1. How to Manage Your Practice
Things You Never Are Told
During Your Residency
Steven M. Rudich, MD, PhD
Associate Professor of Surgery
Director, Liver Transplant Services
University of Cincinnati College of Medicine

2. Myth (I)
 Since I am in academics, I do not
need to worry about doing the
“niceties” of dealing with referring
doctors, as I would if I were in private
practice

3. Myth (II)
 SinceI am the greatest surgeon
since Michael DeBakey, patients are
going to come from 100’s of miles to
see me and referring doctors will not
want any other surgeon to touch their
patient

4. Myth (III)
 AsI need a crane to lift my CV, I will
have the biggest _____ practice this
side of the Atlantic Ocean

5. Fact
 Although you are a well-trained
surgeon, remember: that just like a
plumber or other tradesperson, you
provide a service.
 If you make it (very) difficult for your
customers (ie, referring docs) to deal
with you, your business will suffer

6. Ultimate Truth
 Your “real” customer is the patient
 ALWAYS DO THE RIGHT THING, FOR
THE RIGHT REASON, at THE RIGHT
TIME
– Learn from us, see our mistakes
 You would be surprised to see how often
the right thing is not done:
– It takes experience and learning the hard
lessons to sometimes know what the “right”
thing is

7. The 5 “A’s” of Surgical Practice
 Available
 Affable
 Able
 Approachable
 Accountable
[Note were “Ability” is placed!!!]

8. What We Will Talk of:
 Letters/Notes/Documentation
 When/How to speak to your referring
doctors (ie, your customers)
 We will go through the “process” from
patient referral to the final (second) post-
operative check and long-term follow-up

9. Patient Referral
 Who is your voice?
 How promptly do you return the initial call to you?
– ASAP, even take the initial call from the OR.
 If the referring docs has to play too much phone tag with you, it will
be easier to call someone else!!!
 Getting an appointment to see you:
– Should benchmark for one week to see you
 Pre-visit triage:
– Waiting to get ALL studies prior to initial visit vs seeing patient
sooner without all data you can have
 Remember always: YOU ARE PROVIDING A SERVICE.
THE EASIER AND MORE PLEASANT YOU MAKE THINGS
FOR YOUR CUSTOMER BASE, THE MORE LIKELY
YOUR CUSTOMERS ARE GOING TO WANT TO DEAL
WITH YOU!!!

10. Categories of Letters Sent to
Referring Doctors
 Initial
consultation letter (note)
 Follow-up visit letter
– Completion of work-up note
– Pre-operative visit note
 First post-operative visit letter
 Second post-operative visit letter
 Subsequent visit/long-term follow-up
visit letter

11. General Comments Concerning ALL
Letters Sent to Referring Physicians (I)
 First name or Dr. ___
 Time frame to benchmark to get the letter into the
referring doc’s hands
– One week from office visit to letter in referring doctor’s
office
 Summary
 Tell them what a great job they did in recognizing
this pathology/disease
 Tell them what a great job he/she did in working-
up this patient prior to sending him/her to you

12. General Comments Concerning ALL
Letters Sent to Referring Physicians (II)
 Always give your immediate contact
information for them to reach you
 Always state in beginning of letter the
purpose of the patient seeing you
that day
 Try to remember to state in the letter
the day and date of the office visit

13. Why Spend Time Dictating Well??
 Colleagues and referring docs get the impression that you
know what you are doing
 Expression of plan:
– Work-up of disease
– Operative plan
 Medical-legal issues
 Billing purposes
– Review of systems, etc
 Remind you weeks/months/years from now your thoughts
concerning the disease state, what you found, and why you
did what you did
 Marketing:
– You care enough and are thoughtful enough to delineate things

14. Issues Pertaining to Communicating with
Referring Doctors
 Remember, chances are they are busier than you
and they see more patients than you
– Be patient and expect to play phone tag with them
 My rule: I try to reach the referring doc one time
(for a particular thing); if I cannot reach him/her I
leave a detailed message and request a call back.
I do not re-call the doc for the same issue, unless
it is an URGENT matter
 Always be as positive and upbeat as you can
possibly be

15. “Appropriate” Times to Communicate with Your
Referring Physicians
 Time of initial referral
– Input and opinion from referring MD
 At completion of all pre-operative studies and the formulation of the
“final” plan
– Review briefly what YOU found during your work-up and how you are
using this data to decide what to do
 Immediately following the operative event
– Tell them what wonderful things you did to help their patient, and what
a great job the doc did in recognizing the disease and starting an
evaluation
 Following the first post-operative visit
– Review pathology with doc; speak about other consultants needed
(such as oncology, etc) and if the doc has a preference
– Plan for who will take ownership of post-op surveillance studies
 Select times during long-term follow-up and surveillance of
recurrent disease
– At time of disease recurrence, make sure this is shared with the
referring doc and they know that YOU were responsible for finding the
new disease

16. What/When/How to Communicate
with Patients and Families
 General issues:
– Show pictures and radiographs
– Plan for return to work
– What to expect in terms of pain and how we
are going to help you deal with that
– Show where incisions will lay
– Anticipated length of hospital stay
– ALWAYS, ALWAYS ask your patient (and
family) if they have further questions

17. “Milestones” in Communication with
Patient and his/her Family
 First consult visit
– Plan for work-up
 Final pre-op visit
– Review all studies; final operative plan
 Day of surgery
– Review with family what you saw, what you did
 First post-op day visit
– Review with patient what you saw and what you did
 Day of discharge
– Activity instruction, new medications
 First post-op visit
– Review path, plan for surveillance
 Second post-op visit
– Review plan for surveillance
 Subsequent follow-up visit

18. First New Patient Visit
 Always say “hi” and introduce yourself
 Always apologize for keeping your patient waiting
 Bring films in room to show the patient
 Have schematic drawings available to correlate
radiology with “simple” picture as well as to use
for showing operation you may be performing
 People do not like to feel as if you are rushing:
template off an appropriate amount of time to
spend with new referrals
 Always ask: whom do I need to thank for sending
you to me and allowing me to be of help?
 Try NOT to be in scrubs

19. Initial History and Physical
 History of present illness:
– When did you first notice this
– What is different now that Dr. ___ sent you to see me?
 Radiology studies to date
 Other important studies already done as part of
work-up
 Summary
– Probably the most important part of dictation as you will
be referencing back to this for future letters
 Niceties to include in your letter

20. Initial History and Physical
 Donot be afraid to say that you
need to collect more data/do more
tests prior to deciding what is best
course of treatment

21. Initial History and Physical
 Patient: At end this first visit:
– Give patient your business card
– Ask if any further questions
– Go over plan: what tests needed
 Referring doc: At end of initial visit:
– Call to thank
– Great job you did in recognizing the disease and starting
work-up
– Tell him what additional studies you need which he or
his group can do
– Give your initial thoughts and where you think work-up
will go
– If additional consultants are needed (ie cardiology
clearance) ask if he has a preference or if you can
arrange for such

22. Second Pre-operative Visit
 After all studies you initially ordered at time
of first visit have been obtained
 After all other outside data (path,
radiology) has been brought to you and
reviewed
 After all results from outside consultants
are made available to you
 Purpose of this visit: To relate to the
patient your FINAL PLAN, in terms of what
you are going to do

23. Second Pre-operative Visit
 Make sure you give ample time to ask
questions
 Give patient an “out” and offer to obtain a
second opinion on your plan
 Review anticipated hospital course,
approximate time patient should expect to
be hospitalized, time able to get to full
activities, as well as back to work
 Review with patient plan to achieve
analgesia

24. Second Pre-operative Visit
Referring Physician Note
 Use your summary from initial consultation note to
review course with patient PRIOR to you seeing
him/her
 Next review ALL NEW STUDIES YOU
OBTAINED as part of your work-up
 Re-do the summary including results from your
work-up and how this changes the preliminary
diagnosis
 Give a brief statement of YOUR opinion
concerning how the “disease” should be treated
 Give a definitive statement on WHAT YOU PLAN
TO ACCOMPLISH by surgery
 Niceties

25. In the Operating Room
 Bring films
 Bring your office chart!!
– By definition, the best and most definitive note
on that patient should be yours.
– In case of some emergency, you want the best
and most complete data on that patient in the
OR with you.
 Try to see patient before they go to sleep.
Of ALL THE STRANGERS in that room,
the patient has at least seen you twice.
That brings some element of security to
them.

26. Operative Note
 Pre-op diagnosis  Brief clinical history
 Post-op diagnosis – Use summary piece from
second pre-op visit
 Procedure performed
– What brought patient to OR?
 Surgeons  Operative findings
 Anesthesia – What you found; what do want
 Fluids administrated to remember about this
 Drains operation weeks, months,
years from now
 Complications
– Cardiac events,
 Procedure in detail
iatrogenic injuries – What you actually did in OR, in
as much detail as you can
stand
 Sponge, needle, instrument
counts
 Patient disposition

27. Notes on Operative Notes
 Dictate the operation ASAP; as soon as you get
back to your office
– Delaying will only let you forget salient details which
might be important
 BE HONEST. We all make mistakes.
“Forgetting” to include something, like having to
repair an iatrogenic injury, can have serious
consequences for people managing your patient
down the line
 Dictate your own operative report:
– Billing purposes
– Medical-legal purposes
– Ability to better recall what you did later if you dictated
the note yourself
– Basis for your clinical research

28. What You Do Immediately
Following Surgery
 Develop your own “ritual”:
1. Call referring doc from OR
2. Speak with family in waiting room
3. Go to office and dictate operative report
4. Give chart and films to your office staff
5. ?Speak to patient on your way home, after
he/she has cleared effects of anesthesia
6. Send e-mail to your staff reminding of follow-up
or other “different” things needed for
surveillance based upon your operative findings
and surgery
a) Oncology consult, etc

29. First Post-Operative Visit
• Go over surgery with patient:
• You would be surprised how often people do
not know what operation you performed on
them
• Review final pathology with patient:
• It is reasonable to delay this first visit if the
pathology is not back yet
• Draw pictures of what you did during
surgery, and findings
• Describe to patient if you found anything
different than expected and how that
changed your pre-operative plans

30. Physical Examination at
First Post-Operative Visit
 Examine incision
 Try to remove staples sooner than later, if
medical feasible
 If place steri-strips on wound, remember to
educate patient on when/how to remove
these
 Remember, with few exceptions, if wound
looks wrong, it probably is!!
– Bite the bullet, and be aggressive with
opening/packing wounds. You will rarely regret
this.

31. Patient Education at
First Post-Operative Visit
 Review medications. Make sure patient is back on
all pre-op meds, as oftentimes things are lost in
translation in the transition to outpatient
 Educate about analgesia:
– Despite what you might think, most patients are under-
medicated for fear of becoming a druggie, this is well
known
 Review with patient plan to return to full activities,
driving, as well as to work
 Review plan for disease management:
– Future consultations, surveillance imaging, when to
return to see PCP and/or referring physician

32. Letter to Referring Doctor
Upon First Post-Operative Visit
 Sendout a “Packet” to all referring
doctors, in which will be:
– Operative report
– Pathology report
– Discharge summary
– First post-operative visit letter

33. Letter to Referring Doctor
Upon First Post-Operative Visit
 Start off letter by what brought patient to OR, and
major findings of pre-op work-up
 Include operative findings (from your op note)
 Include post-op course (from your memory or
from d/c summary)
 Include review of pathology (from path report
which should be in your clinic chart by the time
you see the patient)
 Include a review of pertinent laboratory data at
time of discharge
 Include a brief summary of any post-op
complications up until this first post-op visit

34. Letter to Referring Doctor
Upon First Post-Operative Visit
 Finishthis letter with your opinion as
to continued plans for the patient:
– Radiographic surveillance
– Colonoscopic surveillance
– Referral for med/rad oncology
– Laboratory surveillance
– When you plan to see patient again

35. Phone Call to Referring Doctor
Upon First Post-Operative Visit
 Remind doc of the patient
– As, like you, they may not remember the patient off the top of their
head
 Remind doc of what a great job they did in recognizing the disease,
making the diagnosis, and starting the work-up
 Review the surgery you did, what you found, and how this is going
to really help this patient
 Admit to any post-op complications and what YOU are doing to
help in that regard
 Decide as to follow-up plans and who will be responsible for
obtaining surveillance studies, obtaining consultants (onc,
cardiology), etc
 Thank the doc for allowing you the privilege of being of help
to their patient as well as to him/her
 If remotely true, tell the referring doc how easy the surgery
was, and how you appreciate being able to work with him/her
for the best possible care of his/her patient

36. Second Post-Operative Patient Visit
 Purpose: Give patient another chance to
ask questions
 Another opportunity to provide education
– Back to work, ADLs, etc
 Emphasize plan for follow-up and
surveillance (which you will be organizing)
 Review plans for post-operative treatments
done by other docs
 “Hand-off” patient’s care to next provider
who will be running the show following
successful surgery

37. Second Post-Operative Patient Visit
 End this visit with this:
– “You know how to reach me for any
problems whatsoever”
– Make sure your staff has given patient
24 hour number as well as routine office
number

38. Second Post-Operative Patient Visit
Letter to Referring Doctor
 Purpose:
– To review entire post-op course
– Pin down responsibility for post-op
surveillance studies
– Make sure who is taking responsibility
for post-op treatments/consultants
 No real need to make a phone call to
referring doctor unless you really feel
compelled to do such!

39. Final Thoughts
 You provide a service
– ALWAYS REMEMBER WHO ARE YOUR CUSTOMERS
 Remember the FIVE “A’s”
 It is really a privilege to do what we do
– Be grateful for what you have and what you have been given
 Do not just be a technician
– To be called this, exclusive of other things, is an insult
 Judgment and clinical acumen makes you a surgeon,
not being able to physically perform a particular
operation
 Everything you do, from how you run your office, the
clarity and thoughtfulness of your notes, to how your
secretary answers your phones, reflects upon you and
ultimately helps to decide the success of your practice.