Asthma not only impairs the breathing and quality of life of more than 25 million people who live with it, it poses an immense financial burden to the U.S. healthcare system. The Centers for Disease Control and Prevention (CDC) estimate asthma’s costs in the U.S. at over $80 billion per year.
	
	While physicians often struggle to keep their asthmatic patients in good health, experts say that new treatment approaches and medications may be able to reduce these costs and improve quality of life for asthma patients.
	
	“This is a very exciting time for asthma management and treatment,” says Fernando Holguin, MD, MPH, director of the asthma program at University of Colorado’s pulmonary sciences and critical care division.
	
	Holguin is particularly enthusiastic about the field’s move toward personalized and precision medicine, where each  patient’s individual needs can be assessed and treated.
	
	For example, even a few years ago, most asthmatics were treated mainly with corticosteroids and bronchodilators, he says. Now, for those patients with especially severe symptoms-and for whom the usual drugs fail-doctors can use blood work and skin testing to determine the patient’s phenotype and allergic profile. Those whose asthma is affiliated with high eosinophils, an allergic cell, may qualify for biologic drugs.
	
	In addition to the biologics, those with severe, hard-to-treat asthma may benefit from the macrolides family of antibiotics, which includes azithromycin. These drugs can act as a powerful anti-inflammatory in the airways for people with severe asthma. “Studies have shown that using azithromycin two times weekly can reduce the rate of exacerbations by as much as 25 to 30 percent,” Holguin says.
	
	While these won’t work for everyone, they can offer relief for people who struggle with severe illness.
	
	Another technique for severe asthma is called bronchial thermoplasty, where a small catheter in the airway emits radiofrequency heat into the smooth muscle, according to Laran Tan, MD, FACCP, the director of Loma Linda University Health’s Comprehensive Program for Obstructive Airway Disease in Loma Linda, Calif.
	
	The radiofrequency heat treats asthma’s chronic inflammation by reducing the airway smooth muscle so it doesn’t constrict so tightly, Tan says.  Studies find the treatment may reduce exacerbations for up to five years after treatment.
	
	


	
	While new treatments are promising, before trying any remedy physicians should determine if patients really have asthma, says Holguin. “Roughly 30 percent of people that are labeled as having asthma by their providers do not have the disease.”
	
	The confusion often results from the fact that asthma is not just one disease, says Alex McDonald, MD, CAQSM, a family physician with Kaiser Permanente in Fontana, Calif. It’s a set of diseases characterized by chronic inflammation in the airways that creates obstruction, as well as coughing, wheezing, and shortness of breath, he explains. It’s easy to misdiagnose asthma when a patient has just been exposed to an environmental allergen, or is having trouble getting over a respiratory virus.
	
	In order to diagnose asthma, physicians should do a pulmonary function test, using a spirometer, McDonald says. The machine measures the amount of air the patient can exhale over several rounds. Then the patient takes a dose of a bronchodilator to determine if that improves airflow.
	
	But that may not be enough, says Tan, since “asthma tends to be related to allergies and the environment.” Phenotyping through blood work and skin testing can allow physicians to target medications tailored to patients with more severe forms of the disease, he says.
	
	“We’ve realized that a lot of patients with severe allergies have elevated igE [immunoglobulin E]. Now we have biologic therapies that can specifically target the inflammatory response in these patients’ blood,” Tan says.
	
	Phenotyping typically breaks down asthma into three primary categories, McDonald says:

Mild, intermittent, which is the easiest to treat, most commonly with a “rescue” bronchodilator inhaler

Mild, persistent, which requires a controller medication of some kind in addition to a

Moderate to severe, persistent asthma, which may require corticosteroids, long acting beta agonists and potentially more complex treatments such as biologics, macrolides antibiotics or bronchial thermoplasty.

However, treatments may not be effective if physicians haven’t helped the patient determine the root allergens causing their exacerbations, McDonald says.
	
	Many patients aren’t aware of the environmental triggers causing their attacks, Tan says, such as cutting the grass, or snuggling with their cats and dogs.
	
	He says that often when taking histories he learns that a patient has lived with asthma their entire life and accepted the impairments that come with it as normal.
	
	It’s the job of physicians to help these patients understand that an impaired life isn’t normal or necessary, Tan says. “Then we have to try to show them how that better life could be obtained through regularly using inhalers, avoiding specific allergens, etc.”
	
	Additionally, about one third of asthma patients are known as poor perceivers, says Kathleen Dass, MD, FACP, a member of the American Academy of Allergies, Asthma and Immunology. “That means they feel good until they really don’t feel good, so basically they end up in the hospital or just drop dead.”
	
	She stresses to primary care physicians that most of these exacerbations are preventable with the right diagnosis and treatment plan.
	
	


	
	Even after diagnosis, it can be challenging for physicians to get patient adherence in order to reduce the severity of illness and encourage (or promote) use of healthcare services. Experts agree that developing a strong relationship with patients and being proactive in asking questions can help to achieve both aims.
	
	McDonald takes a lack of patient adherence as a sign that something is wrong and he needs to find out what. “I hate the term noncompliant. That’s medical jargon. I always ask, ‘what’s happening?’”
	
	He says reasons can range from a patient being unable to afford their medicine, to a bad reaction to a medication, to  the patient’s pharmacy not stocking the right medication. Sometimes they’ve simply never been asked why they struggle to take their medications, he says.
	
	For issues related to cost, McDonald points patients to a program called Good RX, which helps them find lower-cost medications.
	
	Dass, who sees a lot of low-income patients, always asks patients if they can afford a medication at the time she is ready to prescribe. She then makes it clear that she will offer them resources if they cannot. She also encourages patients to put their inhalers beside their toothbrushes, as that makes it more likely they’ll use them both morning and night.
	
	Holguin accepts that patients will not always going be able to make dramatic changes to their work or home environments, where they are often exposed to allergens, so he focuses on positive gains to encourage them toward healthy behaviors.
	
	Rather than chiding a patient for smoking, for example, he’s more likely to guide them toward steps they can take to feel better.
	
	He uses the metaphor of treating a wound with a Band-Aid versus antibiotics to help them understand the severity of their disease. “When you put a Band-Aid on a cut, it looks better, but if it gets infected and festers, and you keep slapping a Band-Aid on it, it doesn’t actually fix the problem,” he says.
	
	Holguin finds that patients can relate to that analogy, and he bolsters it with printed information they can read at home to better understand their disease.
	
	The more physicians learn about their patients’ barriers to treatment, the more likely they are to find a treatment that works, Tan says. He uses the example of a single mother who’s going back to school.
	
	“She can’t come in every month to get her injections, maybe she can’t find a ride or doesn’t have childcare. For her, maybe home therapy of bronchial thermoplasty is better than injections. These kinds of discussions need to be had with the patients, rather than just looking at their labs,” he says.
	
	


	
	Along with the physical symptoms of asthma, Holguin says, physicians should be aware of asthma’s impact on mental health. “Anxiety and depression exacerbate asthma and asthma exacerbates anxiety and depression. So you have to manage all the co-morbidities.”
	
	This means developing and maintaining a strong referral network with mental health providers. If providers don’t already have such referrals, they can direct patients to resources such as the National Alliance on Mental Illness; the National Institute of Mental Health; ask patients to contact their insurer for a list of providers, or recommend they see a mental health professional with whom they already have a relationship.
	
	Holguin keeps an open line of communication with his patients. Many of them have his cell phone number and email address and he checks in with them frequently. “Having patients contact me is not a burden. I’d rather have a conversation with someone about what’s going on than them rushing to the emergency room,” he says.
	
	McDonald says that diagnosing and treating a patient is just the beginning of the physician’s job. “Now we start to educate our patients and reinforce that we have to live a healthy lifestyle in order to continue that momentum of good lung health.”

Articles

While physicians often struggle to keep their asthmatic patients in good health, experts say that new treatment approaches and medications may be able to reduce these costs and improve quality of life for asthma patients.

Best practices in managing asthma patients

Cyberattacks pose a clear and present danger to all healthcare stakeholders, including physician practices. These days, cyberthreats are so common that the question is no longer if an attack will occur, but when.
	
	A 2018 cybersecurity survey by Black Book Market Research found that 90 percent of healthcare organizations have experienced a data breach since the third quarter of 2016, and nearly 50 percent reported more than five breaches. In 2017, a task force working under the U.S. Department of Health and Human Services deemed cybersecurity in healthcare to be in “critical condition,” a claim that was followed by many sizable breaches in 2018.
	
	The outlook is indeed sobering and likely to leave the average resource-strapped physician’s practice feeling helpless. How do small- to mid-sized healthcare operations tackle this mammoth challenge when most physician practices lack IT departments and in-house cybersecurity experts?
	
	When it comes to securing systems and data, it’s important for organizations to take a step back, start simple and move forward strategically. Cybersecurity is a journey, not a destination - and you don’t always need to tackle everything at once. Every practice environment faces different threats, so it’s important to understand your own unique situation and plan your approach accordingly. Outlined below are three key steps physician practices should take to gain a better understanding of their cybersecurity needs and determine their next steps.
	
	


	
	Current reports suggest that ransomware and other cyberattacks are on the rise. Notably, ransomware attacks are expected to quadruple in healthcare by 2020, 

. Meanwhile, Gartner, a leading industry research and advisory firm, expects the global cloud services market to grow by 17.3 percent in 2019, opening the door to new vulnerabilities and threats online.
	
	The industry is also witnessing growing threats related to advanced phishing and password spraying and stuffing-dangers that often get little attention. Phishing tricks users into giving away sensitive information by posing as a legitimate person, usually through an email that appears to be from someone they trust.
	
	Password spraying occurs when an attacker obtains a list of emails and usernames from an organization, usually through scripts that crawl Google and LinkedIn, and then attempts to gain access to accounts through commonly used passwords. Password stuffing is even easier, since the hacker gains access to username and password pairs and then applies them to large numbers of accounts until they gain access to the network.
	
	“CEO fraud” is also on the rise in healthcare. In these instances, criminals impersonate an executive as part of an email scam. Using similar writing styles and email signatures, the sender will request the recipient to perform a certain action. For example, a criminal posing as an HR executive may ask an employee to change payroll accounts or to wire certain transactions to different account numbers.
	
	


	
	Many physician practices have not taken the critical step of conducting regular vulnerability assessments because they believe their organization is too small to attract an attacker. But not knowing your vulnerabilities can hurt you,  since both large and small organizations are exploited continually.
	
	A comprehensive assessment will simulate potential attacks and test infrastructures to identify weaknesses and risks. That gives practices a complete picture of their environment from an attacker’s perspective.
	
	Quarterly vulnerability assessments are recommended not only to test for new risks, but to ensure that previous  weaknesses were fully addressed. When deployed properly, these analyses should provide practices with information on which devices and applications are vulnerable along with possible risks.
	
	It’s important that all key stakeholders come away from these assessments with a full understanding of each vulnerability, its perceived risk level and its potential solution.
	
	In addition to vulnerability assessments, a penetration test should be conducted annually. This technique produces a more in-depth examination of security controls by employing a cybersecurity professional to conduct a “test hack” by attempting to find ways to breach an organization’s network.
	
	


	
	Once a practice’s weaknesses are identified, the next step is remediation. Far too often, healthcare organizations make less-than-optimal choices because they react out of fear or they choose the most affordable solution as a band-aid approach.
	
	That response is understandable on one level. Most small- to mid-sized physician practices are not in a position to purchase an expensive and comprehensive cybersecurity platform to address every angle of the security landscape.
	
	A better approach begins with understanding that there is no cookie-cutter solution to cybersecurity. More than ever, healthcare executives, owners and administrators need customized strategies that provide practice-specific tools and filter out unnecessary elements that can keep physician practices from addressing their own unique security situations.
	
	The right partner can help you identify where to start by focusing on priority areas that represent the most bang for your cybersecurity buck. Perhaps the first goal is optimizing firewall management.
	
	Alternatively, the greatest need could be to strengthen the security of appliances and devices such as phone systems, Wi-Fi, email gateways or network access control. Expert guidance is critical to defining and developing a practice’s cybersecurity strategies at the right time and with the right tools to minimize the potential for breaches and ensure the most cost-effective solution.
	
	Physician practices face unprecedented demands on their time and resources. While current trends demand that organizations prioritize cybersecurity, it’s important to remember that the best approach does not generally take a linear path.

These days, cyberthreats are so common that the question is no longer if an attack will occur, but when.

3-step plan to protect against cyber attacks

Healthcare organizations have been using patient satisfaction scores since the late 1980s to improve care delivery and calculate physician and staff bonuses, among other purposes. Now, in the shift toward value-based care, such scoring is playing an even greater role in determining physician reimbursement and helping patients choose a physician.
	
	But is it also changing the way physicians practice medicine?
	
	Physicians, frustrated with feelings of powerlessness over how the scores are determined, fear that they give patients too much influence. Experts say the scores are here to stay, and offer suggestions for ways to approach them in the future.
	
	“Physician reviews threaten the core values of medicine,” says Dana Corriel, MD, an internist based in Pearl River, N.Y. “Medicine is inherently built on the beauty of a patient-physician relationship. To add a review system into it almost makes it dirty.”
	
	Patient satisfaction scores may make patients feel better by providing an outlet for their frustrations, but a 2014 study in Patient Preference and Adherence shows they may promote job dissatisfaction, attrition and even inappropriate clinical care among some physicians. Not only are scores not necessarily accurate at identifying negligent or incompetent physicians, according to the American Journal of Medicine, they do not correlate with better patient outcomes.
	
	However, since patient evaluations aren’t going away, there are steps physicians can take to adapt to this reality.
	
	


	
	Corriel fears that these scores cause physicians to prioritize pleasing patients over doing what they feel is medically correct. “We run into a problem, because healthcare isn’t always about pleasing. It’s about making decisions that are evidence-based,” she says.
	
	She feels that patient scoring can, essentially, be weaponized to manipulate doctors. She points out that, as many patients turn to the internet to research their medical issues, they also come in with preconceived notions of their problems, a particular prescription they think they should receive, or how they want to be treated.
	
	“If you’re a physician and you deviate from that, the worry is that it’s not going to be acceptable and then the patient has the [score] to fall back on if the physician doesn’t do what the patient wants,” she says.
	
	In a group practice where she formerly worked, a patient left a terrible review of the entire office and medical staff. “It turned out he hadn’t even seen me, nor had he seen any of my partners. He had seen a primary care provider from the floor above,” she recalls.
	
	In her experience, patients also expect physicians to know everything, then react negatively when they don’t. “I know a little bit about a lot of things-that’s what an internist does,” Corriel says. “If someone asks me a question that’s very deep into the specifics about an organ system, I may not know it. That doesn’t make me a bad doctor. Patients don’t realize that we’re not superhuman.”
	
	

Scoring is biased against women and minorities


	
	Another problem, research finds, is that patients are more likely to give negative reviews to women and minorities, particularly African-American physicians.
	
	Natasha Sriraman, MD, MPH, FAAP, associate professor of pediatrics at Eastern Virginia Medical School, in Norfolk, Va., says she has experienced such discrimination as an Indian woman, and has seen it among colleagues who are also minorities.
	
	“I’m a woman and a minority.  I’m basically [zero] for two,” she says. “When I bring up [bias against minorities] in meetings, even with doctors and administrators, everyone is shocked.”
	
	She cites another example of a fellow woman doctor who is also Indian. “She saved a man’s life and he told the male nurse, ‘I don’t want that woman taking care of me.’” Sriraman adds, “[Patient satisfaction scores] put a lot of power in patients’ hands who may not deserve the power to trash somebody who’s working really hard.”
	
	


	
	Sriraman grew weary of feeling that she and other physicians had no say in how patient scoring decisions are made, especially when they’re tied to bonuses and salaries. So she joined the board of her hospital and spoke to the CEO about what she sees as the unfairness of tying bonus and salary to reviews, over which physicians have little control.
	
	“We doctors have to use our voices,” Sriraman says. “We need to make waves.” She feels that the responsibility for patient satisfaction should fall more on the practice managers or the hospital CEOs.
	
	She adds that physician autonomy is being stripped away, and having a voice is one way to get it back, by sitting on a local hospital, regional, or a health insurance company board.
	
	“We need to groom physicians to become leaders. Because you have people who have never been to medical school, never seen a patient di e, have never had to tell a parent their child has cancer, making these decisions,” Sriraman says.
	
	


	
	Perhaps the most frustrating part of patient evaluations is that, “Patient complaints are rarely about physicians,” says Guillaume de Zwirek, CEO and Founder of Well Health, a healthcare software company in Santa Barbara, Calif. “About 96 percent of complaints are related to bad customer service. Insurance didn’t cover it and no one communicated it to the patient, or the wait time was long, for example,” he says.
	He points out that most of a patient’s healthcare interactions are not even with the physician, but with the front office, the billing team, the care coordinator, the pharmacy and so on.
	
	“Communication is the problem in the vast majority of complaints, and it’s hard for patients to be heard,” de Zwirek says.
	
	He says the best way to handle these common complaints is to empower all non-physician staff members to handle patient concerns in the moment. He believes that giving the administrative and front desk staff the training and tools to do so will give them greater autonomy, which can improve patient satisfaction, as well.
	
	He suggests a variety of ways to do this including through improved technology, compensation bonuses and small thank-yous, or even appreciation days. “These people are super important, and what makes the engine run. When they feel valued, they deliver better results.”
	
	Sriraman also believes that patients often leave negative scores out of frustration and because they don’t know where else to take their complaints. She says that a lot of patient frustrations can be resolved at the practice management level. “Practice managers have to be our advocate and our ally. They should be the ones addressing negative reviews or scores with the patients,” she says.
	
	


	
	Regardless of these frustrations, patient scores, in some form or another, are likely here to stay.
	
	“We should all be nice to our patients, listen to them, and treat them with respect,” Corriel says. “I think [patient satisfaction scoring] sets out to achieve that, and in that sense I do think there’s pros to it,” Corriel says.
	
	Moreover, there is value in having satisfied patients, says Josh Johnson, Ed.D, PA-C, a physician assistant at Ali’i Health Center in Kailua Kona, Hawaii. “Based on journal studies, patients who are satisfied are more likely to follow through with their treatment plans and to recommend their provider. They’re more likely to go back to that provider to seek medical care in the future.”
	
	Johnson says that taking the time to communicate to patients that physicians are open to resolving problems along the way  may also help improve scores later. “It’s about being proactive and educating patients.”
	
	He says physicians can also get in front of scoring by talking to a patient before a survey is sent home.  For example, as a patient is discharged from the hospital, or at the end of a clinical encounter, ask, “Is there anything that we could have done better that would’ve improved your experience here?’”
	
	Johnson accepts that scoring isn’t going away. Instead, he tries to use it as a motivation to improve. “If I know my scores in one quarter, I ask myself: ‘How am I going to implement change?’ That’s what medicine is, right? It’s looking at something wrong and asking what I can do to improve it.”

How patient satisfaction scores are changing medicine

Many practices are adopting an all-hands-on-deck approach to deliver the suite of services required to achieve comprehensive patient care. Experts say medical assistants (MAs) can be cost-effective contributors to these emerging care models.
	
	MAs work under the oversight of physicians, physician assistants, or nurse practitioners in outpatient settings. Their duties range from clinical work, such as recording blood pressure readings, to administrative tasks, such as scheduling patients.
	
	According to the Bureau of Labor Statistics, the median wage for an MA in 2018 was about $16 per hour, or $33,610 per year. There were more than 634,000 MAs in the field in 2016 with job growth expected to be substantial, increasing 29 percent over the next decade.
	
	Practices looking to hire medical assistants should consider each candidate’s education and certification, as well as past medical and administrative work experience. MA positions typically don’t require college degrees.
	
	While there is no licensing for MAs, the two most common credentials are Certified Medical Assistant, which is earned through the American Association of Medical Assistants (AAMA), and Registered Medical Assistant, earned through the American Medical Technologists (AMT) agency.
	
	“It’s important for physicians to understand that certified MAs can have a variety of training experiences,” says Marie Brown, MD, MACP, an internist at Rush University Medical Center in Chicago. Her practice includes three certified MAs, supporting two internists. One of Brown’s MAs completed some nursing classes plus several years of on-the-job training-rather than a structured MA education program-and passed the AMT certification exam with a near-perfect score.
	
	Beyond that, practices should also consider a prospective hire’s interpersonal skills to understand how the candidate would support the daily objectives of patient care. Brown suggests, for instance, that MAs should be comfortable enough to ask questions when they need more information.
	
	


	
	MAs are equipped to manage some of the new practice responsibilities that have emerged under value-based care initiatives, according to Donald Balasa, JD, MBA, CEO and legal counsel for the AAMA. Patient-centered medical homes are especially well suited to make use of MAs, who can carry out a number of health management strategies, he says.
	
	Emerging roles for MAs include:

Prevention outreach specialist or panel manager-identifies patients with care gaps and communicates with them to encourage adherence to recommended care;

Patient navigator or patient advocate-acts as a liaison between the patient and the healthcare system in an effort to reduce barriers to care;

Clinician-qualified to deliver certain services under Medicare’s Chronic Care Management and Transitional Care Management programs.

MAs acting as prevention outreach specialists can enhance quality scores, which can translate into bonus payments for the practice. For example, medical assistants can review patient records to identify those overdue for preventive screenings, then follow up with reminders and scheduling.
	
	Balasa says the supervising physician sets the criteria for the targeted populations, indicating who should receive which preventive screenings and when.
	
	At Brown’s practice, MAs review records for patients on the next day’s schedule to identify gaps in preventive care such as immunizations, mammograms, or colonoscopies. When a gap is found, the MA prepares the order for the physician and makes it available in the EHR.
	
	“When the patient comes in the next day, the doctor knows the care gaps have been evaluated, the orders are queued, and the doctor just needs to sign off,” Brown says. “It has tremendously increased our percentage of patients who have those gaps met.”
	
	Research shows employing MAs as panel managers is especially effective at increasing colonoscopies, Balasa says. About 37 percent of individuals age 50 and older have not received the recommended colorectal cancer screenings, according to the American Cancer Society, so there’s ample opportunity for panel managers to make a positive impact.
	
	A 2017 study published in Preventing Chronic Disease demonstrated that MAs working in federally qualified health centers in North Carolina were able to increase the percentage of patients up-to-date with colorectal cancer screening from 23 percent to 34 percent. Another study published in Quality & Safety in Health Care in 2009 showed the expanded MA role was associated with a 123 percent improvement in colonoscopy referrals among seven practices in Utah.
	
	


	
	As a patient navigator, the MA takes on a communications role, advocating for the patient with sensitivity to cultural, socioeconomic, age, gender, or other personal characteristics. It’s a valuable asset for practices that are eligible for bonus payments based on patient satisfaction scores.
	
	In this position, a medical assistant would need well-developed interpersonal skills. An MA who is bilingual, for example, might act as a translator in the exam room or at the reception desk to ensure a patient with language barriers can adhere to care plans.
	
	“Being bilingual is important, but it extends beyond that to include familiarity with the customs of certain ethnic or cultural groups,” Balasa says.
	
	He adds that in some Islamic and Hmong  communities, female patients want to be treated only by female clinicians. In those cases, culturally sensitive patient navigators can manage the appointments in a way that works for the patient and the practice. “It makes it easier for the patient to function within the health system,” Balasa says. “It’s a relatively new role for the MA that’s tied into quality.”
	
	


	
	Under Medicare’s Chronic Care Management and Transitional Care Management programs, certain services performed by MAs can be billed as “incident to” the services of the overseeing physician or advanced practice provider (chronic care, non-face-to-face service code CPT 99490 and transitional care management codes CPT 99495 and CPT 99496). In other words, practices participating in the two programs can get paid for work performed by MAs.
	
	Some examples of chronic care management duties for MAs include recording patient health information and keeping comprehensive care plans up to date electronically.
	
	Transitional care management services include providing education about available community resources as well as communication with service providers to support the patient’s transitions from one care setting to another.
	
	“Even if that information is conveyed by telephone or electronic means, those services are billable under these two programs as incident to the services of the delegating physician,” Balasa says. “This is a new area in which medical assistants are getting involved in chronic care management.”
	
	Balasa says the contributions of MAs in the team-based care environment are making a difference in how practices function. And when an MA’s work has a positive effect on a patient’s health-such as when a reminder call leads to a mammogram that detects cancer-Brown believes the physician should commend the MA.
	
	“This is hard work, and they enter into it to help people,” she says. “Highlighting the importance of their role in health coaching and adherence is key.”
	
	


	
	In May, the Annals of Internal Medicine reported that a significant number of physicians are experiencing burnout, with the economic cost resulting from the associated turnover and reduced clinical time estimated at about $7,600 per physician per year.
	
	In response, many practices are hiring greater numbers of non-physician providers. Medical assistants can be among the most cost-effective additions to practices’ staff because of their lower pay relative to nurses or physician assistants. Ideally, a practice would aim for two MAs for each physician, according to Brown.
	
	Paula Lozano, MD, MPH, a pediatrician and researcher with the Kaiser Permanente Washington Health Research Institute in Seattle, says there’s a payoff when practices employ well-trained MAs and allow them to take on a range of duties. However, physician leaders might need to get comfortable with delegating tasks to MAs.
	
	“Primary care is a team sport,” Lozano says, because the sheer volume of data-gathering, care-planning and care-coordinating is too much for a physician to manage while also trying to care for patients. Although it seems obvious, Lozano says, the relationship between the physician and the MA must be built on mutual trust so the team can function effectively.
	
	“The days are gone when care was a doctor-centric model, where the doctor does everything and makes all the decisions, while the other staff members around the doctor do the stuff at the margins,” she says.
	
	Lozano has conducted research demonstrating best practices in team-based care, and she recommends an approach that allows MAs to take ownership of care-management tasks. However, with many markets experiencing labor shortages, practices should also consider enhanced compensation packages for MAs-not just in terms of wages, but also training and career advancement opportunities-to recruit and retain the best assistants.
	
	“Remember MAs are among the lowest paid health workers,” Lozano says. “To the extent that we take work off the physicians and give it to the MAs, it’s only fair that we reflect that in the compensation.”

Practices looking to hire medical assistants should consider each candidate’s education and certification, as well as past medical and administrative work experience.

How to hire great medical assistants

It used to be that when a patient experienced a bad outcome from a treatment or procedure, doctors were advised not to apologize, or even express sympathy to the patient or their family, lest something they said be used against them in the event of a malpractice suit.
	
	But the conventional wisdom regarding apologies has started to change. Now, experts say, the answer to the question “Should you apologize?” is “it depends.” In part, that has been driven by the growing number of states passing so-called “I’m sorry” laws, which say that doctors’ apologies to patients can’t be used as an admission of guilt, says Fred Cummings, JD, a malpractice attorney with Dickinson Wright in Phoenix, Ariz.
	
	By late 2018, 39 states and the District of Columbia had enacted laws regarding medical professionals making apologies or sympathetic gestures, according to the National Council of State Legislatures.
	
	But even without such laws, Cummings says, there are ways for doctors to apologize and express empathy without saying they are to blame. “Sometimes doctors have to make judgment calls, and even if it doesn’t turn out the right way, it doesn’t mean making the judgment was wrong,” he adds. “Talking about that with the patient and regretting the situation doesn’t necessarily get the doctor in trouble with the patient.”
	
	Richard Boothman, JD, a healthcare risk management consultant in Ann Arbor, Mich., and a former trial attorney and chief risk officer for the University of Michigan Health System, favors apologies under some circumstances.
	
	“The standard of care is not to be perfect or clairvoyant, it’s to be reasonable,” he notes. “But there are times when a physician just drops the ball and makes a mistake. And at that point an apology can be healing for both the physician and patient.”
	
	But if an apology is offered, he cautions, it has to be sincere and viewed in the larger context of the trusting doctor-patient relationship. “You can’t look at it as some risk management strategy that you just roll out and hope the patient or their family satisfied, then walk away,” he says.
	
	The drawback of apologizing is that “you can’t unring that bell once you do it, so you have to be darn sure you know what you’re talking about,” Boothman says. While at the University of Michigan Health Systems he told doctors, “It’s always fine to so say to a patient, ‘I’m sorry this happened, it’s not what any of us planned, and we’ll get to the bottom of it. But let’s take care of your immediate medical needs and we’ll have another conversation about this later.’ That’s what we wanted.”

How to thread the needle when talking to patients about medical mistakes.

Should doctors  apologize for mistakes?

Doctors frequently worry about getting sued for malpractice, and with good reason. Although the number of lawsuits has been declining in recent years, there were still more than 11,500 filed in 2018, according to data compiled by LeverageRX, an online lending and insurance broker for healthcare. Meanwhile, malpractice payouts rose nearly 3 percent compared to 2017 to about $4 billion.
	
	In spite of those daunting numbers, physicians needn’t think of malpractice suits as inevitable. Understanding the reasons for lawsuits can help doctors minimize the chances of being sued and improve the odds of a favorable outcome if they are.
	
	The main point to remember, experts say, is that most malpractice suits are not really about money. “Any plaintiff’s lawyer will tell you that no patient walks into their office screaming, ‘I want a million dollars,’” says Richard Boothman, JD, a risk management consultant in Ann Arbor, Mich., and a former trial attorney and chief risk officer for the University of Michigan Health System.
	
	Instead, Boothman says, lawsuits usually are the result of injured patients or their families wanting to find out what went wrong, who was responsible for it, and to see that it doesn’t happen to others.
	
	With that in mind, what can doctors-particularly those in primary care-do to reduce their legal exposure?
	
	


	
	A good place to start, according to those with experience in malpractice cases, is to establish trusting and open relationships with patients. That, in turn, requires two things: good communication skills, and lots of face time with patients.
	
	Fred Cummings, JD, a malpractice attorney with Dickinson Wright in Phoenix, Ariz., says that a significant motivator among many of his clients is the feeling that their doctor didn’t spend enough time with them, or wasn’t really listening when they described their health problems.
	
	Moreover, without a trusting relationship patients are less likely to reveal personal information, such as drug use or sexual activity, that their doctor needs to properly diagnose and treat them, says Darrell Ranum, JD, vice president of patient safety and risk management for The Doctors Company, a medical malpractice insurer. Ranum adds that patients who trust their doctor are more likely to adhere to a medication regimen and obtain recommended follow-up tests and procedures.
	
	Cummings acknowledges the difficulties most primary care doctors face in spending as much time with patients as they-or patients-would like. That challenge makes it vital to find ways of maximizing the limited time they do have, such as by using scribes to record and enter data for patient visits, thereby allowing the doctor to focus entirely on the patient.
	
	


	
	In addition to spending time with patients, Cummings and others emphasize the importance of effective communications-oral and written-for heading off malpractice suits, and bolstering a doctor’s case if they are sued. “It’s not enough just to be a brilliant diagnostician, you’ve got to be able to communicate your diagnosis to the patient and have that patient feel confident that you know what you’re doing,” Cummings notes.
	
	His observation is supported by data from The Doctors Company. “We find that one of the key factors [behind malpractice suits], appearing in 21 percent of our claims, is a lack of communication between the patient or their family and the physician,” says Ranum.
	
	Effective written communication covers areas such as explanations for referrals, interpreting lab results, and clear and contemporaneous documentation of patient visits.
	
	“In my experience, the number one reason for a successful malpractice suit lies in the charting,” Cummings says. “Either something that wasn’t charted that should have been or because not enough of the reasoning behind treatment decisions was recorded in the chart. So the more accurate your charting, the better.”
	
	


	
	Boothman agrees, and emphasizes the importance for malpractice defense of documenting a patient visit as soon as possible. “When my clients were sued, one of the first things that I needed to do was to recreate the circumstances,” he explains. “I can’t do that if they don’t have a note with enough detail so that years later, if a lawsuit does arise, we can recreate what happened at that visit.”
	
	Accurately diagnosing a patient can be especially challenging for primary care doctors because of the wide range of medical problems they encounter, Ranum says. The largest category of patient allegations in The Doctors Company study-39 percent-were diagnosis-related. That means physicians have to be careful to follow a differential diagnosis process, and document that they have done so.
	
	“If the physician’s diagnosis is questioned at some point in the future, and the documentation reflects a thoughtful and systemic approach to arriving at a diagnosis, then the doctor is more likely to be seen as being reasonable in their approach rather than negligent for missing a diagnosis,” Ranum says.
	
	


	
	Boothman notes that a practice or organization’s culture plays an important role in ensuring patient safety and thus the frequency of malpractice suits. “In workplaces where the physician is regarded as captain of the ship and the people around him don’t feel empowered to raise concerns about a patient’s treatment, that culture can create a higher medical malpractice risk,” he says.
	
	Conversely, he adds, when physicians treat other members of the care team as equals and welcome their questions and suggestions, “Then you know the patient is going to get the benefit of many sets of eyes and lots of brains thinking about that patient, and it creates a much safer situation for everyone concerned.”
	
	Another essential aspect of practice culture for minimizing malpractice risk is creating, and adhering to, protocols for ensuring patient safety and maintaining good communication, such as training receptionists and other staff members to know when they can respond to a patient’s question and when to refer it to a doctor.
	
	Similarly, Ranum says, primary care practices need systems for confirming that patients follow through on referrals and recommended procedures. He cites the example of a patient referred for a chest x-ray for pneumonia, the radiologist identifies a possibly cancerous lung nodule, but forgets to send the results to the primary care doctor.
	
	“So the physician never follows up on that lung nodule and a few years later the patient has worsening symptoms and is identified with lung cancer,” he says.
	
	


	
	A further area where primary care doctors can get into legal trouble is failing to make referrals when they are warranted. “Sometimes primary care docs can get in over their head if they don’t seek assistance,” Ranum says, such as when a patient repeatedly sees their primary care physician for the same symptoms.
	
	“If all the standard remedies are not working, then it’s time to move that patient on to a specialist who can maybe identify the real cause of the problem,” he advises.
	
	But from a legal standpoint, merely referring the patient isn’t enough. Primary care doctors also have to document that they made the referral and followed up with the patient. “I will tell you that unless confronted with some documentation that they were given a referral slip, every patient [in a malpractice suit] will say they don’t remember getting a referral,” Cummings says.
	
	Moreover, he adds, under some circumstances primary care doctors who continue treating a patient for the problem for which they referred the patient to a specialist can be held to the medical standard of the specialist in a malpractice suit, even if the patient doesn’t see the specialist.
	
	“So refer often, but if the patient doesn’t go, make sure you document that,” Cummings advises. “And at some point you need to send the patient something in writing about their noncompliance and what it might mean for them medically.”
	
	In the end, Boothman says, the best way for doctors to avoid getting sued for malpractice is by putting the patient at the center of everything they do. And while that may sound obvious, it is often difficult given the many pressures, from seeing additional  patients to improving quality ratings, that can pull them away from patient care. Nevertheless, he says: “Doctors always need to remind themselves what a remarkable statement of trust it is that patients put their well-being in the physician’s hands and do the things doctors do to patients. It’s a staggering privilege.”
	
	“What typically happens is that there’s a failure to input or access information that is vital to a patient’s health,” he explains. “Therefore, that information is not communicated to another medical care provider who is also involved with the patient’s care and something bad happens.”
	The Doctors Company study found system errors like fragmented EHRs (i.e., a system where key sections of a patient’s record aren’t located together), technology failures, and electronic data routing issues did contribute to some claims. But Zaslow says true technology-related cases are uncommon.
	
	“Unfortunately, because these systems aren’t as user-friendly as they often claim to be, and because medical providers have a lot of responsibility keeping track of a lot of things for a lot of different patients, important information just isn’t being inputted in the right way,” he says.

November 10, 2019 edition

Best practices in managing asthma patients

3-step plan to protect against cyber attacks

How patient satisfaction scores are changing medicine

How to hire great medical assistants

Should doctors apologize for mistakes?

How to avoid malpractice suits