Recruiting recruiters

Feature Articles | Spring 2013

 

As the liasons between employers who want to hire doctors and doctors who need positions, physician recruiters can be very helpful. You’ll likely encounter:

√ Internal recruiters. An internal recruiter, also known as an in-house or staff recruiter, is employed by the health care organization for which they’re recruiting. By filling positions within the hospital or other health entity for which they also work, internal recruiters have a bird’s-eye view of the organization and community. A benefit of working with an internal recruiter is that they tend to be more familiar with the community and will be accessible after your hire, too.

√ External recruiters. By working independently with different health care clients, external physician recruiters, also known as search firm or agency recruiters, place physicians for many different organizations. Their services are generally free to physicians, and they receive a commission from the organization if one of their candidates takes the job. A benefit of working with an external recruiter is that you’re able to get advice from a third party who might be able to give you a wider view of your opportunities.

 

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Ask, ask and ask again

Feature Articles | Spring 2013

 

Your potential longevity with an organization is at stake, so it’s essential that you’re bold in your questions. The list may be long and varied, but they center around two main questions: Can you work here? Can you live here? Here are some other questions for starters:

√ What’s a typical workday like?  It’s important to know when your day will begin, when it will end and what’s expected of you during the in-between hours. How many patients must you see, and what kind of time can you spend with them? What’s the mix in terms of demographics and payers? Also, if you talk to or shadow other young doctors, find out how the medical director or department head solicits opinions and listens to others.

√ What’s the call schedule?
Make sure you understand both the frequency and intensity of coverage. If it’s just you and two partners, for instance, you may be covering more often, but seeing fewer patients than if you’re part of a larger call group. A larger group could mean call is less frequent but involves many patients, many hospitals and many more hours. Make sure you get a complete picture of how it works.

√ What’s the community like?  You’ll likely have many questions about the area’s amenities. But also ask about the demographics and economy. Is there a sufficient industrial base to attract new citizens? Because an area’s stability or growth can affect your potential patient pool, it’s important to identify its viability, not just its ambiance.

 

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Managing your social media presence

Feature Articles | Spring 2013

 

1. Always be professional and mindful of privacy (and hipaa). Encourage a follow-up connection by phone or at an office visit when patients complain or overshare on social media.

2. Sign up for Google Alerts. Track yourself and your specialty to find blogs to respond to, hear what people are saying about you and your specialty, and catch and correct errors in ratings sites.

3. Find a champion or be a champion. If you’re in a private practice and don’t have an interest in social media, find out if one of your colleagues is savvy. Work out a system to share the workload. And if you’re secretly a social expert, volunteer to take the lead in your practice.

4. Be where your audience is. For example, Facebook might be an essential communication platform for a pediatrics practice, but it might not be an effective way to reach patients for narrow subspecialties.

5. Provide content. Blend original, supplied, generic and curated content for frequent and current social postings.

6. Know legal and organizational limits. Use disclaimers where appropriate, seek appropriate advice, and learn and follow your organization’s social media policies.

7. Keep boundaries. Know the difference between your personal Facebook and a company page, and maintain appropriate boundaries between personal and practice connections.

 

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Trying video? Try this

Feature Articles | Spring 2013

 

1 Speak to your audience. Are you trying to reach physicians or patients? Video is a great medium for either, but you’ll need to tailor your message appropriately for the audience.

2 Appearing on television? Remember to keep your responses digestible. Practice responses to anticipated interview questions in advance to help you stay on point.

3 Video is a gift that keeps on giving! Remember to repurpose your video appearances on YouTube, on your website, in directory listings, and on iPads for patients visiting your office.

4 If you’re creating your own videos, consider having someone interview you (instead of just talking into the camera alone) to allow you to respond in a natural, flowing way.

 

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5 tips for marketing your website

Feature Articles | Spring 2013

 

1 Know your audience.

Tailor patient content for patients, physician content for physicians.

2 Consider SEO.

It’s not enough to have a good looking site; people have to be able to find it. And it must be updated on an ongoing basis to maintain strong search rankings. Consider keeping your site fresh by adding a blog, or working with an SEO consultant, or both.

3 Update your content regularly.

When hiring a firm to build your website, request that they build it in a content management system so you can update it regularly. Being able to update your site with current information yourself helps you meet patient information needs without phone calls, which saves you and your staff time.

4 Get the right partner.

If you’re hiring help to build your site, tinker with your SEO, or manage your web ads, keep trying until you find the right match. Make time to review reports and manage your service providers to keep them producing results.

5 Measure your traffic.

Google Analytics offers detailed reports of how users navigate your site, and it’s free. Learn what draws people in and what pages they exit from.

 

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Dealing with the shortage of primary care providers

Methods for easing a shortage of primary care providers include increasing Medicaid reimbursement rates and changing policy for graduate medical education.

By By Jeff Atkinson | Reform Recap | Spring 2013

 

A hallmark of the Affordable Care Act is increasing the number of Americans covered by health insurance. Three of the main ways of accomplishing that are the expansion of the Medicaid system, the individual mandate to purchase health insurance, and the availability of tax credits to help purchase insurance for persons earning less than 400 percent of the poverty level. In 2012-13, 400 percent of the poverty level is $44,680 for an individual and $92,200 for a family of four.

With these initiatives, approximately 32 million more people will be covered by health insurance by 2014. In addition, a growing number of Americans are reaching Medicare age, and their health care needs are greater than those of Americans in younger age groups. The Census Bureau projects that in the next 10 years there will be a 36 percent increase in the number of Americans over 65.

Shortage of 62,900 in 2015
The growth in the number of people covered by public and private health insurance means an increased need for health care providers. The Association of American Medical Colleges estimates that there will be a shortage of 62,900 physicians in 2015 and a shortage of 91,500 physicians by 2020—about half in primary care.

Health care policy analysts generally recommend that between 40 and 50 percent of the physician workforce provides primary care. In recent years, the proportion of primary care physicians is 32 percent according to a 2010 report from the Department of Health and Human Services Council on Graduate Medical Education (COGME).

To increase the number of primary care providers, the Affordable Care Act seeks to attract more providers to primary care by increasing Medicaid payments to 100 percent or more of Medicare rates. Physicians eligible for the increased payments are family physicians, pediatricians, internists and certain subspecialists.

Eligible physicians need to be board certified in one of the designated primary care specialties or attest that at least 60 percent of the Medicaid codes they billed in the previous calendar year were for primary care codes specified by the Affordable Care Act and its regulations. Obstetricians and gynecologists do not qualify for the increased rates, even though they provide primary care.

The increased rates for primary care include payments for work done by advanced practice nurses and physician assistants if they are operating under the supervision of a physician, but the higher rates are not available if the nurses or physician assistants are working independently.

Payment impact varies by state
The impact on pay for primary care physicians will vary significantly from state to state since currently each state sets its own reimbursement rate. Nationwide, in 2012 the average fees for Medicaid physicians were 66 percent of the Medicare rates according to a survey commissioned by the Kaiser Family Foundation.

The lowest rate was in Rhode Island (58 percent of Medicare rates); the highest rate was in Alaska (242 percent of the Medicare rates). The foundation said that, on average, Medicaid fees for primary care services will rise by 73 percent. A state-by-state summary of the new Medicaid physician fees is available online at kff.org/medicaid/upload/8398.pdf.

The cost of raising primary care Medicaid rates for 2013 and 2014 is estimated to be $11.9 billion—a cost that will be borne fully by the federal government. The Accountable Care Act does not specify what happens to the rates after 2014. If the rates drop or if the federal government tries to shift a significant amount of the added costs to the states, the program may be less successful in securing the services of primary care physicians willing to accept Medicaid patients.

To help meet the need for more physicians, 18 more medical schools are being established. The Association of American Medical Colleges reports there will be an additional 7,000 graduates every year for the next decade.

Currently, however, there is not a plan for a corresponding increase in the number of residency positions paid by the Medicare system. The federal government through the Medicare program (and, to a lesser extent, the Medicaid program) has been the primary funder of graduate medical education (GME)—paying $11.5 billion per year to more than 1,000 hospitals at a cost of about $100,000 per resident per year.

Another U.S. government agency in the Department of Heath and Human Services—the Health Resources and Services Administration—also is working to increase the supply of primary care physicians. In February, the Health Resources and Services Administration announced it was making a $4 million grant to the Wright Center for Graduate Medical Education in Scranton, Pa., and the A.T. Still University of Health Sciences’ School of Osteopathic Medicine in Mesa, Ariz., to train osteopathic residents in primary care.

During the first year, the program is expected to place 29 residents in community health centers in medically underserved areas throughout the country (not just in Pennsylvania and Arizona).  Dr. Thomas McWilliams, associate dean for graduate medical education at ATSU, said that currently, more than half of the available seats are unoccupied for the July 1 start date, but he expects more applications to be made after the allopathic match in March.  For more information on the program, see news.atsu.edu/index.php/archives/1561.

Conflicting policies on paying for GME
Graduate Medical Education is caught between conflicting policy goals. On the one hand, there are calls for increased funding, particularly for primary care training programs. The Association of American Medical Colleges has recommended a 15 percent increase in GME positions (4,000 per year) to meet growing health care needs.

On the other hand, the cost of GME is considered by many to be excessive. The number of residency slots has been capped at 1996 levels, although some exceptions have been made, and the Accountable Care Act provides for a moderate increase of 300 physician training positions per year. The political pressure to avoid further increased deficits makes it difficult to obtain increased funding for GME. Congress and the White House have not developed a unified plan to handle the issue.

The Institute of Medicine, part of the National Academy of Sciences, is studying the issue of GME and how best to align financing with the needs of the public for the health care workforce. The Institute’s report is due in 2014. Among the issues that will be considered will be the appropriate level of funding for teaching hospitals and proportion of funding for teaching hospitals versus community-based clinics and health centers. Recruitment of physicians, particularly for primary care, also could be increased by more use of medical school scholarships and loan forgiveness programs.

Jeff Atkinson (JAtkin747@aol.com) teaches health care law at DePaul University College of Law in Chicago.

 

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Competition is alive and well

These tips from a recruiter can help you secure the job you want.

By By Patrice Streicher, Associate Director VISTA Physician Search and Consulting | Job Doctor | Spring 2013

 

In the mid-90s, a buzz of excitement vibrated through the walls at Fox Hill Associates, the physician recruitment firm where I was employed at the time.

A new technology called the World Wide Web promised access to physician candidates within just a few key strokes on our newly purchased shared office computer. The days following the grand announcement, I recall daydreaming about how wonderful life was going to be.

Fast forward to 2013. Despite the ongoing conveniences afforded the recruitment process, recruiting physicians is as difficult as ever. The current shallow pool of viable physician candidates creates a paradox in which practice decision makers have become highly selective by requiring candidates to meet specific professional and interpersonal criteria before extending an offer. Recruiting entities regard their recruitment and retention efforts as nearly synonymous.

The investment in recruiting long-term physician candidates with ties to the area, a solid skill set, desirable interpersonal attributes and practice philosophies similar to the incumbent medical staff are key to building and retaining a strong medical community.

Over the course of my more than 25 years of experience in the industry, I have logged a few unspoken and “just shy of traditional” observations that I have been known to share selectively with my physician candidates. Here they are for you.

In building a successful career, keep it simple by abiding by these rules of engagement
√ Never burn a bridge.
√ Always look for the silver lining.
√ Be the answer, not the problem.
√ And perhaps, most importantly, be polite and mind your manners.

1. Know the practice administrator’s mantra.
Even in the midst of a physician shortage, administrators and hospital boards’ recruitment mantra continues to be unwavering: “It is better to not fill a position than hire the wrong candidate.” And though it is seems counterintuitive, practices will wait for the ideal candidate, in some cases for years.

2. Opportunity does not equal employment.
Over the years, I have spoken with physicians who have boasted that opportunities for them are limitless. One family medicine resident recently informed me that he had so many opportunities to choose from that if he were blindfolded, he could point to a spot on a map and be assured a position in that location.

Admittedly, I would agree that jobs for physicians are plentiful. But I would argue that available opportunities equal open positions, not assured employment. Competition, especially in prime locations and for select specialties, is alive and well. Practices with a well-tuned recruitment program interview multiple candidates before choosing a new associate.

3. Make lists.
The most successful practice searches start when the physician begins their job search with a focused conversation with a spouse or significant other involved in their final practice decision.

Devise a “must have” and “wish” list that includes both preferred and realistic location and position attributes. Do this before starting your search. Over the years, I have observed that those with a mutually agreed upon practice search plan experience a streamlined process, alleviate distraction delays, ease expending unnecessary energy and avoid wasting valuable time on empty objectives.

In my opinion, physicians listing as many as 15 state location preferences are either benchmarking the market, shopping opportunities, or fear they will miss out on an opportunity.
Though there is no harm in exploring more than one region, I suggest augmenting your location options incrementally to avoid being overwhelmed and paralyzing your decision-making process.

4. Timing is everything.
In the United States, the nonverbal communication of “time” is used as a measure of the importance of one person to another. Specific to recruitment, the expedience or delay in our responding to an email, text or voicemail communicates to the sender—whether real or perceived—their importance.

Upon engaging a practice representative, be prompt and responsive to their emails and calls. Be timely with communicating new developments that arise.

In my tenure in the industry, I have witnessed CEOs and Medical Directors who interpret delayed candidate replies as unprofessional. On occasion, after weeks of unresponsiveness by a candidate, the bad taste experienced by some executives warrants them eliminating the physician from consideration.

Rest assured, these executives understand you have a full plate. However, trust me when I say that in a time when attrition is a prevalent business practice model, everybody is feeling that their cup runneth over.

5. Mind your manners.
Recruitment is a communication proposition that imposes judgments on verbal and nonverbal messaging.

When interviewing candidates, practice executives evaluate prospective physician matches with regards to their incumbent physician culture. Conversational style, approachability and etiquette during an on-site interview undoubtedly make unforgettable impressions on decision makers. Firsthand candidate interactions; word-of-mouth; and advanced networking in physician programs, medical communities and specialty markets have advanced or stifled a physician’s career and ability for promotion.

Patrice Streicher (patrice.streicher@vistastaff.com) has 26 years of combined health care experience in physician recruitment and patient care delivery systems. She has served on the National Association of Physician Recruiters (NAPR) Board of Directors since 1996.

 

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Rural Gems – Escape the city

Not every small community fits comfortably under the label of “farm town.” Here are four locations more properly considered “rural gems.”

By Eileen Lockwood | Live & Practice | Spring 2013

 

For some physicians, big cities, complete with their many amenities, are the destinations of choice. But there are a number of smaller locations offering good positions, surprising family opportunities and—perhaps best of all—easy integration and heartwarming patient acceptance, not to mention state-of-the-art facilities.

Here are four welcoming examples: Ruidoso, N.M.; Wellsboro, Pa.; Crete, Neb.; and Ironwood, Mich.

Skiing, skiing and more skiing
Ironwood, Mich.

In Michigan’s Upper Peninsula, Jim Hubbard, M.D., enjoys his access to skiing.

Say but the word “skiing,” and Jim Hubbard, M.D., is a happy man. “When we were kids in Washington State,” he reminisces, “my folks would haul us up to the mountains four or five times a year, and we would cross-country ski.” Now in Ironwood, Mich., this Upper Peninsula transplant says: “Now it can be four or five times a week.”

The UP is well-known for its huge piles of the white stuff in winter. In fact, Yoopers, as the residents are nicknamed, like to define their climate as 10 months of snow and two months of poor sledding.

Ironwood conveniently offers no fewer than five ski resorts to accommodate enthusiasts like Hubbard and is also a link in the cross-country Wolverine Nordic Trail System. One resort, on Mount Zion, is owned and operated by the local Gogebic Community College, which uses it as a training facility for its ski area management program.

Hubbard’s route to this town near the Wisconsin border was, in a word, circuitous. The University of Washington School of Medicine, where he received his degree, focuses heavily on training physicians to work with underserved populations. After a residency in Tacoma, where this emphasis continued, he says, “I looked all over the country, including lots of places in the Midwest. In Ashland, Wisc., a recruiter told me, ‘If you like this job, you should also look at (an opening) in Michigan.’ I had to get out a map because I thought the whole Upper Peninsula region was part of Canada.”

In Ironwood, he says, “I liked the doctors, the area, the people and the hospital. They met all my professional criteria, and my wife really liked the area, so we came here.”

After 12 years, he’s still enthusiastic. “Besides winter, it’s gorgeous up here with not too many people, and there’s no shortage of things to do,” he says. “We also joke about there being traffic. There’s never any here, except for two or three cars on the road.” Not only that; his wife has been able to start a chain of shoe stores (Superior Shoes, with a bow to nearby Lake Superior) with her brother in Indiana. With online sales, it’s possible for her to live in a small town.

As for Hubbard’s own professional progress, when he arrived, “a lot of patients were migrating out to have babies because of a lack of obstetricians. Now I personally do 90 to 100 deliveries a year, and my partner does the rest—a total of 150.”

Hubbard’s employer is Aspirus Grand View Clinic. The Ironwood hospital is a critical access facility with full surgical center, urgent care, in-home physical therapy service, a sleep lab, the sole retinal specialist in the entire UP and specialty care including cardiologists, oncologist and physical/occupational therapist, with on-site radiology and lab services. In June, work will start on a major ER renovation.

Ironwood’s place on the map became important with the discovery of iron ore in the 1870s, but the lumber industry played a heavy part in the mix, thanks to the abundance of trees in the wilderness. The railroad arrived in the 1880s, and immigrants from locales such as Finland, Sweden, Germany, Italy and England began arriving to fill the job openings. Today the heritage persists (and so does a tasty food from Wales, the pasty).

In modern Ironwood, neither snow nor sunshine keeps residents from enjoying other forms of culture, such as performances by two theater organizations and the Ironwood Dance Company. With no professional sports within easy reach, local residents lend their cheers to the athletes at Luther L. Wright High School, especially when they meet Hurley High, one of the longest-running rivalries in American high school sports.
The field is larger for Hubbard, who takes off in his airplane during the summer to enjoy minor league baseball games in Ohio and downstate Michigan. The “local” team for him is in Appleton, Wisc.­­—four hours south by car but a mere hour by plane.

GASLIGHTS AND GOOD FOLKS
Wellsboro, Pa.

Wellsboro is home to Pine Creek Gorge, aka The Grand Canyon of Pennsylvania (above). Below, gaslights contribute to the town’s charm.

It was a cold, windy, snowy January day when the husband-and-wife team drove into Wellsboro, Pa., for the first time. Edmund Guelig, M.D., was finishing his residency at the Geisinger Clinic and, recalls his wife, physician assistant Daria Lin-Guelig, “We were looking for a (good) community to practice in.” But on that day, she recalls with a chuckle, “it seemed like we would reach Neverland before Tioga County.”

Their fortitude was rewarded. That was 22 years ago, and the trip is still vivid in her mind. “One spin down the gas-lit, snow-covered Main Street—the gaslights will do it every time—and I said to Ed, ‘This is it. We can cancel the rest of the interviews. This is where we need to be.’”

Today they work together under the aegis of Soldiers + Sailors Memorial Hospital, itself a tribute to sturdy perseverance. In 1919, five local families filed a building application. The Great Depression literally depressed, but didn’t end, their plans. Twenty-three years later, on August 25, 1942, the hospital opened. In the next two years, some 4,000 patients were treated and 600 babies were born there.

After a number of expansions and upgrades, the hospital became part of the Laurel Health System, which was integrated into Susquehanna Health last October­—providing greater patient access to a bevy of specialists and the 226-bed Williamsport Regional Medical Center. Also in 2012, Soldiers + Sailors opened a new emergency department and a same-day surgery unit. In keeping with the spirit of community friendliness, it provides a physical and aquatic therapy center, sponsors an annual golf tournament and supports a number of recreational programs in cooperation with Wellsboro Parks and Recreation.

For the Gueligs, it was a good move indeed and their practice has been rewarding in many ways.  “We had a vision of working together in a rural setting,” he recalls, “where you’re not just in it for yourself and just for your career. You are truly part of the community.” Lin-Guelig adds an interesting perspective: “Small towns are like spider webs,” she says. ”Our relationships are intertwined, and therefore stronger, more meaningful and more personal.”

In 2011, Guelig was named Pennsylvania’s Family Physician of the Year. He’s also medical director of the Soldiers + Sailors hospice program—and a firm advocate of the “rewards and sense of gratification that come from being a family doctor in a small rural community. (Only in this setting can you have) the experience of treating three generations of a family in a small town,” he says. His childhood experiences growing up in a small Wisconsin town (Waupun) played a big part in shaping his life, and they stayed with him as an undergraduate at the huge University of Wisconsin and then as a medical student at West Virginia University.

In Wellsboro, “intertwining” became part of their four children’s lives, too. “They got to experience real community life in a way that may be disappearing,” Guelig says. “I delivered babies of their teachers, and I can’t go anywhere where you don’t expect to see people on three or four different levels.” Although his now-grown offspring have scattered to cities across the country, he adds, “We reflect on what they took away (from their childhood experiences), and we know that a part of them understands human relations.”

Another experience that he cherishes has been an offshoot of his woodworking hobby. Several patients operate the sawmills where he gets his wood. When he questioned one owner who undercharged him, he was told that it was his “doctor discount.”

Wellsboro, about 120 miles east of Scranton and an hour’s drive northwest from Williamsport (famed for its annual Little League World Series), was named for Mary Wells, the wife of one of the 1806 town founders. To this day, it exudes the New England aura that captivated Lin-Guelig—wide boulevards, spreading elm and maple trees and, of course, gaslights, not to mention its historic district encompassing structures dating from 1835 to the 1950s. The mix includes early homes and grand 1890s mansions, as well as several churches and public buildings. About 600 are now on the National Register. As one city promoter puts it, “The district is among Pennsylvania’s architectural gems.”

The area’s natural beauty hasn’t escaped the Gueligs, either. Three state forests surround Wellsboro, but the most notable feature, in Tioga State Forest, is the 47-mile-long Pine Creek Gorge, aka the “Grand Canyon of Pennsylvania,” which descends at its deepest point to 1,450 feet and encompasses waterfalls and other scenic wonders. Canoeing and rafting are among the Gueligs’ favored activities, as well as hiking and bicycling. Enthusiastic winter visitors—and locals—can strap on their cross-country skis for a trek on the nearby Rail to Trail route—or zoom along some 800 miles of groomed snowmobile trails.

But the main “hobby” for this husband-and-wife team is a farm on the edge of town, complete with horses and chickens. “When the kids were young, we also raised lambs,” he says. “There’s also an orchard, and my wife also does a lot of canning. (All in all) we feel that this is a nice complement to medicine.”

Its bucolic atmosphere aside, the city is doing “quite well economically,” says Mary Worthington of the Wellsboro Area Chamber of Commerce. Five nearby major highways help make it an attractive location for several small industries. Worthington notes that nine substantial employers attract an influx of workers. One of those companies, Osram Sylvania, is carrying on a long tradition. Wellsboro is the site of one of the first factories where light bulbs were mass-produced.

YEAR-ROUND Playground
Ruidoso, New Mexico

Gary Jackson, D.O., and his family moved to Ruidoso, N.M., 22 years ago. They were attracted by the community, educational opportunities for their children, and the skiing.

High in the mountains of south-central New Mexico, the town of Ruidoso beckons to dedicated skiers and horse racing enthusiasts, not to mention hunters and fishermen. But, more than that, it offers residents and newcomers a captivating combination of mountain/forest surroundings, friendly togetherness and a certain urban sophistication.

For Gary Jackson, D.O., the skiing possibilities were too hard to resist. After growing up in Pittsburg, Kan., attending the University of Kansas and getting his medical degree from the Kansas City College of Osteopathic Medicine, he and his wife-to-be entered the Army. To complete his military commitment, he eventually became assistant chief of pulmonology at William Beaumont Army Medical Center in El Paso, Texas. The short distance from there to Ruidoso, N.M., (about 2 and a half hours) was too tempting to ignore, so New Mexico became the couple’s frequent snowy downhill destination. Before long, the lure of Ruidoso itself became too hard to resist.

Today, Jackson is the medical director of Lincoln County Medical Center and also provides coverage for four other area groups. The hospital itself is part of a unique partnership among the County of Lincoln, a local board of trustees and Presbyterian Health Services. The latter operates eight facilities in the state.

In the 1990s, the hospital was recognized by the Centers for Medicare and Medicaid Services as one of the top small hospitals in the U.S. “One of our big changes,” Jackson reports, “was that we became a critical access institution. In the last two years we’ve been bringing on board a hospitalist system. Our ER is open 24 hours a day, seven days a week. We’re building a new physicians’ office building directly across from the ER, for both current practitioners and for outreach specialists such as cardiologists and neurologists.”

One specialty is particularly important in a winter resort area: orthopaedics. With specialists from Alamogordo Orthopaedics and Sports Medicine, Lincoln can provide close-to-home joint replacements for visitors and residents alike. There’s also a strong in-house physical therapy program.

But Jackson and his wife had other reasons for settling in Ruidoso 22 years ago. “I think we moved because we wanted a nice environment for our children to grow up in and a good educational opportunity for them as well.” Sierra Blanca, 7,000 feet high and frequently living up to its “snowy mountain” name, is another plus. “I appreciate it every morning, and when I travel I really am eager to
get home,” he says.
]Not only that. “We’re a friendly area, with a community spirit that I think is unique to Ruidoso. Community members hold together to help each other.”

When winter disappears, the recreation of choice is horseracing at the Ruidoso Downs Race Track. The  Hubbard Museum of the American West, unique gift shops, interesting restaurants and children’s attractions also attract visitors to the area.

CORN AND CARE
Crete, Neb.

The odds are heavy that anyone breakfasting on Corn Flakes or munching on Fritos can trace them to the Crete, Neb., area cornfields—and the local Bunge Milling Co., whose roots date to 1869—two years before the town was officially organized.

It was one of the first corn processing operations in the U.S. As early as 1878, its goods were being shipped to points as distant as Scotland.

Nebraska is Cornhusker territory, right down to Crete’s cornfields and the Bunge Milling Co. pictured here from a tower at nearby Doane College.

Leon Jons, M.D., surely has treated a good number of Bunge employees during the 22 years that he’s been practicing family medicine with Saline Medical Specialties, a practice affiliated with Physicians Network, which in turn is part of Catholic Health Initiatives. Jons arrived in Crete in 1990 after earning his degree and completing residency at the University of Nebraska Medical Center in nearby Lincoln, where he now lives and where his wife is a teacher.

As for his own choice of work area, he reports that University of Nebraska medical students were encouraged to consider rural locations. He ran a private practice for nine years, then joined the Saline group, where he finds much satisfaction. “Practice in a rural community is much different than in the city,” he says. “Over the years we’ve worked with complicated obstetrical patients, done some of our own surgery, taken care of our own hospital patients and done a lot of public relations work.” He’s also found that patients are more cooperative.

But there are other advantages. “I think that financially, rural physicians do better than physicians working in the city. We’re a rural health clinic where Medicare and Medicaid reimbursements are much higher.” Another reason: “Rural physicians tend to do a lot more procedures, with much higher reimbursements. Also, there’s a malpractice cap, so insurance rates are low. Another advantage is that we have a great deal of autonomy and a lot of leeway in what we practice and how we want to practice.”

Jons’ idea of recreation is relaxing at his cabin on the Missouri River, but he also enjoys exercising and spending time with his family. All in all, “the quality of life in rural Nebraska is really good. I think people shy away from rural areas thinking that there’s nothing to do and they’re too far away from entertainment (and other city attractions). I find that not to be the case. I think that most doctors find that wherever they are they can have a vibrant social life if they want one.”

There’s also room for innovation. The city’s hospital, Crete Area Medical Center, is Exhibit A. In the last three years, it has become one of the nation’s pioneers in embracing a new philosophy and system of health care—the “patient-centered medical home” initiative. So far, it’s the only recognized program in Nebraska outside of Omaha, according to CEO Carol Friesen. “In the U.S., 75 cents of every health dollar is spent on chronic disease care,” she says. “We made the commitment to spend time working with patients to achieve better control of the three biggest of them—diabetes, hypertension and hyperlipidemia. Today, for instance, the national average of uncontrolled diabetes is 36 percent. Ours is under 6 percent.”

By encouraging patients to carefully monitor blood sugar, for instance, and contacting them often to make sure they’re complying and following other healthy practices, doctors and nurses help prevent repeated hospital stays, thus reducing health care costs. “We don’t think it’s right to take patients’ money or insurance unless we’re giving them the best care possible,” adds Friesen.

A second aspect of the medical home program is open access. “We will take care of every sick patient today,” she says. “We believe that health care is where you need it and when you need it. That has always been our goal.” So that local residents can get more complicated treatment close to home, the medical center brings in 20 to 25 specialists each week from Bryan LGH Health, its parent in Lincoln. In the meantime, the hospital provides several services beyond what might be expected in a 25-bed critical care facility, such as surgical suites, imaging, emergency and rehab departments, an in-house lab and a pharmacy. All of the above probably played a part in its 2012 National Rural Health Quality Award from the National Rural Health Association.

Even though Crete is a mere 25 miles from Lincoln, Neb., Mayor Roger Foster notes that “Most of the community is surrounded by farmland, and probably 40 percent of the kids in school have some sort of rural relationship.”

It’s a population mix that has become unexpectedly diversified in the last 10 years. Over the years, the immigrant stream has included many Eastern Europeans, and Crete became what Janet Jeffries, the spokesperson for Crete’s Doane College, describes as a “hotbed of Czech culture.” More recently, there have been new population influxes. In fact, according to Foster, minority groups comprise about 50 percent of students in the school system.

Physicians at Saline Medical Specialties are now seeing a large Hispanic influx. “I have learned a little Spanish as the years have gone on, and it’s a good thing. I do about 30 percent of my visits in Spanish, and we also have four people in the clinic who can translate,” Jons reports. “I’ve enjoyed learning how to deal with these patients culturally.”

Eileen Lockwood is a frequent contributor to PracticeLink Magazine.

 

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Improvements in imaging machines

New ultrasound technologies make for happier physicians and patients.

By By David Geer | Spring 2013 | Tech Notes

 

In medicine, as in every market, an increasingly large, positive market impact generally translates into growing market value.

So with a forecasted global ultrasound systems market value of almost $11.2 billion by 2022, according to one report by Visiongain Ltd., it is no wonder that PracticeLink Magazine is reporting about physicians’ applications and opinions of two significant contributions among new ultrasound products.

Practical, pocket-sized Vscan ultrasound device
Price: $7,900
For more information: vscanultrasound.gehealthcare.com

The Vscan ultrasound tool fits in a lab coat pocket.

The Vscan from GE Healthcare is a mobile ultrasound visualization tool that fits neatly inside a physician’s lab coat pocket for anytime, anywhere ultrasound scanning for use in primary and emergency care, women’s health and cardiology.

Jason Jurva, M.D., a non-invasive cardiologist at the Milwaukee VA Medical Center, was looking for immediate access and views into patient heart function and structure when he found this new visualization tool.

“Of all the portable ultrasound devices, none of them are really pocket sized and travel with you all day from clinic to clinic except for the Vscan,” he says. It is the first portable ultrasound—about the size of an older generation cell phone—that offers instantaneous information, making a vast majority of diagnoses possible at a moment’s notice, Jurva explains. “At not much over a pound, it’s pretty innocuous and not too heavy to carry around all day,” he says.

And Jurva does carry the Vscan around in his daily practice, using it when rounding in the cardiology outpatient clinic at the Milwaukee VA Medical Center, for example. When Jurva is consulting with a patient and evaluating them for the first time, he can perform a quick scan of the heart, learn about the function and condition of the heart muscle, and share that information with the patient on the spot. “I can tell right away whether a patient has severe valvular disease and show it to them,” Jurva explains.

“And when seeing victims of active chest pains, I can look at the heart muscle to risk stratify them for their next treatment or early aggressive treatment.” The Vscan has utility across Jurva’s practice, running the gamut from healthy walk-in patients to critically ill people, wherever he needs to know what is going on with the patient at that precise moment.

These timesavings are especially important with critically ill patients.

“I can answer questions in one appointment in an outpatient setting, offering patients peace of mind without requiring them to make a second trip to the hospital to get their results,” he says.

Vscan features
“The Vscan’s built-in screen is larger than that of an average smart phone. The device delivers a good quality image for that screen size including color Doppler for direction and speed of blood flow across the heart valves. I can take diagnostic quality images on nearly everyone including people on ventilators,” Jurva says.

And there is no comparison between the Vscan and the typical echocardiogram when it comes to speed, availability and convenience.

When Jurva orders an echocardiogram, someone prints the order and takes the machine to where the doctor needs it, then boots it up and uses it.

“It can take one to three hours to get the results read,” Jurva says, “but the Vscan boots up in 15 seconds, enabling a point of service diagnosis in your hand. In two to three minutes, you can answer primary questions about the patient’s heart.”

Jurva’s favorite Vscan feature is the ability to demonstrate heart scan results to the house staff as well as the patient during rounding. “It enables a more intimate patient procedure because I am right there, telling them the results instead of calling them later,” he says.

As for Jurva’s wish list for future Vscan features, he is looking forward to lower pricing for his colleagues’ sakes. “Then it would be readily available to more doctors. It is fairly priced, but more than a physician can afford for daily rounds.”

Judy Mangion, M.D., applies the Vscan across research, teaching and patient care. Mangion is a cardiologist at Brigham and Women’s Hospital and was curious about the Vscan and searching for the right opportunity to acquire one when she managed to squeeze it in with a larger order. “I have since found the Vscan useful for fulfilling my patient care, teaching and research missions at this teaching hospital,” she says.

With reference to her patient care and teaching missions, Mangion uses the device as part of her rounding in inpatient cardiology with the house staff to enhance her instruction in physical diagnosis and to introduce cardiac ultrasound to residents.

Mangion has found the Vscan equally productive in outpatient care. “When outpatients return for follow up after a micro valve repair, I may not be able to justify a follow-up echocardiogram, but I can use the Vscan (to determine whether the heart murmur has increased),” she says.

Mangion further applies the Vscan to her heart failure population. “With this population, it is challenging to know what the patient’s volume status is,” says Mangion.

During a physical diagnosis, she examines the neck veins to see whether these appear distended. If so, the patient has an overloaded volume status. Mangion performs these kinds of examinations daily to determine the next form of treatment. But conclusions about volume status are difficult to make by eyesight alone if the patient is very large or thick skinned, Mangion explains. And she must make these kinds of decisions several times a day. With the Vscan, Mangion can take a closer look to be certain whether the neck veins are distended or flat and small. “I can be pretty sure of an accurate volume status assessment when using the Vscan,” she says.

The Vscan also provides evidence for patient consultations. In a case of atrial fibrillation, the patient was concerned about having what he saw as an expensive comprehensive echocardiogram. The resident who was working with that patient called Mangion, who was able to do a bedside Vscan in search of abnormalities. Finding an aortic insufficiency, Mangion was able to make a case to the patient for ordering the full echocardiogram. “Because of what I showed him, the patient agreed,” says Mangion.

When asked for her wish list of potential features for the Vscan, Mangion says, “It would be beneficial if GE could build an electronic stethoscope into it so I only need to carry the one device.” The device does occupy space in a lab coat, Mangion explains, and it can be challenging to fit it and a stethoscope in there as well. “And it would be really something,” Mangion adds, “if they could develop a 3-D Vscan to do scans in 3-D and download them to a computer for all the post processing.”

Improved Colorectal Care using the 3-D Flex Focus 400
Price: $69,900 to $89,900
For more information: bkmed.com/flex_ focus_400_en.htm

The Flex Focus 400 from BK Medical is a small, light, portable 3-D ultrasound machine with a high-resolution monitor, a fully cleansable keyboard and an optional four-hour battery.

Teresa deBeche-Adams, M.D., Colorectal Surgeon at the Center for Colon and Rectal Surgery, Florida Hospital, was looking for a 3-D ultrasound machine that could also produce better images with more detail when she found the Flex Focus 400. “We use it primarily for pelvic floor disorders and to make diagnoses pertaining to incontinence, rectal prolapse and rectal cancers in order to stage the patient properly, and to look at tumors and lymph nodes,” she says.

With pelvic floor disorders, deBeche-Adams and colleagues are able to make multiple diagnoses from one ultrasound examination using the Flex Focus 400.

“We can offer a better targeted therapy or treatment such as chemo, radiation or surgery for rectal cancers and we can taper our plans to the specific type and stage of tumor the patient has for better outcomes,” deBeche-Adams says.

Flex Focus 400 provides 3-D views.

Flex Focus 400 Features
In this unique ultrasound mechanism, a crystal takes the images while moving up and down inside a wand that the physician inserts into the rectum. “We can see inside the rectum top to bottom using 3-D images created on the device, all while the patient experiences a more comfortable exam,” says deBeche-Adams. She and her colleagues can examine tubes and surrounding tissues while looking at different slices or planes through the recreated 3-D cube visualizations of the area.

deBeche-Adams is particularly pleased with the increased level of patient comfort with the Flex Focus 400 (over a previous 2-D ultrasound machine) as well as the capacity to perform a much wider range of tests thanks to the 3-D technology. “These new images are very impressive when you see them side-by-side with old images from the previous technology. They are much better quality,” says deBeche-Adams.

As smaller, more evolved ultrasound machines advance the technology revolution, their investigative precision should insinuate itself into more planes of examination, closing the gap between near-immediate, exhaustive and accurate diagnoses and targeted rather than explorative treatments.

David Geer is a frequent contributor to PracticeLink Magazine’s Tech Notes department.

 

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What does it take to grow rich?

Three strategies to build the lifestyle you deserve.

By Brian Luster and Steven Abernathy | Financial Fitness | Spring 2013

 

Did you work your way through medical school, pay off debt, make tremendous sacrifices to end up in a successful medical practice, and believe that wealth would just “happen” once you started earning the salary you envisioned?

It seems like common sense: save more, have more. But the way most people handle their finances is broken.
Take note: If you don’t plan to accumulate wealth, you may not. With the monumental changes ahead in the practice of medicine, lack of planning can saddle doctors and their families with unseen burdens.

There is a good reason why families like the Rockefellers have built and maintained wealth over several generations while, according to The Family Business Institute, 60 percent of affluent families have historically lost their wealth in the second generation, and 90 percent have lost their wealth by the third.

Today, you can protect and grow your wealth the way the Rockefellers did and today’s billionaires do. How? Make savvy wealth management choices—and know what’s out there.

There are three distinct strategies every high net worth individual and family must adopt to ensure their business and financial lives are being handled effectively.

Strategy 1:
Focus on protecting your assets from litigation and other claims, and actively work on succession planning.
Asset protection is a vital piece of the wealth creation puzzle. Remember: If you have money, there is always someone who wants to take it from you! Through proper planning and the use of trusts, limited partnerships and various corporate structures, you can often protect the vast majority of your hard-earned assets from creditors, litigators, malpractice claims, the government (taxes, Medicaid, etc…) and even former spouses or business partners.

The better you learn to protect your assets, the more assets you’ll have to ensure that you can live the lifestyle you want today and also have generational wealth to pass on to your children and grandchildren.

As crazy as it may sound, more than one in three people with a net worth of $10 million or more do not currently have a will or a trust and have not named a trustee or administrator for their estate. According to Beating the Midas Curse from Rodney Zeeb and Perry L. Cochell, 37 percent of the people who have the most to lose have done little or nothing to protect their wealth for future generations.

Cornelius Vanderbilt was the world’s richest man of his generation with a fortune of over $100 million (equal to $4.8 billion today). Wanting to keep his fortune intact, he left $95 million to just one of his sons, William, who, when he died, divided what had become a vast fortune at the time, $200 million, among all of his children.

The next two generations spent lavishly, very quickly squandering the entire fortune, destroying what Cornelius and William had built. It’s a prime example of the old adage “Shirt sleeves to shirt sleeves in three generations.”

Strategy 2:
Hire a team of independent financial experts whose goals are aligned with your own.
Before there was any real regulation, people like the Rockefellers took steps to ensure that, when they invested their money, they did it with expert research and guidance.

Instead of just trusting the advice of a broker, banker or commissioned salesperson, they hired independent financial advisors to work directly for the family. These advisors studied and weighed the merits and risks of each investment opportunity to understand how it would fit into the bigger picture before making any decision. This is similar to how a Family Office Model operates today.

Today’s multi-family office model lowers the costs of hiring an expert team, all of whom serve as fiduciaries—meaning they are legally obligated to act in your best interests. Why is this so important?
Less than 3,000 of the 1 million-plus registered securities representatives and insurance agents in the United States are fiduciaries. We recommend our clients only engage people who have audited track records and proven experience working with high net worth individuals and families.

Strategy 3:
Achieve optimal financial outcomes through teamwork.
Expert advice must be well coordinated, and all aspects of every decision must be taken into consideration to ensure your investments work together for your benefit. If a professional does not oversee and integrate your team, chances are your business and personal investments are not optimized. Every piece of the puzzle needs to be evaluated and understood. When you make a decision, know how it will affect the other parts of your financial life.

Coordination not only saves hours, but also in many cases is far less expensive than a brokerage relationship. When the effects of each possibility are thoroughly evaluated and your representative brings results to you, this is the Family Office at work. There are specialized Family Offices with a focus on various professional arenas.

The legal and financial decisions and plans you make today should include a component that will maximize the amount of wealth to be passed along to the next generation. Enjoying your lifestyle starts with the right mindset; dedicate yourself fully to your medical practice and delegate wealth management matters.

Steven Abernathy (sabernathy@abbygroup.com) and Brian Luster (bluster@abbygroup.com) are from The Abernathy Group II Family Office (abernathygroupfamilyoffice.com), which sells no products and receives no commissions. It is independent, employee-owned, and governed by an Advisory Board comprised of thought-leading physicians and professionals.

The information contained in this article is provided solely for convenience purposes only and all users thereof should be guided accordingly. The Abernathy Group II does not hold itself out as a legal or tax adviser. If you wish to receive a legal opinion or tax advice on the matter(s) in this report please contact our offices and we will refer you to an appropriate legal practitioner.

 

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