This document summarizes a meeting of the Academy at the new VCU medical education facility. It notes that while medical students still approach medicine with curiosity and compassion, the volume of information to be learned has exploded. Teaching and learning are trying to adapt, with an emphasis on work-life balance for students and residents. However, medical education is very expensive, leaving students with large debts. The document discusses how these changes will affect the future medical workforce.

1. ast fall your Academy
held its general meeting
at the new VCU medical
education facility. For
many of us it was an opportunity to
recall our own medical education and
how what we learned has changed.
It was also an eye-opening chance to
peer into the future of our profession.
As we met and spoke with our
medical student guides, we were re-
minded that these students approach
medicine with the same kind of
intellectual curiosity and compassion
that we had when we first donned the
white coat.
But what was also apparent was
how the sheer volume of informa-
tion to be learned has exploded in
recent years. Teaching and learning
is trying to adapt. “Old-timers” like
me spent hours, days, and months
in the clinical setting learning how
to manage various medical problems
hen I look back at
medical school and
residency and all the
habits and thought
processes that were ingrained into
me to help me care for my patients,
thinking like a businessperson was
nowhere to be seen. Doctors don’t
usually think like businesspeople.
Our problem-solving is patient-
focused, rather than process-focused.
Profit and loss statements, human
resource management and strategic
planning put most of us to sleep.
My father, who was an attorney
Moving forward togetherB Y P E T E R A . Z E D L E R , M D
L
WINTER 2015 n VOLUME 21 n NO. 1
WWW.RAMDOCS.ORG
Musings on running
a medical practice
(Or, what they never taught me in med school)
B y I S A A C L . W O R N O M I I I , M D , FA C S
RR A M I F I C A T I O N S
When the 45 physicians at Ortho-
Virginia agreed last fall to merge with a
large orthopedic group in Northern Vir-
ginia, their decision hinged on two fac-
tors: improving the“economies of scale”
on the business and operational side of
the practice and improving the quality of
clinical data.
“Physicians are scientists by train-
ing and they love data and the ability to
benchmark each other,”explained Jim
Perkins, the longtime administrator of
OrthoVirginia who has served as the rep-
resentative on the board of RAM.
W
“Moving,” continued on page 2
Peter A. Zedler, MD, FACOG
is a partner at Virginia Women’s
Center and president of the
Board of Trustees of the
Richmond Academy of Medicine.
and waiting for that patient to arrive
so that we could hone our new-
found practice skills. Today’s medical
students can work with sophisticated
simulators to test their skills and then
run the scenario over and over in a
single afternoon.
The work schedule for students
and residents also has changed
significantly. There’s an increased em-
phasis on “work-life balance,” with
recognition that working 36 hours
straight may not be good for the doc-
tor or for the profession (not to men-
tion relationships or marriages). As
these students and residents take our
place, will they, indeed, experience
less professional burnout, divorce, or
— tragically — even suicide? While
there are many opinions about this
paradigm shift in medical educa-
18 Lessons from Ebola
tion, it will clearly affect the medical
work force, and it behooves those of
us who were trained differently to
understand it.
Our fall meeting at VCU also
gave us a better appreciation of the
financial challenges facing medical
students and graduating residents.
Medical education is expensive!
Most cash-strapped states, including
Virginia, have less money to con-
tribute, so these young physicians
are often left to climb mountains
of debt. They can sometimes face
obligations topping $100,000. It’s no
wonder that many young physicians
feel they must give up their original
dream of pursuing, say, the practice
of primary care, and decide to find a
more lucrative surgical specialty. As
OrthoVirginia’s
big merger: The
numbers add up
BY C H I P J O N E S
“Merger,” continued on page 3
Creating a larger database of treat-
ment outcomes feeds“the desire to suc-
ceed that’s inherent in doctors,”Perkins
said in an interview.“So the idea that we
can make things better is a very good
reason”for merging.
Or as he told the Richmond Times-
Dispatch in October:“This merger helps
people do their jobs better.”
By merging on Jan. 1 with Com-
monwealth Orthopaedics, a 37-physician
group with offices across Northern Vir-
ginia, the new group became Virginia’s
largest orthopedic specialty practice.
They kept the OrthoVirginia name.
Based in Chesterfield County, Or-
thoVirginia now has 82 physicians and
21 offices, as well as an MRI facility and
physical and occupational therapy clinics
in central and northern Virginia. It also will
serve several outpatient surgery centers.
The deal was in the works for more
than a year and, Perkins said, was a natu-
ral outgrowth of the professional affilia-
tions and friendships that the surgeons
developed over the years.“I think the
surgeons met each other at meetings
and said,‘We ought to work more closely
together. We’re in the same state.’”
Because they operate in two separate
markets — with many miles of Interstate
95 between them — Perkins said the deal
did not trigger any antitrust concerns.
Perkins noted that quality metrics
can be a touchy topic for doctors when,
Jim Perkins
“Musings,” continued on page 2
and a gifted businessman, used to tell
me to find a job I loved doing and do
it well and the money would come. In
general I think that is true. However,
I have learned over the years that
you can’t assume the money is being
managed correctly in your practice
unless you pay attention to how it
comes to be there and where it goes
after it arrives.
The processes that get the money
— contracts with insurance compa-
nies, collecting co-pays, precertifica-
tion of procedures, filing insurance
claims and following up on collecting
the money — don’t just happen auto-
matically. They require that diligent
people do their jobs well in an honest
manner. Without this, a medical prac-
tice will likely fail.
It never ceases to amaze me how
much it costs to practice medicine.
We live in a world of high overhead.
Personnel and office space are the two
The dating game3

2. 2 W I N T E R 2 0 1 5
me to step on it. Usually when this
happens, after a little first aid from
people I trust, I learn from it and
move forward.
I hope this issue of Ramifications
helps you focus on some of these
issues in running a medical practice
and perhaps makes you aware of
some new issues or approaches to the
business of medicine. I believe that
the key thing for doctors to remem-
ber is to take the time to pay atten-
tion to these seemingly boring details.
Patient care is very demanding and
we spend most of our time doing just
that. Still, we don’t want to be like
the ostrich that sticks its head in the
sand when it comes to the details of
our business. That is generally a bad
idea (like stepping on a snake). R
Dr. Wornom practices at Richmond
Plastic Surgeons and is the editor of
Ramifications. He can be reached at
Wornom@richmondplasticsurgeons.
com
P R E S I D E N T
Peter A. Zedler, MD
V I C E P R E S I D E N T
Harry D. Bear, MD, PhD
T R E A S U R E R
Ritsu Kuno, MD
S E C R E TA R Y
Sidney R. Jones III, MD
E X E C U T I V E D I R E C T O R
James G. “Jim” Beckner
E D I T O R
Isaac L. Wornom III, MD
C O M M U N I C AT I O N S A N D
M A R K E T I N G D I R E C T O R
Chip Jones
cjones@ramdocs.org
(804) 622-8136
A D V E R T I S I N G D I R E C T O R
Lara Knowles
lknowles@ramdocs.org
(804) 643-6631
A R T D I R E C T O R
Jeanne Minnix
Graphic Design, Inc.
minnix1@verizon.net
(804) 405-6433
R A M M I S S I O N
The Richmond Academy of Medicine
strives to be the patient’s advocate,
the physician’s ally, and the
community’s partner.
Published quarterly by the
Richmond Academy of Medicine
2821 Emerywood Parkway, Suite 200
Richmond, Virginia 23294
(804) 643-6631
Fax (804) 788-9987
Nonmember subscriptions are
available for $20/year.
The opinions expressed in this
publications are personal and do not
constitute RAM policy.
Letters to the editor and editorial
contributions are encouraged, subject
to editorial review. Write or email
Communications and Marketing
Director Chip Jones at
cjones@ramdocs.org.
To become a member of
The Richmond Academy of Medicine,
Inc., visit www.ramdocs.org and join
today. For membership questions,
please contact Kate Gabriel
at kgabriel@ramdocs.org or
(804) 643-6631.
O N T H E W E B
www.ramdocs.org
R A M I F I C A T I O N S
W I N T E R 2 0 1 5
V O L U M E 2 1 n N O . 1
RR A M I F I C A T I O N S
“Moving,” continued from page 1
our best and brightest face this vicious
cycle of medical economics, trying to
find a physician to care for patients in
the primary care setting will become
increasingly difficult. This, too, is
changing the profession, and finding
a solution should be a priority for all
of us.
As RAM gets off to a running start
in 2015, we can see that the chal-
lenges to the best practice of medicine
just keep coming. I would love to tell
you that life is going to get easier, but
I would be fibbing. The challenges
include the constantly shifting, never
clear morass of new government
regulation and ever-changing rules by
the payers, which never seem to be
understood by the patient or doctor. It
makes no sense to us either when we
hear, “That was covered last year but
not this year.”
Adding to our list of concerns
is the increasing competition from
fellow physicians or the hospital that
would like to admit your patients; the
need to keep up with medical knowl-
edge; and the expense of maintaining
certification.
Your Academy recognizes how
difficult this juggling act can be and
strives to fulfill its mission to be “the
physician’s ally.” We continue to
work with the Medical Society of Vir-
your practice, in the doctors’ lounge,
or at one of our social events. In
some cases, these articles may simply
provide reassurance that you’re doing
the right things.
As we all cope with continuous
change, I want you to know that
your Academy has your back. With
that in mind, I encourage you to
take this year to become involved in
RAM in whatever way seems to work
for you. When you do, you’ll find
yourself helping those 2,500 of your
colleagues who are facing the same
challenges and the same future. Why
not face it together?
The end of 2014 marked the end
of a remarkable twenty-year run by
RAM’s talented Executive Director,
Deborah Love. As she begins her
travel adventures and expanding her
garden, Deb has graciously agreed to
work as a consultant to help guide
our Honoring Choices ® Virginia
advance care planning effort.
Please welcome James G. “Jim”
Beckner who has joined the Academy
as our new Executive Director. Jim
has the knowledge, experience and,
most importantly, the passion to help
us face the many challenges of this
year and beyond. We’re excited about
having another great year, moving
forward together! R
biggest expenses, followed closely
by supplies and malpractice insur-
ance. For those of us in independent
practice it comes at us when payroll
comes around and we see what leaves
the bank account to pay the salaries
and taxes for all the people who work
for us. It also comes at us when we
sign the checks to pay for all the other
things listed above. Physicians who
practice in large multispecialty groups
may think they are immune from this,
but I can assure you there is a busi-
nessperson somewhere keeping track
of their expenses too.
Finding good people to help you
in your practice is critical to its suc-
cess. This is true of nurses and all of
the administrative personnel from
the front desk to the business office.
Managing them is not an easy task.
Human resource issues are as real at
our medical practices as they are at
any business—perhaps more so, given
the complex regulatory environment
involved in practicing medicine today.
Having good processes set up, setting
expectations and providing appropri-
ate counseling when these are not
met are the key to being sure they
don’t become big problems. A good
practice administrator is worth his or
her weight in gold. So is a good CPA
and practice attorney. They can do
so much to help run your practice in
an efficient, productive way and help
you as a physician focus on caring for
your patients.
Being in a practice with a group of
other doctors has many advantages. I
am personally blessed to practice with
a great group of plastic surgeons. You
can share calls, bounce ideas off each
other and help each other care for
your patients. Being together allows
you to do many things you cannot do
practicing alone when dealing with
hospitals and insurance companies.
But group practice also involves tough
issues about money, people and duties
which have to be dealt with. In many
ways it is like a marriage. Before join-
ing up you really want to be as sure as
you can that the people you are work-
ing with are people you get along with
because as the great Neil Sedaka once
sang, “Breaking up is hard to do.”
I wish I’d known these things
at the start of my medical practice.
Early in my career I assumed all of
these important details would just
take care of themselves — that they
would just sort of … happen. But I’ve
learned the hard way that they don’t
always just happen. Indeed, some
education about managing a business
should be part of the education of all
doctors. I’m certain that sometime
over the next year, I am going to find
out something else I don’t know any-
thing about that is going to surprise
me about the business of medicine.
Something that’s out there like a
snake in the weeds, just waiting for
“Musings” continued from page 1
ginia on issues that affect the practice
of all the physicians of the Common-
wealth as well as Richmond. Togeth-
er we are exploring how to eliminate
prior authorization in the state and to
reduce the burden of maintenance of
certification. Earlier this month, we
continued our tradition of sponsoring
the largest “White Coat Day” delega-
tion to the General Assembly. This
is always a wonderful opportunity
for doctors to see how “the sausage
is made” and for legislators to hear
from you, their constituents.
We want to be a safe sounding
board for ideas that affect doctors. In
this issue of Ramifications you will
find thoughtful articles that affect
the practice of medicine. Hopefully,
they will spark further discussion in
© Richmond Academy of Medicine
Jim Beckner
59%offinalyearmedicalresidents
reportedhavingreceivednoformal
trainingonemploymentissuessuch
ascontracts,compensation,coding,
andreimbursementmethods.
Source:MerrittHawkins2015SurveyofFinal-YearMedical
Residents.

3. w w w . r a m d o c s . o r g 3
onsidering that most docs
spend more time at work
than home, finding the
right practice can be as
important as finding the right spouse.
The analogy, of course, is not new.
In fact, dating website eHarmony
now offers a job match service using
the same algorithms it developed to
help members find a spouse.
There’s someone for everyone
Hiring a new physician is like
finding a mate, said Dr. Mark
Rausch, CEO and medical director
at BetterMed’s Midlothian location.
“Especially in smaller physician
groups like ours, you truly are ‘mar-
rying’ that physician who’s joining
your practice. You need someone
who has the same set of values.”
So how do practices find the right
fit? Not surprisingly, it’s rather like
asking a friend to set you up. Rich-
mond has the advantage of top-notch
medical schools nearby to draw from
and it is a desirable location for
many, so a lot of practices don’t have
to look far. Often, candidates are
knocking at their doors.
“We actually have fellows from
cardiology fellowships in the south-
east who call us directly who want
to be in the area with an independent
group,” said Ann Honeycutt, execu-
tive director at Virginia Cardiovascu-
lar Specialists.
The dating game: How to find
your perfect (physician) match
B Y L I S A C R U T C H F I E L D
“Since I’ve been here, we’ve tried
to focus on new Fellows who have just
finished their training, and we have
never run ads,” noted Honeycutt.
“We’ve thought new Fellows would
be an easier transition, unless we’re
looking for a very specific skill. It also
assisted with succession planning.”
VCS, like many practices, surveys
physicians every few years to check
on retirement plans. “We look at age
by specialty across the practice, as
well as geographic locations,” she
said. “From there, we map out a
medical staff recruitment plan.”
That recruitment plan should
include digital elements. Physician re-
cruitment firm Cejka Search reminds
clients that today’s job hunters are
tech savvy, responding to targeted
emails and social media. The firm
also reminds clients that as they’re
checking out potential hires, those
If nobody’s knocking, it’s not hard
for her to find candidates. “Generally,
when we begin recruiting, I start with
my existing physicians and ask, ‘do
you know anyone who may want to
be in Richmond with our group?’ and
reach out to contacts they may have.”
“You network, let people you trust
know that you’re looking,” said Kit
Young, administrator and director
of information systems at Richmond
Plastic Surgeons. “Sometimes, there’s
an opportunity to reach out to medi-
cal schools and say we’re looking to
put someone in if it’s the right fit. I’ve
found that a secretary or administra-
tive assistant can be a good contact.”
“We used to be able to pick and
choose from physicians we met at the
hospitals,” said Jo DiPerna, office
manager at Pediatric Associates of
Richmond. “But now, with hospital-
ists, we don’t have that same oppor-
tunity, so we rely on contacts.”
C
say, they’re required by the govern-
ment, insurers or hospitals. Gauging
performance metrics are different,
though, when they’re“used to sup-
port the doctor to be as produc-
tive as he or she wishes to be,”he
said.“Internal measurement is less
objectionable because it’s among
colleagues. They understand what it
takes to be an orthopedic surgeon
so they’re more inclined to accept
their brethren’s review than they
would somebody else’s.”
The wider and deeper database
can also be used to improve the
measurement of patient satisfaction,
he noted.
OrthoVirginia also hopes to
improve its“economies of scale”in
tracking what Perkins called“the
long list of compliance issues”—
including those created by the
Affordable Care Act such as“mean-
ingful use”of electronic records for
patients. The merged metrics also
can help feed the alphabet soup
of reporting requirements that can
give doctors indigestion (e.g. OSHA
and PRQRs).
From a business perspective,
he said the merger makes sense as
OrthoVirginia achieves cost-savings
in areas such as accounting, payroll
and retirement plan management.
Asked about the inherent risks of
merging with another large practice,
Perkins said,“Risk number one is
that the most important asset of any
organization is its people.”He said he
was working hard to keep up morale
among employees who were wor-
ried going into 2015 how the merger
would impact them.
“That’s the challenge,”he said.
“We have two good groups with
good people.”But for the merger to
make economic sense, some staffing
realignment is inevitable, according
to Perkins.
The second challenge he called
“logistical and bureaucratic”— key
details such as making sure the new
practice is using the correct federal
and state tax identification numbers
so that everyone gets get paid for
their work.
Chip Jones is RAM’s communications
and marketing director.
“Merger,” continued from page 1
“Dating,” continued on page 4
Mark Rausch, MD KitYoung

4. 4 W I N T E R 2 0 1 5
candidates are checking employers
out, so practices should keep websites
and Facebook pages fresh.
First dates
So once you’ve found some quali-
fied candidates, how do you find out
if they’re right for you? Great clinical
skills aren’t enough; a new physi-
cian needs to fit in with a practice or
health system’s culture.
First dates are important. “We will
bring a physician recruit in the night
before for a dinner and then a full
day touring offices and trying to meet
as many of the other VCS physicians
as possible. I spend a fair amount of
time with them to make sure they un-
derstand the mission of the practice,
general contract terms and partner-
ship track,” said Honeycutt. “If that
goes well, we generally bring them
back with their spouse. I arrange a
bigger dinner, sometimes a cocktail
party, arrange to meet with a Realtor
and encourage them to stay a couple
of days.”
Candidates typically spend a day
— or more — touring offices, speak-
ing with administrators and seeing
firsthand the way a practice operates.
“Everybody’s a little bit on their
guard,” said Rausch. “You hope to
vet that out while you’re having din-
ner with them. You talk to the can-
didate casually, and with the spouse,
to find out more about them and
whether they’re truly going to mesh
with your group.”
In 2015, there are a lot of options,
from traditional independent practices
— large or small — to large health
systems.
“The healthcare market is chang-
ing rapidly and there’s a lot of un-
certainty out there,” said Chelsea L.
Miller, JD, director of physician inte-
gration, Bon Secours Medical Group.
“A lot of people are looking to join
a hospital group. I think people like
that they can come in and focus on
seeing patients and not have to worry
about the headaches of practice man-
agement.”
Bon Secours has acquired and es-
tablished many new area practices in
the past five years, growing its roster
of providers from 161 in 2008 to a
projected 400-plus this year. “We can
ask primary care candidates where
they’d like to work, in a smaller
practice or a larger practice,” said
Miller. “Would they be comfortable
in a startup practice or inheriting a
retiring physician’s patient panel? We
can pick and choose and talk to them
about multiple opportunities.”
Bon Secours providers adhere to
the “Ethical and Religious Directives
for Catholic Health Care Services,”
a guiding set of principles from the
United States Conference of Catholic
Bishops. That doesn’t cause many
problems, said Miller. “There are
certain things, such as reproductive
health, that you want to be transpar-
ent and talk about. However, we
find that most physicians embrace the
underlying tenet of Catholic health-
care — providing compassionate care
to all people, particularly those at the
margins of society.”
Hospitals will sometimes take part
in a three-way hiring situation, said
Jim Perkins, practice administrator at
OrthoVirginia, where the hospital sub-
sidizes the cost of bringing a needed
specialty to an area. “When this hap-
pens, hospitals must be compliant with
many federal regulations concerning
demonstrated need,” he said.
“If there’s a need for a specialty
and it’s underserved in the area, they
“Dating,” continued from page 3
Chelsea L. Miller, JD
Experienced physician recruiters
recommend having a long-term
(3-5 years)“big-picture”plan, and a
shorter-term, one-year recruiting plan.
Source: Association of Physician Staff Recruiters

5. w w w . r a m d o c s . o r g 5
will subsidize bringing that physician
on,” said Young. “So it can lower the
risk for the practice.”
Say no to mercy dates
And just as you shouldn’t get
married just to get married, hiring
someone who isn’t a good fit for the
practice can be disastrous. Rausch
remembers one such occasion at a
former job.
“Basically, we were desperate,” he
admits. “We had more volume than
we could handle and were a small
group and our salaries didn’t quite
match the going market rate. So we
hired someone we knew wasn’t a
strong candidate, but they accepted
our offer.”
And yes, it turned out as badly as
feared. “It was atrocious,” he said.
“It could have ruined our relationship
with the hospital and hospitalists as
well as our metrics.”
After a few months of that, the
physician was let go. “But then, of
course, we were right back where we
started.”
The proposal
Once you’ve found a good can-
didate, said Nick Weeks, managing
partner of Creative Healthcare Solu-
tions, don’t be coy. He wrote last June
in Physicians Practice: “If you delay
too much in communicating with the
physician after you begin the recruit-
ment process, he may feel you are
not organized or don’t value him as a
provider. This opens up opportunities
for your competition, even though
your practice might be (or might have
been) the physician’s first choice.”
You’ve found him or her, you
feel good about it and you’re ready
to propose. Get that pre-nup ready.
In addition to negotiating the typi-
cal signing bonuses and relocation
expenses, there’s more to think about.
Medical search and consulting
firm Merritt Hawkins counsels clients
to spell out in writing exactly what
is expected of the physician, and to
make sure to accurately project the
financial potential of the practice so
that expectations are realistic.
“Some people wait until a new
physician joins the group to set the
ground rules,” said Young. “I think
you set ground rules before the hire.
Otherwise if you’ve got a mess on
your hands after the hire, you’ve got
to document, document, document.
“You set the rules early for every-
thing, from how to treat staff to how
the practice handles on-call assign-
ments. You can’t make assumptions.”
Physicians, she noted, aren’t al-
ways comfortable having discussions
like this, but an administrator is there
to help keep things in order. “I love
to give people the tools to solve their
problems.”
The honeymoon
There’s a lot of work involved in
onboarding a new physician, includ-
SAVE THE DATE
May 2, 2015
A Fashion Physical for Community Health
RAMA Foundation (RAMAF), the fundraising arm of
RAMA, is dedicated to raising funds for educational
and charitable purposes affecting health and health
care in the Greater Richmond area.
RAMA, a non-profit organization of physicians &
spouses, promotes community health and education,
sound health care legislation, and fosters friendship
and support in the medical community. Physicians Got
Fashion succeeds projects such as the long running
RAMA Benefit Antiques and Fine Arts Show, as the
major RAMAF philanthropic endeavor.
COMMUNITY PARTNERS AND
SPONSOR OPPORTUNITIES
AVAILABLE
For ticket, sponsorship, and other information visit
www.RAMAF.org or contact
Helen Zuelzer at hzuel@aol.com
The Richmond Academy of Medicine Alliance
Foundation presents the 2015…
SAVE THE DATE
A Fashion Physical for Community Health
Join us for cocktails, heavy hors d’oeuvres, and
fabulous fashions modeled by local physicians… &
more!
SATURDAY, MAY 2, 2015
7 pm to 10 pm
The Tuckahoe Woman’s Club
Proceeds to Benefit:
Access Now: provides free specialty care to
uninsured, underinsured and/or low income
individuals
SACKS: distributes toiletries and clothing to
area ERs to aid victims of sexual assault
Nursing & Allied Health Scholarships:
provides student financial support
Medical Society of Virginia Foundation:
seeks to improve health care access
throughout the Commonwealth
ing credentialing, orientation, mar-
keting and staff integration. Accord-
ing to a recent study by Cejka Search
and the American Medical Group
Association, the average turnover rate
for physicians in their second to third
year of practice is 12.4 percent and
small groups suffer from 20.8 percent
turnover among physicians in those
early years. The study also showed
that extended onboarding correlates
to higher retention of physicians in
the early years with a practice.
“You set up new hires to be
successful, not frustrated,” said
Honeycutt. “We have an orientation
session and meet frequently so we
can identify areas that are a problem.
People might take it for granted that
he’s a doctor, so he knows what to
do. But he doesn’t.”
“We’ve made a concerted effort in
past years to improve our onboarding
process,” said Bon Secours’ Miller. In
addition to mentoring and orienta-
tion sessions, the health system hosts
new provider dinners with senior
administrators. “It’s an informal
discussion of their experiences, head-
aches … the things we can follow up
on and address.”
Pediatric Associates’ DiPerna
makes sure all new hires have a
couple of mentors to answer their
questions, tries to assign the stron-
gest nurses to work with them and
ensures they have strong IT support,
a frequent cause of frustration.
As in romance, it’s the little details
that really make a relationship work.
Young keeps an eye out for little
things that might escalate. “Once, a
physician was always quiet and polite
and I had to tell staff just because
someone isn’t barking at you doesn’t
mean they don’t need the same re-
sponse.”
Melissa Byington, president of the
locum tenens division of CompHealth,
suggested in a Physicians Practice
2013 blog that practices think about
how they can help new physicians be
more comfortable before they start,
such as giving them a staff directory
and detailed maps of offices and
hospitals, including parking and
entrance information.
Having a confident new physician
on board, wrote Byington, ultimately
can impact patient outcomes, reduce
liability — and improve long-term
retention.
And your practice can live happily
ever after. R
Lisa Crutchfield is a Richmond-based
freelance writer.
$321,000
Typical recruiting budget of healthcare
organizations, up from $245,000 in 2012.
For heavy recruiters (50 or more searches),
the cost can exceed $500,000
Source: Association of Physician Staff Recruiters 2014 member survey.

6. 6 W I N T E R 2 0 1 5
THE DOCTORS COMPANY DOES.THE DOCTORS COMPANY DOES.THE DOCTORS COMPANY DOES.THE DOCTORS COMPANY DOES.
As the nation’s largest physician-owned
medical malpractice insurer, we have
an unparalleled understanding of
liability claims against cardiologists.
This gives us a significant advantage in
the courtroom. It also accounts for our
ability to anticipate emerging trends and
provide innovative patient safety tools
to help physicians reduce risk. When
your reputation and livelihood are on
the line, only one medical malpractice
insurer can give you the assurance that
today’s challenging practice environment
demands—The Doctors Company.
To learn more, call 866.990.3001 or
visit WWW.THEDOCTORS.COM.
CORONARY
ARTERY STENT
INSERTION
PACEMAKER
PLACEMENT
CARDIAC
CATHETERIZATION
STRESS TEST
THE FOUR MOST COMMON PROCEDURES LINKED TO CARDIOLOGY CLAIMS
Source: The Doctors Company
16%
19%
55%
10%
DOES YOUR MEDICAL MALPRACTICE INSURER
KNOW WHICH PROCEDURES ARE MOST
FREQUENTLY LINKED TO CARDIOLOGY CLAIMS?
DOES YOURDOES YOURDOES YOUR MEDICAL MALPRACTICEMEDICAL MALPRACTICEMEDICAL MALPRACTICEMEDICAL MALPRACTICE INSURERINSURERINSURER
KNOWKNOWKNOW WHICH PROCEDURES ARE MOSTWHICH PROCEDURES ARE MOSTWHICH PROCEDURES ARE MOST
FREQUENTLY LINKED TOFREQUENTLY LINKED TOFREQUENTLY LINKED TOFREQUENTLY LINKED TO CARDIOLOGYCARDIOLOGYCARDIOLOGY CLAIMS?CLAIMS?CLAIMS?CLAIMS?CARDIOLOGYCARDIOLOGYCARDIOLOGY CLAIMS?CARDIOLOGYCARDIOLOGYCARDIOLOGY

7. w w w . r a m d o c s . o r g 7
Patients today expect a seamless,
professional encounter with office
staff. They want to be connected tech-
nologically but still seek the warmth
of a personal relationship. Staff that
can transition from one mode to the
other will enhance the patient experi-
ence. Consider working with your
staff so they become more comfort-
able transitioning between electronic
data entry and personal interactions.
R
Making patient connections
B Y K I T Y O U N G
First impressions
There are many roadblocks which
impede our ability to connect with
our patients. The demand for more
information, collection of payments,
electronic medical records, data col-
lection and outdated office layouts
are just a few factors that can impact
a patient’s experience. Our interac-
tion with our patients should be
pleasant, engaging and meaningful.
Awareness of patient’s challenges
We need to be sensitive to the
fact that patients are not at their best
when they come to see us. Remind-
ing ourselves that patients may not be
feeling well or are anxious can help
us have a positive interaction. This is
easy to forget when we are busy and
trying to manage multiple tasks.
Greetings matter
Staff should have the skills to
properly greet patients. Have you
ever walked into an office and the
person sitting behind the counter tells
you to sign in and have a seat while
staring at his or her computer screen?
Wouldn’t it have been nice if they
smiled and made eye contact with
you? Technology has impacted how
we communicate with others. Sending
a text or an email is an efficient mode
of communication but frequently
lacks that personal touch. As a result
many have not learned how to prop-
erly greet or address others in person.
Helping staff develop this skill ben-
efits the practice and can positively
impact the patient’s experience.
Kit Young is administrator
and director of information
systems at Richmond
Plastic Surgeons. She
can be reached at kit@
richmondplasticsurgeons.com.
Waiting
for the Doc
21minutes
Average wait time
for patients in the
waiting room.
Wait times vary by region and
by specialty.
Sources:AmericanMedicalAssociation(2011)
andTheArnoldP.GoldFoundation(2013).
How do we interact with patients
while collecting data?
The moment the patient walks
into the office they are inundated
with questions. Do you eagerly
anticipate entering the doctor’s office
to answer multiple questions that
seem irrelevant? We need to keep in
mind that trying to complete all the
necessary information for insurance
purposes or Meaningful Use is not
very pleasant for our patients. We
can direct patients to patient portals
and online access, but the face-to-
face encounter is often spent enter-
ing data into the software. There is
an art to collecting information and
making the interaction seem per-
sonal. Making occasional eye contact
while entering data into the system
and asking pleasantly for necessary
information makes for a positive
interaction. This is much easier if
you have mastered the software and
have developed interpersonal skills.
Having staff role play or practice the
process can help them build confi-
dence and become more comfortable
collecting the data.
Consider your office layout
Over the years, the office layouts
have changed. There was a time
when glass windows divided the
front desk from the patients. More
recently we have moved to a more
open concept with the reception area
open to the waiting room, which is
more welcoming to patients. Besides
televisions and magazines, wire-
less Internet access is important to
patients.
Waiting
for the Doc
48%
of appointments
take longer than the
allotted blocks of
15 to 20 minutes for
patient exams.
Sources:AmericanMedicalAssociation(2011)and
TheArnoldP.GoldFoundation(2013).

8. 8 W I N T E R 2 0 1 5
Charles Lee Williams, MD:
The practice of joy
B Y K AT E G A B R I E L
orn in Richmond in 1916,
Dr. Charles Lee Williams
has been a gift to our medi-
cal community for nearly a
century.
At age 15, he was admitted to
the hospital with a strep infection.
That’s when he decided to become
a physician. Rather than pursuing
higher education after graduation
from high school, Williams drove a
truck hauling freight before taking
over his boyhood milk route
with Virginia Dairy for five
years.
Williams married in
1940, and in 1942 began
his undergraduate stud-
ies at the University of
Richmond. On days he
didn’t bike to class from
his home on East 10th
Street in South Richmond,
he took the streetcar to
campus, stopping first to
load milk trucks for Vir-
ginia Dairy. The route took one hour
which afforded Dr. Williams the op-
portunity to study en route to classes.
He went on to attend the Medical
College of Virginia and worked on its
yearbook, serving as editor his final
year. He welcomed a daughter, Betty,
and son, Marvin, before graduating
in 1948. Following an internship at
MCV, Williams began practice in
1949 with South Richmond physician
Dr. Raymond C. Hooker Sr. That
year he also became a member of the
Richmond Academy of Medicine.
He said he always enjoyed mem-
bership in the Academy and noted
that, as a medical student, he served
as a projectionist for the slide presen-
tations at RAM meetings. He knew
every doctor personally and, from his
vantage point as projectionist, could
see everyone who was present. The
Doctors Exchange would phone if a
message needed to be relayed to the
physician on call during the meetings.
Williams would take a wax pencil and
write a message on the glass slide that
the doctors were viewing for the on-
call physician to “please come to the
telephone.”
Williams fondly remembers being
able to sit down with his patients
2015 RAM events
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1601 Willow Lawn Drive, Suite 800
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“Under the Gun: A Combat Surgeon in Afghanistan”
Westwood Club, 6200 West Club Lane
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12:30 p.m.
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Tuesday Speaker TBD
Country Club of Virginia
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7 p.m. presentation
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meetings, please call the Academy at 804-643-6631.
without being rushed. “I always had
time no matter how many were in the
waiting room,” he said. “I gave a pa-
tient as much time as necessary.” In
his early days of practice, “Nobody
had an appointment. You came in
and registered and waited your turn.”
When he first began practice, office
visits cost $3 and a house call was $4.
A house call would, however, cost an
extra dollar if it required travel across
Falling Creek.
Williams always had his doc-
tor’s bag and was ready for action.
His daughter recalls that her brother
once received a gash in his head as
a result of a swing accident and her
father sewed him up right there on the
playground.
Williams delivered babies for 11
years and did a number of home
deliveries, noting that he learned a lot
from Dr. Hooker during the five years
they practiced together. Williams then
practiced with Dr. Charles Young and
later practiced solo until his son, Dr.
Marvin T. Williams, joined him in
1977. They were then joined by Dr.
Bill Harrington and practiced together
as South Richmond Family Physicians
until Dr. Williams retired in 1988. R
Kate Gabriel is membership
manager of the Richmond
Academy of Medicine.
Charles LeeWilliams, MD
B
Dr. Peter Zedler with medical students fromVCU at our November 2014 Membership Meeting
Dr.Vipal Sabharwal asking a question of
our panelists at the January Membership
Meeting
RAM Board Member, Dr. Colin Gallahan, and Drs. Steven
andTovia Smith at January Membership Meeting at CCV
CHIPJONESJAYPAUL
“You had to
have compassion
and sympathy and
time to treat the
worried well.”
Dr. Williams
DIMENTISTUDIO

9. w w w . r a m d o c s . o r g 9
ll businesses can be at
risk for fraud but medi-
cal practices can be espe-
cially vulnerable because
of the number of transactions and
trust placed on employees to properly
do their job. But by regularly review-
ing your processes and policies, you
can have a better understanding of
how finances are handled. The imple-
mentation of internal controls can
discourage fraudulent behavior. But
it’s incumbent on all physicians who
own their practices to understand
what internal controls are in place
and to understand their own system
of checks and balances.
If you happen to be thinking at
this point, “This is someone else’s
problem,” then think again. In
September 2010, the Medical Group
Physician, protect yourself:
The ins and outs of fraud prevention
B Y K I T Y O U N G
ing in a void and, quite frankly, may
be caught if they choose to succumb
to the temptation to steal.
Next, try to better understand
how financial transactions occur in
your practice. Put another way, step
away from your clinical role and put
on your business hat! It is imperative
to understand how transactions are
handled step-by-step and what checks
and balances are needed to mitigate
risk. Pay careful attention to areas
of high-risk, such as patient pay-
ments (co-pays, payments), payables,
patient refunds and payroll. Are
payments posted in a timely fashion?
A transaction should be entered into
the system at the time payment is
received. How do you handle checks
generated by the practice? How do
you validate that payment is justified?
then she should not have access to
write off patient balances. When a
patient makes a payment, is payment
posted into your system immediately?
Does your employee enter the pay-
ment properly into your accounting
system by patient, date, method of
payment and amount? Does someone
else validate the day’s transactions
and look for discrepancies? How are
the discrepancies handled and how
are they corrected?
Have you noticed a trend here?
Checks and balances — and more
checks and balances!
Speaking of checks: Review
your process for generating checks
and how you validate payments or
refunds. What triggers a check to
be generated? An invoice or refund?
Does the invoice substantiate the
check? Are the checks signed by
someone other than the person who
generated the checks?
Smaller medical groups with 10 or
fewer physicians can be especially vul-
nerable because of the relatively small
staff and less separation of duties. In
small practices, it’s not unusual for
each staff member to take on multiple
tasks. According to the MGMA arti-
cle, it has been shown that the median
loss for businesses with 100 employees
or less was $150,000 compared to
$80,000 with organizations of more
than 100 employees.
The devil, as Ross Perot once said,
is in the details. So evaluate how you
handle deposit slips or daily logs in the
practice. Are deposit slips or logs com-
pleted for each location? Who com-
pletes the deposits slips for a bank?
Are they done daily? Do your deposits
slips match up to your daily post-
ings? If there are discrepancies, what
are the follow up and action steps to
ensure transactions are being handled
properly? If necessary, research and
drill down until you determine where
the breakdown is occurring.
Increase transparency of duties
through cross training. Make sure
multiple members of your staff know
how to do the job. When you no-
tice your staff acting secretive — or
employees not willing to take vaca-
tion — consider this a red flag for
A
where 10 percent will steal, 10 per-
cent will never steal and 80 percent
will steal if conditions and oppor-
tunity exist, according the MGMA
article. Out of the 80 percent, many
stole because of personal financial
issues, ease of opportunity or abil-
ity to rationalize the inappropriate
behavior.
But here’s a key cautionary point
from the MGMA: Often offenders
were long-term trusted employees
with no history of fraud.
Since eight out of 10 thefts hap-
pen because of opportunity, then
your goal should be to implement
policies that try to lessen the chances
for those opportunities to present
themselves. Start by figuring out
your risk and points of vulnerability.
Distribute duties among staff and
Management Association published
an article titled, “THEFT in group
practices cost billions of dollars annu-
ally; Warning: New MGMA research
shows that “honest” employees
embezzle.”
Auditors and forensic accoun-
tants often apply a “dishonesty” rule
assign different duties among vari-
ous staff members. Create checks
and balances within your process so
inconsistencies will become apparent.
Monitor and make sure staff is aware
that processes are being monitored
and validated. In other words, let ev-
eryone know that they’re not operat- “Fraud” continued on page 10
Eight
out of 10
thefts happen because
of opportunity
It has been shown that the median loss for
businesses with 100 employees or less was
$150,000 compared to $80,000 with
organizations of more than 100 employees.
Who signs the checks? How do you
handle payroll? Do you use an out-
side entity to generate checks? Who
reviews payroll and validates it?
Look at how transactions are
handled at your front desk and in the
business office. If a staff member is
responsible for collecting co-pays,

10. 10 W I N T E R 2 0 1 5
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(804) 957-6287
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(757) 220-1246
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501 Lombardy Street
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140103_Ramifications.indd 1 1/6/14 4:27 PM
“Fraud,” continued from page 9
fraudulent behavior. When a staff
member is on vacation, make sure
another employee handles the du-
ties. You should randomly audit
daily transactions. Most impor-
tantly, pay attention to inconsis-
tencies and make note of them.
Remember what J.K. Rowling
wrote in “Harry Potter and the
Sorcerer’s Stone”:
“Enter, stranger, but take heed
Of what awaits the sin of
greed,
For those who take, but do
not earn,
Must pay most dearly in their
turn.
So if you seek beneath our
floors
A treasure that was never yours,
Thief, you have been warned,
beware
Of finding more than treasure
there.”
Kit Young is administrator and
director of information systems
at Richmond Plastic Surgeons.
She can be reached at kit@
richmondplasticsurgeons.com.

11. w w w . r a m d o c s . o r g 11
Developing a practice marketing
strategy — where to begin?
B Y C H R I S T O P H E R R H I N E S
e live in a world
where market-
ing techniques,
strategies and
technologies are constantly changing
and evolving. Marketing decisions
that were made within just the past
year or two might already be stale
and ineffective. Just like in any other
type of business, physicians, directors
and decision-makers in the healthcare
happens to be a 50-year-old high-
income female, then your marketing
and advertising should be primarily
directed at 50-year-old high-income
females. In addition to gender, age
and financial status, location plays a
role. Don’t waste advertising dol-
lars by running ads in a Philadelphia
magazine, for instance, if the major-
ity of your practice’s patients reside
within a 50-mile radius of Richmond.
even (when the time is right) enter-
taining content. Focus less on your
practice itself and instead focus more
on your patients’ needs.
To obtain the aforementioned
industry leader status, it is imperative
to create a professional image for your
business or practice. If your practice
offers the highest quality of services,
your marketing efforts should mirror
that professionalism. Something as
simple as an attractive logo or web-
site design has the ability to influence
patients and customers into selecting
your practice over a competitor’s.
Your marketing message should be
concise, consistent and professional in
every aspect.
Along with presenting yourself
in a professional manner, reputation
is incredibly important, especially in
the healthcare industry. In the digital
marketplace, patients’ decisions are
often influenced by ratings, reviews
and feedback from other patients.
Whether you’re providing tips and
advice through social media platforms
such as Facebook and Twitter or
you’re answering patients’ questions
on your practice’s website, every piece
of communication, public or private,
should echo the professionalism that
contributes to your business being an
industry leader. Positioning your prac-
tice in this way often leads to more
word-of-mouth referrals — aka free
advertising.
How do you decide what type of
marketing and advertising will work
best for your business? In days gone
by, marketing and advertising usually
meant print ads, television and radio
spots, outdoor (billboard) advertis-
ing and a Yellow Pages ad in the
local telephone directory. While those
traditional options are occasionally
still viable, these days you also have
an abundance of digital marketing
options at your fingertips. Along with
your practice’s website, which should
W
“Marketing” continued on page 12
While gaining new patients and customers is
obviously important, connecting via occasional
email blasts is a terrific way to keep current
patients and customers engaged as well.
industry must continuously assess and
adjust their marketing and advertising
strategies.
So where do you start? How do
you go about making marketing deci-
sions that will ultimately lead to a bet-
ter reputation and increased profitabil-
ity? Due to the rapidly shifting digital
and traditional marketing landscapes,
it is completely understandable if you
don’t know where to begin. When in
doubt, begin with the basics.
Make sure your efforts are
focused on connecting with and
engaging your target audience. Create
a profile of your typical customer or
patient. For example, if that person
If you don’t have a clear and concise
handle on your target audience, first
take a step back to focus, before pull-
ing the trigger on a new marketing or
advertising campaign.
Focus on strengths to position
your business as an industry leader
— but don’t sell your services. Most
folks don’t want to be sold to. In-
stead, figure out what your audience’s
needs are and then demonstrate how
your practice can solve a problem
that your customers, clients and
patients might have. Through your
marketing and advertising, prove that
you’re an industry leader by provid-
ing informational, educational and
Christopher Rhines
is a partner and the
director of development
at Torx Media. He can
be reached at chris@
torxmedia.com or by
visiting www.torxmedia.
com.
Morethan
40%
of consumers say that
information found via
social media affects
the way they deal with
their health.

12. 12 W I N T E R 2 0 1 5
“Marketing,” continued from page 11
serve as the central hub of your digital
marketing efforts, it is now essential
to explore the following options:
search engine marketing, email
marketing and social media market-
ing. Search engine marketing refers
to techniques that get your business’
website listed higher in search engine
result pages — Google, Yahoo, Bing,
etc. While gaining new patients and
customers is obviously important,
connecting via occasional email
blasts is a terrific way to keep current
patients and customers engaged as
well. Finally, social media marketing
platforms such as Facebook, Twitter
and Google+ are perfect for sharing
informational, educational and enter-
taining bits of content that help keep
your practice on the collective radar
of your customers and patients.
That’s a lot to digest. For larger
companies that have a dedicated in-
house marketing team, those individu-
als should already be aware of and
implementing marketing and advertis-
ing initiatives. Smaller businesses and
practices, though, often find it benefi-
cial to outsource this type of work, es-
pecially in situations where a practice
does not have a marketing director.
Whether you require assistance with
a single aspect of marketing—social
media marketing, for example ≠≠—
or more of a full-service approach,
including strategy and planning ser-
vices, there are plenty of traditional
and digital marketing firms available
to help with those tasks.
Jumping into the world of market-
ing and advertising may seem daunt-
ing at first. But if you take the time
to develop an intelligent strategy, one
that is finely-tuned to your particular
practice, you will soon begin to see
increased business, a return on your
investment and a leg up on your
competitors. R
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13. w w w . r a m d o c s . o r g 13
Feds target effective communication
enforcement
B y K A R E N S . E L L I O T T, E s q .
s places of public ac-
commodation, medical
practices must provide
free of charge effective
communication to deaf or hard of
hearing patients and/or their compan-
ions. While most physicians know of
this basic requirement, the complex
standards the federal government will
require practices to meet to avoid
fines and penalties may come as a
shock. Most likely your practice does
not have the human resource and
administrative processes in place to
meet the government’s compliance
standards.
In July 2012, the United States
Justice Department (DOJ) announced
its Americans with Disabilities Act
Barrier-Free Health Care Initiative.
The DOJ Civil Rights Division has
now partnered with more than 40 U.S.
Attorneys’ offices across the nation
to target enforcement efforts against
healthcare providers. If the patient
and/or his/her companion complain to
the DOJ that a physician’s office failed
to provide “effective communication,”
the DOJ may well initiate an inves-
tigation. And unless the practice has
implemented the DOJ’s guidelines, it is
at significant risk of paying monetary
damages to the complainant plus a
civil penalty for a first violation of up
to $75,000 and $150,000 for subse-
quent violations.
Finding explicit written guid-
ance proves challenging. As a place
of public accommodation under
the Americans with Disabilities Act
Title III (ADA), physician practices
must furnish “appropriate” auxiliary
aids and services where necessary to
ensure effective communication with
individuals with disabilities. The type
of auxiliary aid or service may vary
depending on the “nature, length, and
complexity of the communication in-
volved.” The published federal regu-
lations require the practice to consult
with the individual to determine the
appropriate aid needed, “but the ulti-
mate decision as to what measures to
take rests with the practice, provided
that the method chosen results in ef-
fective communication.” The regula-
tions further provide that the “auxil-
iary aid is a flexible one” and thus do
not provide precise guidance.
The DOJ’s Technical Assistance
Manual and 1994 supplement also
fail to provide well-defined guidelines.
For example: For “[r]outine doctor’s
visits exchange of notes is likely to
provide an effective means of com-
munication.” “When there is a serious
medical situation, including surgery,
an interpreter is likely to be necessary
for effective communication given the
length and complexity of the commu-
nication involved.” (Emphasis added.)
These examples mislead the
practitioner to believe that a high
level of discretion exists. A review
of the DOJ’s settlement agreements,
however, shows that the DOJ expects
practices to follow a much more
stringent process than indicated by
the published regulations.
The DOJ’s published settlement
agreements enumerate the detailed
standards the DOJ demands of prac-
tices. The DOJ publishes its agree-
ments on its website.
Key procedures that the DOJ
states practices must institute for
ADA compliance include:
• Posting a notice in the office and
on the practice’s website about
the availability of auxiliary aids
free of charge.
• Using the model communication
assessment form attached to the
settlement agreements at the time
the appointment is made or on
first visit, whichever is first.
• Charting to include:
- The completed assessment form.
- Documentation that the assess-
ment has been made, the deci-
sion regarding the auxiliary aid
chosen and why.
- Conspicuous labeling on the
chart to indicate that the patient
or companion is deaf or hard of
hearing and a clear statement
of the mode of communication
selected.
- A record of the ongoing pro-
visions of auxiliary services
provided for each visit and why.
• Maintaining a log of:
-Qualified interpreters
-Interpreter requests
• Training staff:
- To make sure the assessment is
conducted.
- How to properly order an
interpreter which must include
written communication to
the interpreter and written
confirmation back from the
interpreter.
- On the various degrees of
A
“Feds,” continued on page 14
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14. 14 W I N T E R 2 0 1 5
interpreter and determining qualifica-
tions. As Virginia does not require
interpreters to be licensed, physicians
must understand the certification
designations. Virginia has a helpful
publication (see sidebar) explaining
the types of certifications offered
nationally and the appropriate inter-
preting situations applicable to each
level of certification. As the Virginia
designations referenced in the above
publication pertain only to interpret-
ers for state agency needs, the safest
process would be for a practice to
require national certification. Phy-
sicians need to be certain that the
interpreter showing up for the visit
holds the proper level of certifica-
tion applicable for the nature of the
visit so staff must be trained to know
what certification level to request
when initiating contact with the inter-
pretative service. Failure to do so may
lead to a complaint, investigation and
damages and penalties. R
hearing impairment, language
and cultural diversity in the deaf
community.
- To identify communication
needs of persons who are deaf
or hard of hearing.
- On the recommended and re-
quired charting procedures.
- On the types of auxiliary aids
and services available.
- On the proper use and role of
qualified interpreters.
- Regarding criteria to be used
to select an interpreter who is
qualified.
- In the proper use and role of vid-
eo remote interpreting services.
- On how to make and receive
calls through TTYs and the
relay service.
The DOJ agreements state practic-
es must provide a qualified interpreter
for the following situations:
• Discussing a patient’s symptoms
and medical condition, medica-
tions and medical history.
• Explaining medical conditions,
treatment options, tests, medica-
tions, surgery and other proce-
dures.
• Providing a diagnosis and recom-
mendation for treatment.
• Communicating with a patient
during treatment, including physi-
cal and occupational therapies,
testing procedures and during
physician rounds.
• Obtaining informed consent for
treatment.
• Providing instructions for medi-
cations, pre- and post-surgery
instructions, post-treatment activi-
ties and follow-up treatments.
• Discussing powers of attorney,
living wills and/or complex billing
and insurance matters.
The ADA provides that physi-
cians bear the burden of hiring the
“Feds,” continued from page 13
Use legal citations and websites
to help you deal with effective
communication issues:
TheStatute42 USC 12182-12188
www.ada.gov/pubs/
TheRegulation36 CFR 36
www.ada.gov/
DOJTechnicalAssistanceManual
www.ada.gov/
DOJTechnicalAssistance
Manual1994Supplement
www.ada.gov/
DOJSettlementAgreements
www.ada.gov/
VirginiaGuidance
www.vddhh.org/
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15. w w w . r a m d o c s . o r g 15
oday’s financial markets
present a difficult chal-
lenge for investors near
retirement and those that
have income as their primary invest-
ment objective. One key question
many investors face is can you pro-
duce enough income with a tradition-
al portfolio given today’s low interest
rates and low stock dividend yields?
As a doctor, you have worked ex-
tremely hard through years of medi-
cal school, residency and ultimately
as a practicing physician. If you are
nearing retirement, where can you
invest your assets to create the cash
flow you need? There are many
choices, such as: dividend-paying
stocks; fixed income assets; interest
bearing savings accounts; and annui-
ties. Each of these asset classes is a
valid place to invest for income, with
each carrying different levels of risk.
Enhancing your portfolio:
risk and rewards
B Y P H I L I P H . J A N N E Y
unintended consequence of pushing
investors to take on too much risk for
a desired return. However, retirees and
income-seeking investors still have to
invest under current market condi-
tions, though it can be difficult in an
environment plagued by suppressed
interest rates, low stock dividends and
potentially inflated equity valuations
in the near term.
Low stock dividends
One of the primary assets con-
sidered in retirement for growth and
income are individual stocks, stock
mutual funds and equity ETFs. Ac-
cording to Barron’s, the Dow Jones
Industrial Average yielded 2.17
percent over the last 12 months; the
S&P 500 yielded 1.92 percent over
the same period of time. At today’s
stock market valuation, a portfolio
of blue-chip stocks such as Johnson
lifestyle, the best long-term strategy is
likely to live off your dividends and
don’t panic when the market corrects.
However, if a 3-4 percent current
yield in conjunction with pension and
Social Security income is not enough,
you might need to look at other op-
tions to enhance the yield of your
retirement portfolio.
Historically low interest rates
Another key asset many investors
use to produce income in retirement
are bonds or fixed income securities.
I would like to focus here on the level
of interest rates based on the United
States Treasury market. At this writ-
ing (late 2014), U.S. Treasury yields
currently are as follows: 2-year =
0.62 percent, 5-year = 1.63 percent,
10-year = 2.23 percent and the 30-
year = 2.88 percent.
By way of comparison, in the
early 1980s the yield on our 10-year
and 30-year Treasury bonds was
nearly 15 percent! By 2000, 10-year
and 30-year Treasury bonds were
paying close to 7 percent annually.
After more than 30 years of declines,
today’s rates are extremely low at
almost any maturity. Thus, the fixed
income side of an investor’s portfolio
faces many challenges in the future
especially when rates inevitably start
to rise. Bonds have historically been
a large piece of retirement portfolios;
in my opinion, many areas of this
asset class are priced for losses in the
coming years. I believe retirees need
to change the way they think about
the risk of fixed income securities and
T
“Portfolio,” continued on page 16
Philip H. Janney is vice
president/investments at
Janney Montgomery Scott,
LLC in Richmond. He can
be reached at pjanney@
janney.com or at (804)
595-9450.
Another key asset many investors use to
produce income in retirement are bonds
or fixed income securities.
However, in today’s environment of
historically low interest rates and low
dividend yields, it can be challenging
to find a current portfolio yield that
meets many investors’ goals.
Arguably Federal Reserve policy
has played a major role in suppressing
interest rates over the last few years
as the global economy has recovered
from a severe recession. This low
yield environment could create the
& Johnson, Exxon Mobil and Coca
Cola might offer a current yield of
2.5 percent to 3.5 percent. Given low
stock dividend yields, do you need to
rely on capital gains to support your
lifestyle? The answer to that ques-
tion is based on a number of factors,
such as your liquid assets, pension
income, Social Security income and
your spending habits. If the yield on
your stock portfolio supports your

16. 16 W I N T E R 2 0 1 5
possibly reduce the amount of capital
that has traditionally been allocated
to this asset class for retirement.
Enhanced yield at reduced risk
So where can smart investors
go to enhance their portfolio yield
without taking on excessive risk? The
stock market has been a difficult asset
class for buy and hold investors since
the technology bubble peaked in
August 2000. Even at today’s record
highs, the annualized return of the
equity market since the tech crash is
well below the long-term average.
Dividends have made up the bulk of
total stock market returns during this
period of time. I believe the next long-
term cycle is up for stocks; of course,
there will be disruptions as the per-
centage move over the last few years is
unsustainable without a pause.
What about today? The question
we addressed above is do you have
enough assets to live off a dividend
yield of 3-4 percent without drawing
down principal or relying on capital
gains? Given the challenging yield en-
vironment highlighted above, income
investors today can utilize a strategy
that targets returning a high level
of cash flow without stretching for
yield or elevating risk. “Covered call
writing” is a stock strategy designed
to produce cash flow and reduce the
risk of a decline in equity values. Call
writing involves owning stocks and
“selling” call options against those
stock positions. Please look below for
a recent covered call example from
our portfolio:
A. Buy 1,000 shares of stock XYZ,
(1,000 x $47.84 = $47,840)
B. Sell 10 XYZ November $48 call
options. Premium = $1.05/share =
$1,050, or 2.2 percent yield.
C. Options expire the third Friday of
each month (Nov. 21). The total
return if XYZ closes below $48 at
option expiration is $1,050 or 2.2
percent. The next trade would be
to sell the December $48 call op-
tion to collect another “premium”
on the 1,000 shares of XYZ.
D. If XYZ closes above $48 on
Nov. 21, it will be sold at $48/
share. The total return if XYZ is
“called,” or sold at $48, could be
$1,210 or 2.5 percent. Company
XYZ has a current yield of 4.4
percent.
Covered call writing can be a risk
management tool and may offer a
competitive yield when compared to
current stock dividends and fixed in-
come yields. Call writing is a way for
an investor with an income objective
to participate in the potential growth
of the stock market at a reduced risk
while possibly increasing the over-
all yield of a traditional retirement
portfolio. That said, once a call is
written on an investor’s position, the
call writer gives up the opportunity
to profit from an increase in the value
of that stock beyond the call’s “strike
or exercise” price. Investors should
consider whether holding a security
for the long term is part of their objec-
tive prior to implementing a covered
call strategy.
One of the greatest challenges
investors and retirees face today is lon-
gevity. Will you outlive your money?
On top of that difficult question is
the current investment environment
defined by low stock dividends and
generational lows in interest rates.
Covered call writing could be a solu-
tion for you if income is one of your
primary investment objectives. We are
committed to supporting the Rich-
mond Academy of Medicine by offer-
ing members free portfolio analysis
and a free retirement income evalua-
tion. Please do not hesitate to contact
us if we can answer any questions. R
“Portfolio,” continued from page 15
HCA VA
BON SECOURS
VCU MEDICAL CENTER
SOUTHSIDE REGIONAL MEDICAL CENTER
97.89%
97.89%
99.20%
97.91%
VCU MEDICAL CENTER
BON SECOURS
HCA VA
SOUTHSIDE REGIONAL MEDICAL CENTER 96.90%
96.00%
99.00%
99.47%
U.S.
Treasury
Yields
as of late 2014
2-year: 0.62%
5-year: 1.63%
10-year: 2.23%
30-year: 2.88%

17. w w w . r a m d o c s . o r g 17
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18. 18 W I N T E R 2 0 1 5
He becomes dizzy and utterly weak…loses all sense of balance…he is going into
shock. He leans over, head on his knees, and brings up an incredible quantity of blood
from his stomach and spills it onto the floor with a gasping groan. He loses conscious-
ness…the only sound is a choking in his throat…then came a sound like a bed sheet be-
ing torn in half, which is the sound of his bowels opening and venting blood…the linings
of his intestines have come off and are being expelled along with huge amounts of blood.
Monet has crashed and is bleeding out.
Richard Preston, The Hot Zone
lmost 40 years after its
first recognition in 1976
in both Sudan and Zaire
— now the Democratic
Republic of the Congo — Ebola is
causing an unprecedented epidemic
in Western Africa which spread to
Europe and the United States. In over
20 initial clusters of cases of Ebola
in Africa recorded between 1976 and
2014, the largest had involved 425
patients in Uganda in 2000. By early
this year, more than 21,000 cases of
Ebola had been reported, with over
one third resulting in rapidly occur-
ring deaths.
In the original outbreak in 1976
there were 318 cases and 280 deaths
— an 88% mortality. With improved
supportive care in Africa the current
mortality is fortunately lower. But
Ebola is an unforgiving virus causing
infection even after minor exposures.
In the original outbreak 6% of family
contacts became infected, and — as
in all Ebola outbreaks — first re-
sponders and health care workers are
disproportionately affected.
Zoonoses
For immediate perspective, one
should recognize the following: Ebola
is one of the latest in a series of zoo-
noses, diseases spread from animals
to people. In fact, almost every
Lessons from Ebola
B Y R I C H A R D P. W E N Z E L , M D , M S C .
A
Norway, France, Spain and more
recently Italy.
In Albert Camus’ classic novel
The Plague, the protagonist is reflect-
ing on the tragic event:
“But what does it mean, the
plague?” he asks himself. “It’s life,
that’s all,” he responds. I am suggest-
ing that zoonoses are natural, will
continue to recur, and in a word are
“life.”
An unforgiving virus
Secondary transmissions outside
of Africa have occurred — affecting
two nurses in Texas who were treat-
ing the first U.S. case in a traveler,
and a nurse’s aide in Spain managing
the infected priest who was transport-
ed from Africa. In both instances, the
primary patients were managed only
late in the course of their diseases and
were highly infectious. A brief note
about the biology of Ebola may put
the transmissions in perspective:
The infecting dose is probably
very low — maybe only 1000 viral
particles and possibly only 100. The
number of viral particles in the blood
of infected patients, however, grows
exponentially each day:
If on day 1 there are: 10 viruses/
ml of blood, by
l Day 2 – there are 100
l Day 3 – 1000
l Day 4 – 10,000 and so on
l By Day 9 – there are a billion
virus particles per ml of blood, far
exceeding any infectious dose one
can estimate.
The key point is that late in
disease the risk to family members,
funeral participants, first responders
and health care workers is extraor-
dinarily high. Thus, the emphasis
on personal protective equipment
and strict protocols for patient care
management is critical, the so called
“moon suits” and the demanding
rehearsals for managing Ebola in the
hospital by those anticipating a case.
How society reacts to the epidemic
Stepping back to observe the
meaning or impact of an epidemic,
one could argue that how a society
reacts to an epidemic gives a view of
its culture, its thinking, its prepara-
tion and its politics. In my view there
have been a series of problems with
the U.S. response to Ebola:
1. With respect to the first patient
arriving in Texas, he was misman-
aged originally, the true diagnosis
surprisingly not considered on his
initial visit and he was sent home,
only to arrive at the hospital 2 days
later. Since he had had symptoms
for 2 days before seeking any medi-
cal help, he was admitted on day 4
to 5 of his illness, late for support-
emerging infection of public health
importance in the last 30-40 years
has been a zoonosis:
l HIV: jumped from chimpanzees to
people
l Hantavirus: originated in field mice
l West Nile fever: birds
l SARS: bats to civit cats to people
l MERS: bats to camels to people
l Ebola: probably bats to non-
human primates to people
Why zoonoses? The movement of
human populations into the natural
habitat of animals through explora-
tion, war, poverty and hunger leads
to transmission. In the case of Ebola,
it is likely that the infection initially
spread to those seeking food from
bush meat or eating bats.
The tipping point for an epidemic
occurs with the movement of infec-
tion from remote villages to large
crowded cities, offering high numbers
of social contacts for virus transmis-
sion. Once the infection reaches ur-
ban populations, air travel makes an
unusual infection in southern China
(SARS) or a remote village in Africa
(Ebola) or Saudi Arabia (MERS)
only a 24 hour trip away from global
spread. Most of the cases seen in the
western countries have been infected
health care workers transported from
Africa to specialized units for care.
These include units in the U.S., U.K.,
Dr. Wenzel is Emeritus
Professor and Former
Chairman of the VCU
Department of Internal
Medicine. He is also
former President of the
International Society for
Infectious Diseases. He is
the author of a nonfiction
book, Stalking Microbes, as
well as a fictional medical
thriller, Labyrinth of Terror.

19. w w w . r a m d o c s . o r g 19
ive care. The adverse publicity as-
sociated with his care and eventual
demise quickly had a great impact
on the hospital census, finances,
and reputation. Today many
hospital administrators in the U.S.
fear their recognition as an “Ebola
Hospital.”
2. CDC’s initial statements were
at the very least “cheeky” if not
grossly overconfident:
We will stop this infection in its
tracks.
Any hospital in the U.S. can
manage Ebola.
We have a robust public health
response team.
The last statement flew in the face
of the delayed response to removing
soiled bed clothes and towels at the
Texas patient’s apartment; and the
TV images of an uninformed and
unprotected maintenance man spray-
ing the contaminated vomitus on the
sidewalk leading to the apartment
of the Texas patient were disturb-
ing. Furthermore, having an exposed
health care worker board a plane for
Ohio and a laboratory tech go on a
cruise to Mexico while in the 21 day
incubation period were confusing
messages to the public.
3. The financial costs of treating these
patients and preparing for a patient
are enormous, and it is uncertain
who pays for it all:
At the special unit at Emory, just
to manage the waste, there were
4 tractor trailer loads of trash
generated per patient! Even at
hospitals just preparing for Ebola
— the costs of protective gear,
training, disinfection equipment,
and building out isolation rooms
are likely to be over $1 million/
hospital. The r/o cases cost a huge
amount of money, i.e. managing
those travelers from West Africa
who have fever and are eventually
shown to have malaria, typhoid
fever or other non-Ebola infections.
Ebola, science and black swans
Decision-making and national
policies require risk assessment and
clear language. Neither has been con-
sistent in the U.S. response.
Amid this unprecedented epidemic
of Ebola, two polarizing terms have
surfaced as clichés at a time of uncer-
tainty and fear. Science is touted as
the irrefutable basis of public health
statements and policy discussions,
and the phrase abundance of caution
used to justify decisions that may seem
prudent — even scientifically based
yet burdensome. Both have been used
so frequently and broadly that their
meanings have been whitewashed.
The general public presumed that
the early CDC statements were driven
by science — Ebola will be quickly
halted in the United States with its
robust infection control and public
health infrastructures because it is dif-
ficult to spread. Doubts quickly arose
when the first patient was mismanaged
in Texas, two nurses who cared for
him became infected, and follow up of
secondary contacts was confusing.
A subsequent decision was made
to screen incoming passengers from
Western Africa for fever in an abun-
dance of caution, a policy quickly
recognized as based less on science
and more on politics. Ebola has an
incubation period of up to 21 days.
The idea that a single screening on
arrival would have a high yield was
magical thinking. Subsequently,
an enhanced entry screening pro-
gram was instituted which involved
monitoring all arrivals from infected
countries for 21 days — the longest
internal among the range of incuba-
tion periods — for any symptoms and
for any fever. This makes more sense.
The latest controversy focuses on
the pros and cons of limiting social
contacts of returning health care
workers exposed to Ebola while in
Africa. This effort followed the iden-
tification of a returning nurse who
was forced into a home quarantine in
Maine about the same time that an
infected young physician hospitalized
in New York City after 1-2 days of
fatigue and then a low grade fever.
He had traveled in the city and went
bowling while feeling ill.
While debating the merits of any
policy, it should be obvious that the
men and women who volunteer to
help Africans dying of Ebola are role
models and heroes for all of us. Their
return should be celebrated with car-
ing, admiration and deep respect.
The public health response has
been that no type of isolation is
needed for exposed health care
workers, a conclusion they say is
based on science: there is no risk of
transmission if a patient with Ebola
is exposed to another person early in
the course of disease. In contrast, the
governors of New York, New Jersey,
Maine and other states argued for
some limitation of public exposure in
an abundance of caution.
When NIH and CDC cited sci-
ence, what they meant to say is that
no one has ever seen transmission of
Ebola early in disease — not that it
is an immutable fact. The scientific
method is based on hypotheses driven
by current information: one posits
an idea — no risk of transmission of
Ebola early in disease — and the idea
is subjected to rigorous testing. If the
idea is not rejected by new informa-
tion, it remains the accepted concept.
The Viennese philosopher of sci-
ence, Dr. Karl Popper, popularized
this concept while living in the U.K.
in the 20th century: to paraphrase,
even if one sees 1000 white swans in
succession, one cannot conclude that
all swans are white. It remains as the
single best hypothesis. The appearance
of a single black swan, however, ne-
gates the hypothesis. Such Black Swan
events are recognized as rare and
improbable but potentially harmful.
One is forced today to conclude
that CDC has the best information
driving its latest policy statement, and
with the exception of exposed health
care workers, Ebola is not easily
transmitted without contact to body
secretions. The viral load is low early
in infection, and current information
suggests that transmission is unlikely.
However, imagine also the
unlikely: what if a single contact of
a patient early in illness becomes
infected with Ebola? That would be
a rare and improbable Black Swan
event with life threatening possibili-
ties for the individual and possibly
irreparable erosion of confidence
in public health. In other words,
by saying that science is driving the
policy that no exposed person needs
any quarantine during the incuba-
tion period, public health authorities
imply its impossibility and place their
reputation unnecessarily at risk.
I argue that there remain uncer-
tainties about Ebola, that the science
is imperfect, and “always” and “nev-
What on earth prompted
you to take a hand in this?
I don’t know. My…my code
of morals, perhaps?
Your code of morals. What
code, if I may ask?
Comprehension.
Albert Camus, The Plague
er” are subject to challenge. Those
who promote science as infallible
should acknowledge the current limi-
tations and uncertainties. However
improbable, they could argue that the
risk is low — maybe not zero — but
that they have 99 percent probability
of being right.
Pros & cons of isolating exposed
healthcare workers
Recognizing the possibility of a
Black Swan event, one could envision
a modification of the effort to limit
general exposure of health care work-
ers on return from caring for Ebola
victims in Africa. They should be able
to live with friends and family who
accept the small risk of transmission,
and they need not be confined inside
the home if there is no exposure to the
public. A potential burden is that there
may still be some health care work-
ers who would be discouraged from
volunteering their skills in Africa,
sensing a lack of appreciation on their
return from an arduous and emotional
experience abroad. Others may argue
that the need to isolate many exposed
health care workers is too burden-
some. However, there would be two
advantages: an allaying of public anxi-
ety since the general public would not
be exposed, and the protection of the
image of public health should a Black
Swan event occur.
My own view of risk management
is not just to ask what is the worst
thing that has happened anywhere
before now, but instead to ask what
is the worst thing that has happened
anywhere before and then imagine
something still worse, something of a
greater magnitude.
Recall the Fukushima nuclear
power plant on the northern coast
of Japan. Its planners looked at the
worst possible earthquake seen before
and built the plant to withstand a
quake of that magnitude. They never
imagined the possibility of a much
larger magnitude 9.0 quake that in
fact hit on March 11, 2011 followed
by destructive tsunami waves of
14 meters. This Black Swan event
caused great damage to Japan.
The recent CDC decision to
record daily symptoms and tempera-
tures of returning health care workers
is useful. It will begin to test the ac-
cepted hypothesis, to pursue science.
With respect to the lack of a need to
isolate exposed health care workers,
public health authorities at this time
think that all swans are white. In full
respect, I hope that they are right. R
2014 Ebola Outbreak in West Africa -
Outbreak Distribution Map
Ivory
Coast

20. 20 W I N T E R 2 0 1 5
RichmondAcademyofMedicine
2821EmerywoodParkway,Suite200
Richmond,Virginia23294
RRAMIFICATIONS
“Ebola Crisis in Richmond” was
a lead news story for weeks on end
in 2014. Yet, there was no Ebola in
Richmond, only hype generated by
some media outlets. The incident
turned out to be a good example of
sound clinical practice and effective
collaboration between private and
public partners to rule out Ebola
Viral Disease (EVD).
The staff at Crossover Healthcare
Ministries applied a reasonable clini-
cal protocol to address the health of
one of its patients who had recently
arrived in the U.S. from one of the
high risk countries in West Africa
to visit family. A cooperative effort
was undertaken by Crossover, the
Richmond City Health District, VCU
Health System, the Virginia Depart-
ment of Health, the Centers for
Disease Control and Prevention and
the Virginia Division of Consolidated
Laboratory Services to support our
clinical partners. Although far down
the list of possible disease conditions,
out of a preponderance of caution,
the CDC agreed to test for Ebola.
Local health departments in
Virginia are the local representatives
cable disease. For the EVD suspect or
patient, we will work quickly to:
• Work with stakeholders to coor-
dinate care, use of proper infec-
tion control measures including
isolation precautions and decon-
tamination procedures, help to
coordinate specimen collection for
laboratory testing with the hospi-
tal, DCLS and CDC.
• Reach consensus with medical
providers on patient management
and public relations management.
• Conduct an epidemiologic
investigation of suspected and
confirmed cases; conduct contact
investigation.
Quarantine monitoring
Though we still occasionally
evoke quarantine and isolation mea-
sures in Virginia, primarily for TB
control, we have not been involved
in such a substantial undertaking
as EVD in decades. VDH is actively
involved in receiving referrals from
the five major airports in the U.S.
that are screening individuals for
EVD from the high risk West Afri-
can countries. If the person arrives
at Washington Dulles International
Airport in Loudoun, the Loudoun
County Health Department receives
the referral from the airport screeners
and these individuals are then re-
ferred to the local health department
at their place of destination. The local
health department monitors the indi-
vidual for 21 days after last possible
exposure for emergence of disease
and collects information twice daily
including EVD-related symptoms
and fever. VDH has monitored more
than 225 individuals to date, mostly
in Northern Virginia. Only four have
been referred for medical work-up
and no disease has emerged from
those being monitored in Virginia.
The individuals being monitored have
been very cooperative; no one has
broken quarantine requiring manda-
tory quarantine orders issued by the
VDH commissioner.
A PR issue
As public health director for
Richmond, my expectation is that the
medical community will not contrib-
ute to community anxiety and fear
in a highly sensitive public that may
be concerned and confused. It is my
desire that all of us will consider the
well-being of our community while
providing information in a respon-
sible, credible and empathetic manner
that informs our residents. The Rich-
mond City Health District takes the
responsibility of working together for
a healthier community very seriously.
We hope that all RAM members and
others in the medical community will
partner with us to help ensure that in-
formation impacting the health of our
community is provided in a consider-
ate as well as truthful manner. Work-
ing with the media is an important
public health tool to communicate to
our patients — the community. R
Ebola: Fighting fear of a deadly disease
B Y D O N A L D R . S T E R N , M D , M . P. H .
Donald R. Stern, MD, MPH,
is director, Richmond City
Health District. He can be
reached at Donald.Stern@
vdh.virginia.gov.
of the Virginia Department of Health
which sets a high standard for public
health practice and a uniform state-
wide approach. VDH has the author-
ity to implement appropriate public
health control measures (e.g., quaran-
tine, isolation, immunization, decon-
tamination or treatment) for diseases
that threaten the public health.
Planning
VDH and local health departments
are always prepared for problems
that threaten the community’s health.
However, additional planning has
been done to supplement the efforts,
promulgate CDC guidelines and
develop a statewide system of care in
the event that EVD does emerge and
become present in Virginia.
The local public health approach
to EVD is really no different than
with any other reportable communi-
…my expectation is that the medical community
will not contribute to community anxiety and fear
in a highly sensitive public that may be concerned
and confused.
A happy customer gets a free flu shot - one of many services provided by the Richmond City
Health District.