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Why should some doctors spend all those years in school only to do what nurse practitioners and physician assistants do, like family doctors and primary care givers (all noted for referrals)?There were many answers when I found this question, so I was going to pass on it. Some responses I found inspiring, some less so. I completed my residency training for the medical specialty of family medicine in 1990. I do not “do what nurse practitioners and physician assistants do.” My scope has always been more comprehensive and at the same time more targeted. I have done inpatient care, obstetric care, assisting at surgery in the OR, minor office based surgery, school physician services, nursing home care, medical direction at three nursing homes. I am board certified with renewal every 7 years, and I have a certificate of added qualifications in geriatrics with renewal every 10 years. I am a certified medical director with renewal every 6 years. I established a hospital Department of Geriatrics. I have taught medical students. I have taught PA students. I ran a solo medical practice for 25 years. For most of that time I took call every day and night except about 10 days/nights every year; I was available to my patients, and they were respectful of that.I went into family medicine because I was unwilling to cut out big parts of medicine and say, “No, I don’t do that.” The competing specialty for me as a medical student was psychiatry, but it was too narrow. Student loans and lifestyle were not factors. The relatively meager pay for rural family physicians has been a source of resentment, and I am confident that is why “the best and the brightest” are not flocking to primary care. Done right, it is the most demanding medical specialty.A ENT surgeon came to a Department of Family Medicine meeting at our request. His nominal talk was on assessing the painful ear. The important point he made was that he was being abused by PAs and NPs working in primary care offices. He offered to have PAs and NPs come to his office so that he could further their education to stop the unwanted referrals. The hard call in primary care is knowing when your knowledge, skills and available resources are adequate, and when you should refer. He found that most referrals should have been addressed in our offices.It has been asserted that PAs and NPs will save primary care and reduce health care expenditures. I have serious doubts about that, and that ties into the paragraph above. If you know your stuff, then you practice smart medicine. You know from a CBC what further tests are going to pin down the cause of the anemia. You do not order an anemia profile or make a hematology referral. Many (not all) PAs and NPs work from protocols instead of from knowledge.I was going to step off my soapbox, but there is yet one more point. In the first months of my internship (first year of residency training), I rotated for a month into the ICU. I was astonished by the knowledge of the nurses. Six months later I again rotated for a month into the ICU, and I was astonished by how much I had learned. By then I was surprised by how little those same nurses knew. The explosion of knowledge and skills in residency training is phenomenal. Research was published this year on how experienced clinicians assess a new problem. What they do works, and it is not a preflight checklist. It is seat of the pants based on experience. Yes, further evaluation and testing are needed, but these serve chiefly to confirm the diagnosis, not to come up with it. It is the 60 hour workweeks when out in practice that develop that skill. Residency hours have been cut back with the notion that fatigue harmed patients and impaired learning. That decision is being vigorously reexamined. Perhaps the 100 hours a week that I did as an intern was excessive, but 2017 standards may be inadequate.Off my soapbox.

Power Abuse in the OR: The Support Staff as Targets and Patients as VictimsJeanne Crane July 2015Knowledge is power: In order to protect your interests you have to understand your risks. As an advice columnist and investigative reporter for a Woman’s magazine (WNC Woman), I am committed to being a public voice. I respond to the needs of women who are denied their power or are targets of power abuse. As a pioneer feminist, I confronted power abuse. My challenge broke through the glass ceiling into the executive suite and freed a generation of women from bondage. My plea for reader’s comments revealed that my generation did not flush out all of the bullies.My readers, in the OR’S of the medical community, have advised me that the patriarchs (“A social system in which men dominate and are regarded as the authority within the family and society”) escaped exposure when Corporate America was held to a higher standard, because they hid under the mantle of “Good Works.” Patriarchal Surgeons/Bullies are not held accountable for their destructive patterns of conduct, because they see themselves (and are viewed) as invulnerable and all-powerful.My research disclosed the fact that their impediments are known and enabled. The medical profession has facilitated discrimination/bullying by allowing “Patriarchal” leadership to thrive. It is defined by the 2014 Ketchum Leadership Communication Monitor of England as: “a ‘macho’ model of solitary leadership -- a command-and-control approach centered on one-way rhetoric, obsessively controlled messaging and solitary decision-making.”READERS CORNER:Dr. Julia informs me that all is not well for women in the OR:She reports that in her field of anesthesiology she is outnumbered 15 to 1…She is not treated with the same respect as her male counterparts, and work assignments are discriminatory…She feels that conditions would improve if the ratio of males to females was more in balance.Dear Julia,I chose to address your concerns because they mirrored my experience. Your circumstances have an even greater impact on society than mine. My challenge freed hostages in the workplace. You are working under the domination of Patriarchs, and they abuse their power to the effect of society at large. We need to tell the world that it impacts their safety when they put their very lives in the hands of a team of professionals whose leader dispenses negative and disabling energy. This creates an environment where morale and efficiencies are diminished. There is no greater circumstance where the balance of power should rule the day.I fail to comprehend how the medical community escaped the watchdogs the first time around.OR Nurse Karen reports why the Patriarchal Surgeons have escaped exposure:It is political by nature. The administration and surgeons share a symbiotic relationship—a co-dependency so to speak. Most of the surgeons are in private practice and are granted operating room privileges. The bottom line is: Surgeons are not held to a higher standard, because the administration is reluctant to withdraw operating room privileges; the surgeons are cash cows and provide major revenues. The administrators recognize the pressure that surgeons are under and offer anger management courses which few take advantage of. (Isn’t that interesting? They obviously recognize that the surgeons are bullies.) She added, sardonically, that they do not have a program for gender discrimination…Women still empty the bedpans while men do the “real” miracles.I asked Karen to rank the doctors on power abuse: Of the 35 surgeons that she works with 75% abuse their power in contrast to only 20% of the anesthesiologists. She worked in a hospital in another state that also oppressed women. She added that the women surgeons are team players.|Dear Karen,Thanks for enlightening us. By understanding the dynamics, it draws us closer to a solution.My goal is to enlighten society to the fact that they suffer the consequences of chaos in the operating room. Every single woman should pay very close attention to these revelations, because at some point in time she will be either a surgical patient or an advocate for one. I am incensed when I realize that our lives are at the mercy of emotionally immature bullies. I am reminded of the Hippocratic Oath, “First, do no harm.” When Patriarchs give reign to their egos (more specifically, their super egos) and connect with their negative emotions, they block access to their higher natures and Divine Guidance. In addition, their disruptive behavior impairs the efficiency of their assistants. The patient then becomes a potential victim of their diminished abilities.Victim Speaks OutIt is important to know and understand your antagonist before his forceful tactics can be neutralized. I just finished reading a memoir written by Sandra M. Gilbert titled Wrongful Death: A Medical Tragedy—1995. Sandra’s husband was a surgical patient at a University of California Medical Center and died needlessly in the recovery room because of the irresponsible attitude and neglect on the part of the surgeon. As further proof that Patriarchs are enabled, his negligence was covered up. Both Sandra and her husband were professors at the University and colleagues of the offenders. It is a dramatic example of our vulnerability; Sandra declares cynically, “When you enter the operating room it’s a crap shoot” (a Gambling Parlor where the odds are stacked against you).This is not a gender war; males are also targets. Women sustain the most impairment because they represent a wide majority of the support staff. It is the same war that I fought—power v/s force. As David R. Hawkins M.D. states in Power VS. Force: “Power gives life and energy… force takes these away.” My battle was won because Knights—powerful men of honor and peaceful warriors—joined in the conflict. There is a need to employ the help of the Knights in the medical sectors. They are legion; we have all interacted with them and benefited from their sensitivity to our needs. They are also incensed by the Patriarchs who tarnish their honorable profession. My research revealed that surgical Knights are vocal about the need to set standards for a fair, harmonious, and safe operating room. The administrators are obviously not listening, which means that society has to be discriminating when they choose a surgeon. If the surgeon is cold, detached and dismissive (forceful) with the patient, it is more than likely that he treats the OR personnel the same way.Surgeons Speak OutDr. Wen Shen’s very lengthy and insightful article titled Bloody Nice: Is the Quest to Build a Kinder, Gentler Surgeon Misguided?— appeared in a July 14, 2014 article of the Pacific Standard (Page on psmag.com). He is a surgeon at the UCSF Medical Center. The theme of his article was how to tame the Patriarchs without losing their results—how to find a balance between confidence and arrogance, leadership and dictatorship, harmonious teamwork and taking charge when chaos erupts…While he states that the culture has changed and the residents are disciplined if they yell at underlings or throw instruments in the operating room, he does not reveal that the majority of the infractions are by private practice surgeons who are immune to penalties… He admitted that some surgeons come awfully close to personality disorders such as narcissism, obsessive-compulsiveness and paranoia. (The “Faith to Persist” phase of my journey includes my experience with an “Obsessive Compulsive,” and the atmosphere around him was chaotic. Why don’t training programs weed out personality disorders?)...There is also substantial disagreement on how invasive the bullies are. Nurse Karen puts the figure at 75/25 against the odds while Dr. Shen says that there are a little more than half of the surgeons that he would want to operate on him or his family…He asks the question, “Can we carve away the toxic personal qualities that have plagued us for centuries while retaining the guts and perfectionism that are the foundation of our professional ethos?” My answer would be: A tame/emotionally stable surgeon is a healer, because he has an open channel to his Higher Power. God Calling say’s it best: That spirit which, if given a free entrance, and not barred out by self, will enable you to do the same works as I did.Dr. Marty Mackey is a surgeon at John’s Hopkins and an associate professor of health policy at the John’s Hopkins School of Public Health. He helped pioneer the life-saving surgical checklist: Book Summary - The Checklist Manifesto by Atul Gawande, 121912His 2012 book— UNACCOUNTABLE: What Hospitals Won’t Tell You, and How Transparency Can Revolutionize Health Care—holds all of the answers. “This book should be read by all people, not just doctors and health administrators, so they can make wise decisions when it comes to choosing where, when, and who will provide health care for themselves and their loved ones.”He states that Mayo Clinic’s strong hospital culture of quality, safety, and patient-centeredness is rooted in a strong tradition of listening to employees. He adds that not reporting incompetence among peers is part of medical culture that has been around for centuries, and Dr’s and nurses crave administrative crackdowns. He proves the positive affect of anonymous employee surveys regarding competency. When the lower level employees are encouraged to express their concerns, safety accelerates dramatically… Medicine is poorly policed. Getting fired takes an action so egregious or offensive to hospital administration that he has only seen it twice among all of the hospitals in which he worked or trained…State Medical Boards are responsible for disciplining Physicians… the more revenue a doctor brings in, the weaker the hospital’s incentive to look into local allegations (a validation of nurse Karen’s revelation)…A powerful tool in the quest for accountability is the camera. If applied widely, videotaping has the potential to transform medicine by adding accountability to a poorly documented and poorly monitored health system; videotaping gets 100 percent enthusiastic support from nurses.Bully Surgeon Profile“A man convinced against his will is of the same opinion still.”—Dale Carnegie.I am of the mind that a goodly proportion of surgeons have personality disorders that are attracted to the practice of surgery, because they view it as a profession that they can perform with tight boundaries—limited patient interaction and dictatorship/bullying of the support staff. They misapply the advice that they receive in training that cautions them to detach emotionally from the patient. Their antisocial tendencies and emotional boundaries cause them to disengage from everyone to a point of force if necessary. With that mindset I recognize why the bullies have never been reformed—it is counterproductive to their temperaments and feelings of entitlement. No matter how efficient they are at their profession it doesn’t make up for their emotional inadequacy, because it diminishes the effectiveness of the support staff.Drastic measures of reform have not changed the bullies: appeals by benevolent surgeons, Supreme Court support of litigation against a bully surgeon, wrongful death litigation by a victim’s wife, and pending legislation addressing bullying. The only way to protect the victims of abuse is to be pro-active by forcing reform until hospital administrators establish zero tolerance by monitoring performance and enforcing accountability.The following are examples of how the bullies can be banished as females begin to fill the vacancies: Nurse Karen stated that the female surgeons that she encountered were all team players. Dr. Makey revealed that female surgical students outnumber males, and Dr.Shen acknowledges that a slow shift in the gender makeup of the surgical workforce has resulted in a welcome influx of new perspectives and leadership styles.Bully case verdict a warning to doctors:Excerpts from an article published in the April 9, 2008 issue of the Indiana AuthorityJoseph Doescher was a hospital operating room perfusionist, the person who operates the heart/lung machine during open heart surgery. He alleged that Dr. Daniel Raess, a cardiovascular surgeon, aggressively charged him “with clenched fists, piercing eyes, beet-red face, popping veins, and screaming and swearing at him.” Doescher testified that he backed up against the wall and put his hands up, fearing that Raess was going to hit him. Although Doescher’s legal claims were intentional infliction of emotional distress and assault, the trial strategy was to present Raess as a classic "workplace bully." The jury found for Raess on the intentional infliction of emotional distress claim, but for Doescher on the assault claim and awarded him $325,000.In a 4-1 decision, the Indiana Supreme Court upheld a $325,000 verdict against a cardiovascular surgeon accused of being a “workplace bully.” Previously, the trial and appellate court decisions in the case had received nationwide attention because of the interest in the concept of “workplace bullying.” Raess v. Doescher, No. 49S02-0710-CV-424, Indiana Supreme Court (April 8, 2008).Pending legislation:There are compelling strategies developing to challenge bullies by establishing the destructive effects to the health of the victims of their abuse. It is a proposed state law called the Healthy Workplace Bill (HWB) that “plugs the gaps in current state and federal civil rights protections.” The bill has been introduced in 29 states. It describes bullying as: repeated, malicious, health harming mistreatment that takes the form of: verbal abuse, threatening, intimidating or disruptive interference or sabotage (I experienced malicious, disruptive and intimidating interference and sabotage.)…Technically bullying is a form of violence—psychological violence.Drs. Gary and Ruth Namie have founded an organization called the Workplace Bullying Institute (WBI). History of WBI | Workplace Bullying Institute (a must read). WBI is also the catalyst for the U.S. Legislative Campaign for legal reform, advocating passage of the anti-bullying Healthy Workplace Bill. Dr. Gary is the National Campaign Director of HWB. The following link is an engaging video by Gary that details the emotional affects of bullying and appeals for support of HWB: http: //www.healthyworkplacebill.org/takeaction/share.php·· UpdatesOn March 12, 2015, the Utah Senate unanimously passed HB 216 on a vote 24 ayes -0 nays -5 not voting. The bill introduced by House Rep. Keven Stratton and sponsored in the Senate by Todd Weiler, sailed through both House and Senate committees and floor votes in both chambers. The bill becomes law with Gov. Gary Herbert’s signature.New York returns to lead the nation with a complete Healthy Workplace Bill in the Assembly — A 3250. The bill provides legal redress for employees harmed by abusive conduct. It rewards proactive employers who voluntarily protect workers with adequate policies and procedures with a litigation prevention mechanism. It defines the phenomenon and applies to employers in both private and public sectors. Our State Coordinators continue to set the highest bar for comparison. A 3250 has 80 co-sponsors. The Senate companion bill is in the works.Bottom LineNothing will change until the medical hierarchy is forced to support the need for rules of conduct. Hopefully my disclosures and visions will attract the attention of the administrators, and they will become willing partners to the regeneration of an honorable profession. A “worst case scenario” (as in my case) will necessitate the need to file a claim of discrimination or bullying. A fire-proof (accurate and specific) lawsuit charging the hospital and surgeon will lead to a peace treaty/settlement offer that will contain a protocol. Once rules for the game are legally mandated, it will set a precedent for the entire medical community.Readers note:If this report raises your consciousness (What I think about, I bring about.—Daily Word), it should confirm the need to do your homework when faced with surgery, and to spread the word.

I would like to mention some lead generation technique using PPCStrain pointless key phrases.Targeting the kinds of key phrases we reviewed in the previous area, will certainly go a long way in attracting premium quality leads to your advertisements, however there are also actions you can take to proactively fend off much less desirable clicks.Look into your Search Terms Record to identify whether you are getting any type of unnecessary clicks to your advertisements. If you locate any kind of such clicks (or impressions), add those search phrases to your adverse key words checklist-- this informs Google or Bing not to reveal your ads for any of these key words.Going back to our earlier example of web design services, some negative keywords you would likely want to include are: inexpensive, complimentary, styles, institution, jobs and so on. This will certainly make certain you don't squander your money on clicks from customers searching for keyword phrases like "San Francisco website design work" or "WordPress site layout style.".If you followed our standards for tracking and opportunity attribution explained in sections one and also two, you'll currently have the capacity to determine which key phrases are leading to poor quality leads and which search phrases are generating opportunities.You can include them to your adverse search phrases listing to stop receiving traffic from these types of searches if you discover that specific key phrases are mainly generating poor leads.Use ad copy to pre-qualify visitors.Composing ad duplicate that focuses only on raising click-through rates is a mistake. You ought to write advertisements that pre-qualify visitors, to ensure that the traffic you do obtain will be a great deal much more relevant and also targeted to your service. Some of the very best methods of doing this, are by adding the adhering to elements to your advertisement duplicate.Service size.Show that in your advertisement duplicate if you target organisations of a particular dimension. If you want to target bigger services, you can add "business" to your ads as well as develop duplicate such as, "venture course WordPress layout.".Market.You can make that clear in your advertisements if you function with certain verticals. Your ad can review: "WordPress design for health care." This usually functions finest with segmented campaigns as well as key words (see suggestions three and also 4).Rates.Several businesses are awkward adding pricing to their advertisement duplicate, yet this is a good way to extract leads who might not have the budget for your service. You can do this by including text such as, "Starting at $499/month," or "Packages beginning at $10,000.".Target Identity.Including your target personality in your advertisement duplicate is another excellent method of pre-qualifying your ad web traffic and also personalizing your ads. You can do this with message such as "For small company proprietors" or "For differentiating advertising executives.".It's additionally essential to regularly A/B examination your ads to maximize their performance. As a general standard, you need to always have 2 advertisements competing each advertisement team in your projects.You can after that decide which ad is performing much better by considering the number of opportunities and also conversions produced from each, in addition to the click-through rates.Create customized landing web pages for your advertisement groups.As soon as a visitor gets to one of your touchdown pages you've already spent for the click. This implies that steps such as adding added kind fields or confirming for a service email address in an initiative to reduce the number of poor-quality leads, are misdirected. Instead, you ought to concentrate on making best use of the conversion prices of your landing web pages by maximizing the components below.Tailor your touchdown pages to the demands, desires, and also difficulties of your advertisement groups with specific focus on the content you have above the fold.It's ideal to develop special landing pages for each advertisement team. Occasionally this isn't feasible-- specifically if you're working with lots of various ad teams.Need to this hold true, you can utilize vibrant headings and subheadings on your web pages. This will certainly let you alter the content of your landing pages by passing in headlines as well as sub headings as criteria of your touchdown web page URL.It's likewise essential to comply with vital touchdown page ideal techniques to support those who click right into converting. These include no navigating, a content or discount coupon deal in exchange for info, and also images or visuals that include even more details regarding whatever is being used on the web page.Determine which provides drive the most results.Test numerous deals to see which get the most traction. Make sure you look beyond conversions to see which offers are generating the most chances. Some offers to test consist of: complimentary trials, trial organizing, free analyses, examination demands, proposal requests, as well as totally free assessments.Use your competitors for key words motivation.Look right into their approach if your competitors are obtaining precious actual estate on search engine result web pages. Try using similar keyword phrases as well as phones call to activity without blatantly replicating them.While knowing what your competitors are up to can be advantageous for your technique, you should be sure to prevent utilizing their top quality key words in your advertisements. This might make you look much less legitimate, and Google may penalize you. Find out more about that here.Make changes based upon mobile efficiency.You'll be able to identify which tools (smart device, tablet computer, or computer) are driving opportunities if you carried out gadget tracking as defined in pointers one as well as two. If you find that mobile leads are not converting into chances, you can quit running your projects on mobile devices or decrease bids so that tablets and computers receive the bulk of your website traffic.Develop an advertisement schedule.Also if you are running your advertisements 24/7, you must establish an advertisement routine for your campaigns. You can include days of the week or damage your routine down additionally by including per hour sections for each and every day.PPC advertisement is a reliable way to bring in B2B leads. However, many firms battle at producing opportunities and also driving a positive ROI from their campaigns. The 10 methods above will assist you produce targeted projects maximized for top quality lead conversions. They might assist to enhance your profits.