How To Engage Intensively

A practical guide for physician leaders when things go wrong.

There are two types of physician leaders: those that have dealt with a potentially catastrophic issue—and those that haven’t yet.  I’m referring to those incidents that tend to excite the media or bring regulators to your doorstep.  It could be a failure of your quality system or a product recall.  Even worse, it could result in a serious injury or death of one or more of your patients or staff. 

You may be a practicing physician in a clinical role—or a physician seeking a non-clinical role in industry.  Whether you are managing a clinical practice or a commercial enterprise, chances are you will face such a serious challenge sometime in your leadership experience.  The question is how to engage intensively—and lead others through the investigation and problem solving. 

Here is a multi-step process developed for the military that has been adapted for use in industry.  This process can also be modified to fit the needs of a clinical practice.    

Gathering Information

• Use multiple communication channels and early warning systems, such as dashboards, operating reviews, and skip-level meetings to monitor important performance dimensions of your business or practice.
• Take initial reports for what they are…initial.  Acting prematurely before having reliable facts may force you to “put toothpaste back in the tube.”
• Beware the vividness of the moment.  Time settles your emotions.
• Don’t shoot the messenger

 When Deviations from Plan Occur

• Expect bad news to travel to you slowly
• Expect and get over denial ASAP
• Expect the reality to become distorted as it traverses layers of management (not necessarily a result of devious acts).
• Anticipate a “victim” mentality (i.e., it wasn’t my fault) and counter-productive finger-pointing (i.e., it was someone’s fault), which further distort the true underlying causes.

 Getting to the Root Causes

• Collectively, the people closest to the problem (e.g., nurses, technicians, clerical staff, and clinical monitors) know the problem.
• Establish a direct line to these people—and preferably, see them on their turf and in the process.  Do not alienate their management chain—they need to support you and learn the lessons with you.
• A “root cause” is not a restatement of the problem or one of its symptoms—but rather a critical assessment of the underlying cause.
• Strenuously separate fact from opinion.  Keep asking “Why?” until you are satisfied that you have gone deep enough.
• Once you have broken the situation into its component root causes, you need to assemble a “shared reality” before moving forward to “solve the problem.” 
• Problems often stem from a series of causes; avoid focusing only on the last event.

 Problem Solving

• Tie the thread together that links root causes (facts) to corrective actions, which lead to potential solutions (opinions and recommendations).
• Vigorous debate of potential solutions leads to the highest quality decisions—but maintain an appropriate sense of urgency.  Encourage and reward dissenting opinions.
• Develop a detailed plan of action with a clear timeline and accountability.  A good leader shares accountability for the situation, but gives all the credit to the team once success is achieved.
• Be mindful to separate short-term fixes from longer-term systematic solutions—which may require different people, processes and/or a full-scale change management program).

 Lessons Learned

• After the dust has settled, assign a smart non-participant in the situation to do an objective “Lessons Learned” report.
• Teach the relevant colleagues the “Lessons Learned” to avoid repeating the mistakes.
• Remember that anybody can lead in good times.  The best leaders are those who rise up and inspire in times of adversity and uncertainty.

Hey Doctor, What's Your Personal Rate Of Inflation?

I’ve noticed a disturbing trend over the past few years: my gross income has declined but my workload has increased.

I make less per patient and per hour now than I did over five years ago. Whether the reason is malpractice premiums, flat insurance payments, inability to increase fees and collect them, or corporate practice of medicine, one thing is certain: I’m not alone. According to the Medical Group Management Association, in 2006, physicians in my specialty reported a compensation increase of just 2.7%, compared with the inflation rate of 3.2%. We all know why we are feeling the squeeze but the question is, what can we do about it?

Inflation is a general rise in the price of goods and services in the economy. It results in a loss of purchasing power if income fails to keep up with inflation since each dollar of income will buy less of a good or service than it did previously. Inflation is usually measured by the Consumer Price Index (CPI), which reflects the weighted average price of a basket of goods and services consumed by the average household. From 1926-2010 inflation has increased at an average rate of about 3% annually. However, there have been periods such as the 1970s and early 1980s when inflation increased by over 10% annually.

Personal rate of inflation

It should be noted that these numbers deal with averages; a more appropriate measure of inflation for an individual is the personal rate of inflation. Inflation affects individuals differently depending on individual income, geographic location, consumption of specific goods and services, and allocation to various investments. For example, a married physician living in New York City with two college aged children may be more sensitive to inflation due to higher housing costs, heating costs, and education costs than a single physician living in the rural Midwest with no children. The only way to determine your personal rate of inflation is to accurately measure your yearly personal expenditures and compare that with your yearly income.

6 STRATEGIES FOR FIGHTING INFLATION

Work more, faster

Simply put, if your personal rate of inflation exceeds your rise in income, you can always work faster, see more patients, do more procedures, or work more shifts. For incentive-based physicians, seeing more patients per hour not only increases gross income but it also increases pay-per-hour. However, at some point you reach a limit to the number of patients you see per hour, and you increase the risk of making mistakes leading to possible malpractice lawsuits. Similarly, there comes a point where the number of days or shifts you work compromises your lifestyle.

Budget living

A second way to address the inflation gap is to reduce your personal expenses by adhering to a budget. After all, do you really need heated car seats when you live in Florida? Do you need to finish the basement on your 5000 square foot house when you have no children and face $100,000 in student loans? Of course some expenses are fixed, such as mortgage payments, insurance premiums, and child care expenses for which expense reduction is nearly impossible.

Real returns

The third option is to generate inflation-beating returns (known as real returns) from your investments. The goal is to preserve an investment portfolio’s purchasing power so that future liabilities, which increase at the rate of inflation, can be adequately met by an equal or greater increase in assets. Due to the compounding effects of inflation, there is a greater erosion of purchasing power as the time horizon lengthens. Assuming a 3% inflation rate, your purchasing power declines by over half in 25 years, which is well within an individual’s investment timeframe. With just a slight increase to 4%, it declines by nearly two-thirds. In other words, it would take twice as many dollars in 25 years to purchase the same goods and services as it would today assuming average inflation, and almost three times as many dollars assuming inflation rate is 4%.

Next time I’ll talk about some investment strategies to beat inflation. 

How Do You Talk About Your Past Failures?

Let’s face it; we’ve all failed at one point or another.

How can you demonstrate your failure in a positive light so that others perceive it just as positively as your successes?

It’s important to understand that failing at something doesn’t mean you are a failure. It took me years to figure that one out! What helped me understand was to learn about a few good examples of failure that came from programs, people and items we only identify with success.

• "I’ve missed more than 9000 shots in my career. I’ve lost almost 300 games. Twenty six times, I’ve been trusted to take the game winning shot and missed. I’ve failed over and over and over again in my life. And that is why I succeed.”  Michael Jordan loved sports but failed to make his high school basketball team as a sophomore.
• Twelve publishers turned down J.K. Rowling before one gave the first Harry Potter book a chance.  Even then, she was told there was no financial reward in children’s books.
• People Magazine named Brandi Chastain one of the 25 Most Intriguing People of 1999.  She scored the winning goal with her penalty kick during the final game in the 1999 Women’s Soccer World Cup game against China.  However, several games earlier, during the quarterfinals of that same tournament in a game against Germany, Chastain scored against her own American team in an "own goal," which is an accidental kick past the goalie into her own net.
• The script for Back to the Future, written and directed by Bob Zemeckis, was rejected by various film studios.  When finally, released, Back to the Future became the most successful film of the year, grossing more than $380 million worldwide.  It won the Hugo Award for Best Dramatic Presentation and the Saturn Award for Best Science Fiction Film. Ronald Reagan even quoted the film in his 1986 State of the Union Address. The film also marked the beginning of a franchise, with sequels Back to the Future Part II and Back to the Future Part III released in 1989 and 1990, as well as an animated series, theme park ride and video game.
• Ruth Handler debuted her doll, known as Barbie, at an American International Toy Fair in New York in 1959. It was not an instant success. Many claimed that Barbie provided little girls with an unrealistic and harmful example and fostered a negative body image. Despite the criticism, sales of Barbie-related merchandise continued to soar, topping 1 billion dollars annually by 1993. Since 1959, more than 800 million dolls in the Barbie family have been sold around the world and Barbie is considered by some to be a bona fide global icon.

Most people avoid discussing failure and some have a hard time seeing their “failures” as positive and moving on. So how do you overcome and subsequently talk about your failures? And why should you talk about them at all? 

Here are some good reasons why you should embrace failure and talk about it:

Failure demonstrates innovation: In order to innovate, you have to accept that your idea might fail. When companies need innovation, they often look for someone who has not only succeeded, but who has also failed. This isn’t true for every industry, but I’ve heard decision makers secretly look for people who have failed at something, even if it’s not on the formal job description (and I’ve never seen it!). Companies who seek to build innovation, Venture Capital backed firms, firms trying to develop new products, and firms in changing industries are more likely to seek a candidate who’s failed than say, a CPA firm.

Failure demonstrates willingness to take risks: People who take intelligent risks create more value than people who don’t take risks. That doesn’t mean you should make plans to jump off your building with a parachute or take reckless business risks. But understand that businesses and people who don’t take risks don’t grow. Experience with failure will enable you to help others decide which risks make sense.

Past failure is a huge learning experience: Failure means that you get to look back on it, and think “what could I have done to avoid this?” or “how could I have made this turn out better?” Past failure means you’ve learned on someone else’s payroll and now have had a valuable learning experience to draw from so you can help others make good decisions. People who have already failed are better at avoiding failure a second time.  These things make you a good candidate in a job interview or a good candidate to take a business risk on.

Above all, knowing how to talk about your past failures will give you the confidence you need in any situation.   It does for me and it can do the same for you.

Giving A Lecture For Physicians

In all seriousness though, I've been to more than my share of lectures for med students, residents, and beyond. I've heard some people who were clearly naturally good speakers but didn't know how to give a good lecture. Anyway, in my opinion, these are tips you can do to give a good powerpoint lecture:

1. Lots of pictures! Pictures to illustrate your points, not stupid clipart.
2. Limit the number of words on a slide. One thing that drives me nuts is a slide filled with so much text, you can't even begin to read it. What's the point?
3. Involve the audience if possible. A good speaker is engaging without having to even talk to the audience, but if you're like me and not the greatest speaker of all time, asking questions of the audience keeps them awake.
4. Involve the audience BUT don't pick on the audience. I still will never forgive this pathologist who called on me by name to answer a question during a grand rounds with like 200 people in the audience. Even in a small group, I think it's kind of mean.
5. Don't have text fly in from off the screen. Do people still do this? If so, stop it.
6. Don't go into too much detail about research studies. Especially YOUR research studies. Unless of course, it's a journal club.
7. Repeat key points. I've read that people can retain 3 points from any lecture, so figure out what those 3 points should be and make sure to hammer them home.
8. Don't go on too long. After a certain point, no matter how good your lecture is, everyone just wants to leave and won't hear a word you're saying.

Also, if you can possibly manage, do NOT show photos of your children and/or dog during the lecture. Seriously, I hate that. (I'm sorry, I didn't mean that. Your kids are adorable. I love that little hat your daughter is wearing.)

About: Doctor Fizzy works as a physiatrist and blogs at http://doccartoon.blogspot.com/

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Upcoming Product Launches On Freelance MD

We're working hard on the number product launches for physicians to help you increase your income and have more control over your lifestyle.

The first three or four of these will be launched over the next two weeks or so and include a webinar on how to protect and control your online reputation, a membership site that teaches physicians how to add new cosmetic Botox and fillers to their existing clinical practice (Botox Training MD), some videos on social marketing and building relationships and quite a few others. These are being launched in conjunction with other physicians and businessesto have information and expertise that are of value to the Freelance M.D. community.

We are also working on integrating a number of new technologies into our systems and providing greater conductivity for our membersand will be rolling out some new systems in the (hopefully) near future.

One of the principles that we founded freelance and beyond is the idea that there are many physicians who have information that is of value but that is siloed and unavailable outside of the confines of a medical conference or seminar.

One of our goals is to take that information and to make it much more widely available to physicians who want it by building information products and membership sites that allow very specialized information a broad reach and benefit both the author and the consumer.

We will be announcing a number of these products in the next few weeks... and besides just building in announcing these new products, I'll be diving into great deal of detail about how we produce this content and how physicians can benefit from it. My hope is that you'll take a look and give this new system a chance.

PS: As a side note, if you're a physicianor medical provider that has some specialized knowledge that you think would benefit from a wider physician audience please contact us and let's discuss if there is a way that we get that online.

Primum Non Nocere: “Above All, Do No Harm!” Part 1

By Dr. Dean Raffelock D.C., Dipl. Ac., CCN, DIBAK

The popularity and profitability of far too many of the most commonly prescribed drugs have nothing to do with real science… or avoiding doing harm to patients.

The robust sales of these drugs far too often represent a triumph of advertising over science.

Most physicians consider themselves to be medical scientists trained to believe that the double-blind, placebo- controlled clinical study is the ‘gold standard’ of medical science. Drug companies claim to implement this unbiased gold standard on the studies they pay for to test their own products. This has become alarmingly less true. “Above all, do no harm!” has too often been replaced by “Above all, profits!”…and the truth be damned.

One of the most glaring examples of this is the 30 million or more people in the U.S. taking SSRI drugs. The meta-studies are conclusive that SSRIs work only for the most severe cases of serotonin mediated depression. Yet despite all the harmful side-effects (effects!) of these drugs, millions of people with mild to moderate depression are condemned to suffer. Significant weight gain, sexual dysfunction, suicidal ideation, murderous violence, loss of dopamine and the resultant vulnerability toward Parkinson’s disease are just a few of the potential effects from SSRIs. Reflexively prescribing this class of drugs first (especially before counseling lifestyle changes and nutritional strategies) often violates our first priority ‘Primum non nocere.’

In a recent ten-year period, pharmaceutical company spending on ‘direct-to-consumer’ antidepressant ads increased from $32 million to $122 million! During this time many studies that demonstrated no benefits or serious adverse effects were suppressed. Pharmaceutical companies are depending upon the old adage “if they hear it enough, they will eventually believe it.” That is not science, it is the power of repetitive suggestion.

Even very smart physicians with years of medical training are vulnerable to this type of unrelenting, repetitive advertising. What doctor has all the time it takes to read complete original studies and evaluate all the data? Most of the time reading the abstract will have to do. Or… reading the interpretation of the study written by a doctor on the pharmaceutical company’s payroll.

I’ve coached many physicians to learn nutriceutical approaches to mood and sleep disorders. This is always gratifying. Surprising was the fact that some did not know that SSRIs yield no net gain in serotonin. Shocking was the fact that these physicians were not taught enough clinical nutrition to know that our brains and intestinal tracts synthesize serotonin from two simple nutritional precursors…5- hydroxy-tryptophan and pyridoxal-5-phosphate (P-5-P). It is important to remember that we need to have enough serotonin in order for SSRIs to have something to re-uptake!

Unlike tryptophan, 5-hydroxy-tryptophan (5-HTP) does not need a carrier protein to ferry it across the blood-brain barrier, so it is highly effective for increasing serotonin production in the Raphe nuclei. Unlike tryptophan, 5-HTP’s conversion into serotonin within the brain is not blocked by excessive cortisol or catecholamine production. This makes 5-HTP a very effective nutriceutical intervention for many people.

Pyridoxine (B-6) is converted into P-5-P with the assistance of magnesium and riboflavin-5-phosphate. Again...5-HTP and P-5-P are required for the body to make it’s own serotonin. This simple knowledge is critical to know in order to assist a patient wean off SSRIs that either are not helping or making them worse.

Helping patients wean off norepinephrine related drugs and SNRIs requires the knowledge of the nutritional co-factors required to produce and excrete catecholamines. The amino acid L-tyrosine, iron, P-5-P, vitamin C, copper, methycobalamin, 5-methyltetrahydrofolate and P-5-P are all required to make catecholamines. Adequate magnesium is essential for efficient catecholamine excretion.

Atypical antipsychotic drugs are now prescribed on top of SSRIs, even when the SSRI has proven ineffective or is causing very troubling effects. This often deleterious cocktail is ruining the quality of life of millions of Americans.

Three atypical anti-psychotic drugs now top the list of the ten best selling drugs in the U.S. They cause an alarming incidence of blood clots, strokes and diabetes. According to Aboutlawsuits.com, there are presently over 22,000 atypical antipsychotic related lawsuits against pharmaceutical companies and the doctors who have prescribed them.

Physicians recommending these drug cocktails should know the functions and nutritional precursors of all the major neurotransmitters before prescribing drugs that up or down-regulate their function. If for no other reason, avoid a lawsuit. Better yet, learn enough nutritional biochemistry and clinical nutrition to help most mild to moderate mood and sleep issues with nutriceutical not pharmaceutical interventions.

We now need thousands of clinics specializing in helping patients wean off unhelpful or harmful psychoactive drugs! Relatively few of these clinics are now in existence and they can not keep up with the demand to help the millions of patients whose lives have been damaged by the effects of these drugs. Interested physicians just need the knowledge and entrepreneurial spirit to help these people regain their quality of life.

Primum non nocere!

About: Dr. Dean Raffelock is a nationally known expert in integrative health care and consults for physicians nation-wide at Raffelock and Associates. You may contact him at 303.541.9019.

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Are You Resilient?

We like to think we are ... but how well do you really "bounce back" from life's stressful events?

I recently heard a wonderful interview with a woman who is 109 years old, and who continues to live independently, "with all her marbles and profoundly engaged with the world around her", as the interviewer noted.

A gerontologist, the interviewer noted that while the woman most likely has a gene that contributes to her unusual longevity, she also exhibits a powerful trait that professionals in his field call "adaptive competence".  In other words, from his experience with thousands of patients, his opinion is that the key to living to a long and healthy old age is the ability to keep moving forward after life's inevitable setbacks.  It's about being resilient.

It made me start thinking about the physicians I work with in a coaching capacity.  Many of them, I've noticed, are somewhat low on the resilience scale.  Why?  Maybe you can help me understand it.

Is it a function of highly intelligent people,  linear thinkers, who spend too much time thinking about the "what could happens", and the "likely probabilities"...?.  Is resilience, or "hardiness" as talked about in the psychological literature, something that's beaten out of you in medical school and residency, with a myriad of difficult experiences feeding off of each other in some kind of a closed loop?  Are physicians highly trained, with deep but narrow skills that tend to create a feeling of insecurity around their "other" abilities, and a sensitivity to rejection, hardship, or perceived failure?  What keeps docs from having an easy time "bouncing back"?  And what, if any, are the bigger ramifications of this, either for them personally, for their practice of medicine, or for their professional fulfillment?

What we do know is that resilience is one of those psychological traits that really matters both personally and professionally ... it affects how much stress you feel, how well you keep perspective on difficulties, how able you are to maintain healthy coping skills.  People low on the resilience scale tend to dwell on things, feel victimized, get overwhelmed and turn to unhealthy coping mechanisms such as avoidance of issues and escapism (such as substance abuse).  Conversely, people high on the resilience scale have higher levels of trust, tolerance for ambiguity, optimism and adaptability - all things associated with strong leadership and higher degrees of personal and professional success.

The APA (American Psychological Association) specifies a combination of factors that contribute to a person's resilience.  They include:

• The capacity to make realistic plans and take steps to carry them out
• A positive view of yourself and confidence in your strengths and abilities
• Skills in communication and problem-solving
• The capacity to manage strong feelings and impulses

How do you rate yourself?  How well do you:

• View problems as opportunities?
• Learn from your mistakes (and accept that you make them)?
• Seek out new and challenging experiences?
• Have a sense of humor and realistic optimism under stress?
• Succeed despite hardships?

In today's practice environment, the need for resilience is stronger than ever.  In order to thrive in an atmosphere of uncertainty, increased performance demands, rapid change, and a growing feeling of loss of control, many physicians are forced to either "bounce" or flounder.

The good news is that even if you are one of those docs that tends towards the low end of the resilience scale, you can develop these skills ... even if they aren't second nature to you.  Here are 10 tips for building your resilience (thanks to the APA):

• Make connections. Good relationships with close family members, friends, or others are important. Accepting help and support from those who care about you and will listen to you strengthens resilience. 
• Avoid seeing crises as insurmountable problems. You can't change the fact that highly stressful events happen, but you can change how you interpret and respond to these events. Try looking beyond the present to how future circumstances may be a little better. Note any subtle ways in which you might already feel somewhat better as you deal with difficult situations.
• Accept that change is a part of living. Certain goals may no longer be attainable as a result of adverse situations. Accepting circumstances that cannot be changed can help you focus on circumstances that you can alter.
• Move toward your goals. Develop some realistic goals. Do something regularly -- even if it seems like a small accomplishment -- that enables you to move toward your goals. Instead of focusing on tasks that seem unachievable, ask yourself, "What's one thing I know I can accomplish today that helps me move in the direction I want to go?"
• Take decisive actions. Act on adverse situations as much as you can. Take decisive actions, rather than detaching completely from problems and stresses and wishing they would just go away.
• Look for opportunities for self-discovery. People often learn something about themselves and may find that they have grown in some respect as a result of their struggle with loss. Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vulnerable, increased sense of self-worth, a more developed spirituality, and heightened appreciation for life.
• Nurture a positive view of yourself. Developing confidence in your ability to solve problems and trusting your instincts helps build resilience.
• Keep things in perspective. Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective. Avoid blowing the event out of proportion.
• Maintain a hopeful outlook. An optimistic outlook enables you to expect that good things will happen in your life. Try visualizing what you want, rather than worrying about what you fear.
• Take care of yourself. Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing. Exercise regularly. Taking care of yourself helps to keep your mind and body primed to deal with situations that require resilience.

I encourage all of you to think about how your degree of resilience may be affecting your ability to attain personal or professional fulfillment or make positive changes in your life.  When there isn't much you can control, this is the one thing you do have a say in.  If that horse knocks you off, are you likely get right back in the saddle?  Or do you wait a while, nursing your wounds ... or not get back on at all?  It's worth exploring, for your sake and for those who you come into contact with every day.

Especially if you want to live to be 109.