Dr. Chang a Washingtonian Top Doctor for 2012

For 2012, Dr. Chang was selected as a Washingtonian Top Doctor in the field of otolaryngology. This year’s list was published in the March 2012 issue of the magazine.

Dr. Chang a Northern Virginia Top Doctor for 2012

Northern Virginia Magazine published their annual list of Top Doctors for 2012 in their February 2012 edition. Dr. Chang was listed as one of Northern Virginia’s Top Doctor in the field of Otolaryngology (page 72).

Of note, Dr. Chang was nominated by his doctor peers opposed to nomination by a small panel.

What Makes a Successful Hospital – Where Are the Tweakers???

First off, I don’t have a business degree (in fact, I’m a MBA drop-out) nor a degree in hospital administration (does chairing a hospital committee count?), but I do have an opinion (don’t we all) in light of having co-founded a bioinformatics company (iCORD, LLC) in the past based on a patent developed during my surgical residency… But I also admit that the company was ultimately unsuccessful if one measures success in terms of monetary profits, but I can say I succeeded in that my now defunct company’s “product” still lives on at Duke University Medical Center.

It is perhaps my mixed bag background of a few victories and even more failures that I learned a thing or two about what it means to become better… it is what I call evolutionary tweaking or to put it more bluntly… whining and doing something about it. But let’s stick with the “tweaker” euphemism.

Tweakers are annoying and may be a thorn in any administrator’s side, but they produce results. They tinker and tinker in an attempt to improve and better a situation they consider a problem whether it be an engine, a computer program, or an entire production system.

Based on Isaacson’s biography about Steve Jobs, he had it in abundance… even on medical care and devices during his last days.

Apparently, in his very last days of life, he went through 67 nurses before he found 3 he liked. He also refused to wear an oxygen mask due to a perceived poor design until he personally reviewed 5 different mask options and picked the one he liked best.

I’m certainly not promoting a culture where every patient, nurse, doctor, and administrator should start whining and complaining about everything. The hospital would shut-down.

BUT, there should be a culture where incremental tweaks are not only allowed, but encouraged with the expectation that many ideas will fail with monetary setbacks. However, just like survival of the fittest, the cumulative evolutionary cycles of keeping successful ideas and tossing ones that aren’t will lead to a better organization over time… continuously and cheaply.

Home run ideas should not be the goal. Batting consistent singles (or tweaks) are…

There are systems to describe this process: PDSA (Plan Do Study Act), Toyota Production System, Just-In-Time Production, Deming Wheel, Shewhart Cycle, Control Circle, etc.

Now I certainly am not the first to suggest this concept to hospital settings. In fact, I’ve seen PDSA posters tacked on a wall in hospital physician lounges in the past.

However, I have observed great variances in how different hospital systems incorporate this “controlled whining” into their culture and administration.

Some embrace this process wholeheartedly and have succeeded in abundance. Others give lip service and designate the “tweakers” as whiners to be shut-up with bureaucratic red-tape, offensiveness requiring peer-review, or worse.

Employees and staff are a hospital’s greatest assets both in terms of knowledge and production services. A hospital can either embrace trying to unlock the knowledge of what it already possesses or it can stifle them by punishing those who try to “tweak” thereby sending the message to everybody else to stay in the background… passivity being the rule… or voluntarily leave (or get fired).

The long-term success of a hospital system depends on how well it utilizes ALL its resources including not only encouraging an idea a hospitalist physician may have about telephone communication (allowing for faster patient care), but also trying to discover the knowledge trapped in a janitor’s head who just might know how to thoroughly clean a hospital floor in half the time (saving time and money), but is too afraid to say anything.

Adapt or perish. History is replete with immensely successful companies that failed to adapt and are now either bankrupt or nearing death… Eastman Kodak, Tower Records, Borders Bookstores, etc.

And how does a hospital adapt to avoid non-existence? Continuously tweak… even when things are going well. USE all your assets with all guns blazing rather than smothering them.

Celebrate the tweakers!!!

Doctor Distraction Happens… It’s Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out… But that’s like complaining about a leaky faucet when there’s a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this “mandatory” paperwork means is that nurses are calling physicians all the time just so they can check a box on a form… and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery… and often the surgery is already over… and the nurse is still busy filling out forms.

Talk about distraction… a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse’s time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR… ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I’ve already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations… which is true 99% of the time… but never mind that. Heaven forbid we now can’t check that little box that states “consent obtained prior to surgery.” But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a “distraction” analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there’s something fundamentally wrong going on.

It’s probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Reference:
As Doctors Use More Devices, Potential for Distraction Grows. NYT Dec 14, 2011.

Want to See a Specialist Doctor Who Does Not Take Your Insurance? There Are Options…

It is not unusual nowadays that a patient may want to see a specific medical specialist who unfortunately does NOT participate with their health insurance plan. This doctor is what is known in insurance parlance as a “non-par provider.”

In this situation, there are two options.

1) The patient pays the medical bill (self-pay) and forwards the receipt to the insurance company who hopefully will reimburse the patient.

2) The patient can request a “Letter of Medical Necessity” from the primary care doctor to submit to the health insurance company requesting temporary non-participating provider (non-par) insurance coverage.

What does such a letter of medical necessity entail?

The best way to illustrate this course of action is to provide an example. In my practice, I offer several services that many other ENT specialists do not. As such, there are a large number of patients who travel from even as far away as Florida and Arizona to be seen in our Virginia office. Needless to say, many patients have health insurance plans that I do not participate with.

One such procedure is tonsil cryptolysis.

A sample “Letter of Medical Necessity” that a patient can request from their primary care doctor to submit to their insurance company is as follows (the same concept can apply to any type of procedure or specialist evaluation):

John Smith, MDCountry Lakes Family Practice

Dear [Insurance Company]:

I am writing this letter on behalf of my patient, Mary Smith (DOB: 01/01/1965), who has a 10 year history of cryptic tonsils with production of tonsiliths (tonsil stones) on a daily basis. 

Though this problem occurred intermittently during adolescence, it has recurred during adulthood and has become a chronic problem which has affected her overall quality of life.  These stones consist of debris collected in the crypts of the tonsils together with sulfur-producing bacteria which account for the acrid odor and taste.  

I believe Mary is a candidate for a minimally-invasive procedure called tonsil cryptolysis (coblation therapy).  This procedure uses a radio-frequency energy in combination with a conductive medium to form a low temperature (40-80° C) localized plasma field which allows the precise removal of affected tissue while maintaining the integrity of surrounding, healthy tissue.  This results in decreased pain and a significantly shorter recovery time as compared with more traditional methods of treatment.  This procedure can be done in the office under local anesthesia on eligible adult patients.

After an initial evaluation for candidacy, tonsil cryptolysis can be done in an office setting under local anesthesia.  Most patients (70%) require one session for complete amelioration of symptoms. 

As there are no area specialists offering tonsil cryptolysis, I recommend that Mary be evaluated and treated by a non-par provider, Dr. Christopher Chang of Fauquier ENT Consultants located in Warrenton, VA. Please provide temporary insurance coverage in order for Mary to be seen by Dr. Chang.

Sincerely,
xxxxxxx
Dr. John Smith

That’s it!

If insurance declines coverage, than you are stuck with option #1 to self-pay if you really want to see a specific non-participating provider.

In any case, some unique services our office provides for which patients have requested non-par provider coverage include:

• Video/Audio Nasopharyngoscopy for Velopharyngeal Insufficiency
• Endoscopic Staple Diverticulostomy for Zenker’s Diverticulum
• Botox Injections for Spasmodic Dysphonia
• Chronic Cough Evaluation
• Phlegmy Throat
• Chronic Throat Clearing
• Allergy Drops

United Kingdom Ends $17 Billion Electronic Medical Records Initiative

The Wall Street Journal on Sept 23, 2011 reported that the United Kingdom will scrap the entire electronic medical records (EMR) initiative that has been 9 years in the making with nearly 6.4 billion pounds already spent.

That action was hinted at back in August 2011 after a scathing parliamentary report stating the initiative to be wasteful and incapable of delivery.

I’m not surprised…

It’s hard enough to get a group of doctors in one hospital to agree with a treatment plan let alone agree to a medical records system. The problem is exponentially more difficult when applying it to an entire country.

Physicians practice medicine differently… just like teachers have their own unique way of teaching kids. A method that may work for one doctor or teacher will not work for another. Even the method may change depending on how “busy” things are (teacher with a class of 5 kids versus 30 kids) so a doctor in a busy inner-city emergency room will have different flows and needs from an electronic medical records than a rural family practice with a sedate pace. Furthermore, the needs of a dermatologist is very different from a pediatrician. One can’t expect a single EMR system to meet the needs of both perfectly just like one cannot expect a math teacher to use the same teaching methods as a singing teacher.

Forcing physicians to use a single standard electronic medical records without adapting to these realities is bound to fail no matter how much time, training, software, and hardware you throw at it.

A better alternative (my opinion), is to treat electronic medical records like the computers they reside on. There should be many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components… USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the “internet” that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems… but no… they don’t communicate at all… which is why paper reports still exist… which are than scanned into the EMR.

Rather than the government (whether the United Kingdom or the United States) dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

The other more insidious side of EMR is the over-reaching health goal mandates which means well, but runs into the same problem of applying standards to all physicians. Take “meaningful use” set by the Centers of Medicare and Medicaid Services (CMS). One of the core measures of meaningful use is adult weight-screening and follow-up.

Now as an ENT specialist, I see patients specifically for earwax. Why in the world would I want to perform a weight-screening when all I want to do (and what the patient only wants me to do) is get earwax out???

Makes no sense.

Does it to you???

Reference:
U.K. Scrapping National Health IT Network. InformationWeek Healthcare. Aug 4, 2011

U.K. Ends Health-Service IT Upgrade. Wall Street Journal. Sept 23, 2011

New Webpage on Facial Paralysis

Our office has produced a new webpage on the evaluation and management of facial paralysis without any other symptoms.

Click here to read more about this condition.

Sermo iPhone App Review

Sermo is an online physician-only forum where doctors ask other doctors for advice. It’s where we post particularly thorny/difficult medical issues we encounter in our patients (no patient identifiers of course) and pick the brains of thousands of other doctors across many different specialties throughout the Unites States for assistance.

For example, as an ENT, I can post a particularly unusual patient presentation that has me stumped… for example a weird rash on the face… and post it on Sermo. Hopefully, I would than get responses from not only other ENTs across the United States but also input from dermatologists, pathologists, internal medicine, pediatrics, etc.

This kind of multi-brain access has been invaluable, especially since being a solo ENT, I do not have the benefit of having a colleague to easily bounce questions off of.

Until recently, no iPhone app was available to access this forum… until now. Mind you, only physicians are allowed access.

I am fortunate to be one of the first to test out this new iPhone app when Sermo contacted me last month regarding my interest (which I was) and here are my initial impressions when the app was released July 5, 2011.

Overall, it is a functional app that is usable in all the ways I would use it on the desktop.

The homepage is where theoretically, all the most popular destinations on Sermo is shown.

Among the homepage buttons is “Followed” which are postings that I either am following or actively participating in.  It would also be nice if there’s a button to direct me to my specialty postings rather than clicking on “Posts” (which lists all postings in chronological order) or “Popular” (which lists the most popular postings in terms of activity) and than selecting “Specialty” which is the 2nd most common destination for me. ”History” lists all postings or messages that I recently visited.

Adding a new posting appears to be fairly straightforward with two options… One which is triggered by taking a picture (iConsult) of an abnormality (like a CT scan or a rash) as well as one without the need for a picture (Create Post). The iConsult button is a leap forward better than what the desktop can offer. With iConsult, I can use the iPhone to take a picture, add a brief background history, and post whereas with the desktop, you would have to take a picture, transfer to the computer, logon to Sermo, and add the photo manually when creating a new post. The iConsult has resulted in the addition of a new section on Sermo… when I last checked, there’s already been 5 postings to this section.

With any postings, I can add a comment easily or view a brief bio by selecting on the commenter’s user handle.

All in all, a great free app currently available for the iPhone only.

ENT Practices and Physicians Who Twitter…

Did you know Fauquier ENT maintains one of the most comprehensive list of ENT physicians who twitter and are otherwise involved with social media not only in the United States, but in the world?

Check out the full list here. There are 76 and growing!

If you are an ENT practice or ENT physician not on the list, please let me know by DM @FauquierENT and I’ll add you!

If you are a resident in otolaryngology, feel free to let me know as well.

Doctors Don’t Always Take Their Advice (ENT Perspective)

Reuters published an interesting story about research that showed doctors don’t always recommend treatments to patients that they themselves would pursue if they were sick. In essence, if the doctor was the sick person, they would tend to pursue treatments that carry a higher risk of death but fewer severe side effects whereas patients pursue the exact opposite.

Though the clinical scenarios illustrated in the article/research is not reflective of an ENT practice (colon cancer and bird flu), I do see it quite often in other scenarios… the biggest one being when to perform a tracheostomy… hole placed in the throat for breathing purposes often performed in very sick patients in the ICU.

Trachs are often refused by the patient’s family for as long as possible… even weeks until all other avenues have been exhausted before considering a trach.

Although this procedure may sound “scary” and many patients and their families automatically refuse to consider such a procedure, the following (unofficial) survey done on Sermo (online physician community) on February 19, 2008 on physicians nationwide may be illuminating on how worthwhile having this procedure is to recovery. When US physicians were polled at what point they would consider a tracheostomy on themself or their loved one if prolonged intubation was expected, 50% stated trach should be done within the first 8 days of intubation of which 28% wanted it to be performed within 3-5 days. Only 15% would consider a trach after 12 days or longer intubation.

Read the Reuters story here.

Reference:
Better off not knowing: improving clinical care by limiting physician access to unsolicited diagnostic information. Arch Intern Med. 2011 Mar 28;171(6):487-8.