient who leaves a visit with a smile on his face because he's just seen a doctor who listened to his problems and offered help: He has the "happy glow." Here are some ways to increase the number of patients with the "happy glow" each day:

Be confident. You only have a fair chance of curing the patient's problem, but you have a 100-percent chance of helping him or her feel better on at least some level.
Look at the chart before entering the room to determine whether you've ever seen the patient previously. This changes the first words out of your mouth from, "Good morning, Mrs. Jones. I'm Randall Grimshaw," to, "Good morning, Mrs. Jones. Long time no see." Using the wrong greeting creates a bad impression.
Handle tardiness appropriately. If you're more than 10 minutes late, apologize at the beginning of the visit. If you're more than 25 minutes late, apologize at the beginning and end of the visit.
Smile at the beginning and end of the visit.
Make some physical contact. Offer a handshake or a pat on the shoulder at the beginning of the visit, touch the patient during the exam (even if it's just to listen to the heart and lungs) and offer a handshake or a pat on the knee or shoulder at the end of the visit.
Acknowledge others in the room (e.g., "I see you brought your assistant!").
Sit, even if it's just for a few seconds.
Look the patient in the eye, but avoid stare-downs. Keep your expression empathetic or positive.
Give the patient permission to call back (e.g., "Let me know if you have any trouble with your medicine, or if you're not better in a week.").

Patients With Lists

Some patients view any office visit as either an opportunity to catch up on all their neglected health care issues for the preceding months or to get an expert opinion on a variety of inconsequential items for which they would never consider making an individual appointment.

The problems

Trying to handle the multiple problems on a patient's list in a 15-minute office visit can be difficult for several reasons:

It inhibits your ability to stay on schedule.
It inconveniences your other patients.
It increases your stress.
It forces you to spend the first moments with your next patient explaining why you're late, which starts the visit on a negative note.
It increases your medicolegal risk. You may forget an instruction, or the patient may not hear one because he or she is trying to remember so many things. Because more documentation will be necessary and you'll have less time to do it, it may not be as complete. Remember that patients and attorneys hold you to the same standards no matter how many problems you deal with during one visit.
It generates lower reimbursement for the clinic and might reduce your productivity. For example, reimbursement for one level-IV visit would be less than for two level-III visits.
It may cause patients to bring a list of multiple problems to every visit.

Suggested interventions

Ask your nurse to watch for patients with lists and express doubt to them about your ability to take care of several problems in one visit.
Try to determine at the beginning of the visit whether the patient has a list. Look for the list itself, several problems noted by the nurse, very thick charts, hovering relatives, etc. It's better to get the list out in the open in the beginning than to wait for it to pop up after you've initiated closure.
Describe the risks associated with quickly skimming over several problems in a 15-minute visit as opposed to adequately and safely addressing each of the problems. This reinforces that it's a 15-minute visit, that you want them to have safe care and that you do care about addressing each of their problems (just not right now).
Encourage follow-up visits to deal with each problem. Be cautious, though, about telling the patient to come in for a physical to do everything at once. The patient may bring in a list reaching to the floor.
Stay focused, and keep patients focused on the reason they're there. Redirect the history discussion when necessary.
Choose problems wisely. Watch for a patient who spends 12 minutes talking about his or her arthritis pain before bringing up a new chest pain.
Use good judgment. Be resolute without being mean and confrontational.

Refills

Although prescription refills are best done by the patient's primary care physician, or at least in his or her name, there will be times when the physician is unavailable and unfortunately has not left standing orders. In these cases, you will need to make decisions about refilling medications for other physicians' patients. Here are some things to keep in mind when handling prescription refills for your own patients and for other physicians' patients:

Pearls for when you are the patient's primary physician

Leave standing orders for prescription refills for your nurse when you're off or busy. This will limit delays in your patients getting the medication you want them to have.
Give enough refills at the initial office visit to last until the patient's next scheduled follow-up visit.
Don't give too few refills on chronic medications that are safe and don't need scheduled follow-up visits, such as antihistamines, steroid nasal sprays or antispasmodics for irritable bowel syndrome. This results in unnecessary phone messages for you, your nurse, the triage staff and the patient.
Don't pull the patients' charts when refills are requested for chronic medications with a low potential for misuse, such as antihypertensives or thyroid supplements. Chart pulls are expensive and unnecessary in these cases. Instead, have your nurse check the computer for the date of the last office visit or significant lab draw. Ask him or her to write this information on the refill request before giving it to you.
If the requested medication has potential for misuse, consider pulling the patient's chart in order to review phone-message refills by yourself and your partners. Phone-message refills may not be documented in the office computer. However, if you're comfortable with your relationship with and instructions to the patient, this may not be necessary.

Pearls for when you are covering another physician's patients

Consider giving partial refills on weekends and holidays for medications with a potential for misuse. For example, if you get a refill request on a Saturday for 60 Vicodin for a partner's patient, give enough to tide the patient over until the next business day, when your partner can review the request for the larger amount. Alternatively, you can offer the patient a visit that day to help you better understand his or her usage pattern.
Don't refill medications if you don't know what they are. Look them up - even if you think the patient's primary care physician is pretty smart.
Don't refill medications you're not comfortable prescribing. If the patient wants you to refill his or her lithium, do so only if you're comfortable with your knowledge of lithium and bipolar disorder. You'll have more luck saying, "I'm not comfortable doing that," than you will saying, "I won't do that." Where indicated, recommend appropriate subspecialty follow-up to deal with the patient's needs, and document that you've done so.

The Angry Patient

Many patients are angry because they're uncomfortable or scared and have little understanding of the source of their discomfort (regardless of how much they've read about it on the Internet). This anger is often poorly focused and sometimes targeted at their physicians. Some obvious signals that you might be dealing with an angry patient are that he or she has a closed posture, severe countenance and/or tension in his or her voice. Less obvious clues are when you begin to feel angry with the patient or when there is persistent patient misunderstanding about diagnoses or instructions.

Reciprocating the patient's anger by adopting his or her negative body language, becoming cryptic in your instructions and/or sending him or her away (by ending the visit or referring the patient) should be avoided. These tactics will make the patient angrier, which hurts you as much as it does the patient. Putting someone "in his or her place" is not a good thing. Angry patients are often vindictive patients and frequently have attorneys' phone numbers readily at hand. The following are techniques for dealing with anger once it's identified:

Diffusion. Patients are not always aware of their anger. By simply telling a patient that he or she seems angry, you might open the door for a discussion that will cause the patient to quit acting angry toward you, dissipate at least some of his or her negative emotion and strengthen your relationship. This discussion could last an entire visit, but it's time well spent; you're unlikely to get anything accomplished until the patient's mood has improved.

Redirection. Patients may not realize that they're directing their anger toward you. A patient might be angry at a husband who gave her chlamydia or at the cancer that has resulted in a colostomy. Helping a patient figure out what really caused his or her anger (redirecting it) clears the deck so you can re-establish a positive relationship and help the patient get better. However, avoid passing the buck by redirecting a patient's anger toward other physicians. Redirection is a less desirable solution than diffusion since the angry patient remains angry, but it is preferable to separation.

Separation. There may be a few times when you just can't get around the patient's anger, even after you've tried diffusion and redirection at multiple visits. In these cases, you and the patient may be best served by ending your relationship. Approach this with a constructive, rather than punitive, attitude, making it clear that you aren't angry with the patient. Explain that since the two of you haven't been able to work through the problem, you think it would be in the patient's best interest to look for a new physician with your help. If you find this happening frequently, examine the state of your own emotional health.

Leading the change

Recovering from our group's financial and turnover problems has been a tremendous challenge. However, we're a better department and a better group than we were two years ago due to the quality of the new physicians who've joined us as well as the group effort from our established physicians to make our new orientation program work and to hold the department together through difficult times. Perhaps a few years down the line it will be clearer as to whether the aged led the young or the young led the aged.

Dr. Grimshaw is a family physician and co-chief of the Department of Family Practice at Austin Regional Clinic in Austin, Texas.

Copyright © 2001 by the American Academy of Family Physicians.
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