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Male Speaker: Our next speaker is Dr. Ross Taubman. I've had the pleasure of knowing Ross for many years. He is the President Chief Medical Officer of the Podiatry Insurance Company of America, PICA.

Residents don’t often think about the fact that medical malpractice is a thing that we have to deal with and be aware of, and obviously now, it’s, prevention is worth a pound of cure. Those of you who are in practice know exactly what I'm talking about when patients get disgruntled, or have a problem and they look at you with that jaundiced eye, if you will, and say, “What did you do to me? Give me my bunion back. I was better before you even touched me and you never told me this was a possibility.” So it’s a fact of life, it’s reality. So PICA is an incredibly important component of our practice lives.

Dr. Taubman will be speaking in life skill section. Success is all about customer service. And I think we should think in terms of that patient is not only a patient, but a customer in a sense that’s paying for a service. So please welcome Dr. Ross Taubman.

Ross Taubman: Good morning. Good morning. All right. So we’re going to have an interesting conversation and what I'm going to do, is I'm going to talk a little bit about why patients sue their doctors. We’re going to talk about customer service communication, a little bit about documentation as tools to make sure that you don’t get sued. I want to talk a little bit about electronic communication which if you’re a resident here you do a lot of, and there’s inherent risk to that.

I am a full time employee of PICA and PICA is a wholly owned subsidiary of a company called ProAssurance and I'm a stockholder in ProAssurance.

Get them on the plane because there’s 42 wheelchairs and they trying to get them on. The reason is, it’s everybody’s job to get that plane turn around. Why do they do that? Because if they can turn the plane around in 30 minutes, they can fly one more flight per day than all of their competitors which means they can have less – they don’t need to purchase as many airplanes. So there’s a method to it but it’s really about customer service.

So let’s talk about another example of customer service and we all know this one, right? Okay? Well, the old tag line for United was, “Fly the friendly skies of United.” So this is what we remembered now about United Airlines, right? They had four passengers on a flight from Chicago to Louisville and they bump them for four of their employees and this is what we remember, the guy being dragged down the center aisle of the plane and this is what it cost United Airlines, $1 billion for that one event.

Frankly, they could’ve bought four 787 dream liners and flew each of the four passengers they bumped, and flew them on their own private 787 for a billion dollars. So what the heck does this have to do with me? I'm a doctor.

It has everything in your practice because we are in a service business. That’s what we do. Frankly, your patients do not know that you’re triple-boarded, that you have the best three-year residency in the world. They don’t know any of that. Frankly, they don’t even know if you are good at what you do. What they know is, they like you, and they like your staff. That is what they know. And so it totally matters the customer service that you provide

And as I said before, it doesn’t matter what you say or what you think you say to your patients or your staff says to your patients, it’s what they think they heard from you and we’ll talk about that a little bit.

And not only that, you’re very much judged by the people you put around you. So your staff matters. So those of you who say I'm a resident, it doesn’t matter. Well, the people who work in the hospital around you, affect your reputation.

And when you get in practice, the people who work in your office are going to affect your reputation. So it should totally matter to you whether you’re an owner or not or whether you’re a resident or not, about how your patients are being treated, and you shouldn’t tolerate anything less than superior customer service.

So here’s the point. You’ve to marry what the patient wants and what you know in providing superior customer service.

[0:05:00]

And the way to do that is, by communicating in a superior way, and this is a challenge because not all of us practice this are good at it, or think about it on a daily basis.

But the single greatest reason why patients sue their doctors, is because there’s a breakdown in communication. Frankly, it doesn’t really matter what happened to the patient nearly as much as how the patient thinks you handle that situation when something happens.

Communication is about mutual transfer of knowledge. And the mutual is really important here. It’s both what you said and what they hear you say. And one without the other is a breakdown in communication and it leads to problems. And it doesn’t matter if it’s in your practice life, it’s in your personal life, it’s in your marriage, your relationship with your boyfriend or girlfriend, all those things are wrapped in communication, and when those fail, that’s how the relationships fail.

So here’s one of the things that you need to think about. In a podiatric practice, 40% of our malpractice claims come from your office. Why am I pointing that out to you? Because you are surrounded in your office by receptionists, by back office, front office people who are designed to help you and assist you, and what they do in your office is equally as important to what you do in your office and what you say, and how they communicate with people is really important. Because the bottom line is this, that patients will not sue you if they think you care and if they like you. It’s just a fact.

80% of our claims have communication breakdown as the central feature as to why somebody sues their doctor, 80%. And I’m talking about the gamut from very minor things to death cases. So it’s a very important part of what we do. And it’s that lack of information or a misunderstanding of the information that’s at the heart of our poor communication or breakdown in our communication.

So let’s talk about face-to-face communication first. We all – a big part is the verbal part, right? The words we use. But equally important to the words we use is the tone of voice. So all of you guys in here already know this because when you’re talking to your partner, your girlfriend, your wife, it totally matters what your tone of voice is. And you could use the same words and the tone of voice is misunderstood by your partner, right? We all know that. It comes up every single day. So tone of voice is really important.

But equally important or frankly even more important is non-verbal communication. Gestures, body position, facial expressions, eye contact, smiling – all those things are huge parts of communications that are really important. Eye contact is one of the most amazing things when you’re talking to somebody. None of your patients like it if you’re not looking at them when you’re talking to them.

The same thing about eye contact that was really interesting, because at first it’s okay but after a few seconds it gets kind of creepy, right? Okay? So you have to be very careful with your eye contact that it’s appropriate eye contact. For periods of time, look away and then look back at somebody. But those things are really very, very important.

And touch is also – appropriate touching is also very important in your relationship with your patients and all those things are not the words you say or the tone of voice. So in fact, 85% is non-verbal communication. We’re going to talk a little bit in a few minutes about electronic communication, which if you’re young you love to text and talk electronically, and it is a huge impediment to communication because you cannot convey intent by the written word like you can when I’m talking to you directly and I’m using my tone of voice and my body position. So it’s a huge impediment. And what happens in the written word when you can’t convey intent is that the receiver of the information gets to decide your intent.

So how many times have you texted somebody and then you talk to them and they thought you were mad at them and you weren’t mad at them. That’s because the reader is reading your intent. So it’s really important and we’ll talk about that a little bit.

So this is an example. So read these words. Raise your hand if you think I’ve agreed to do something.

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This is not a trick question. I know you’re a little suspicious here. Okay?

So for most of us, we read this as a positive statement. My point about intent. What if I do this?

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What I’ve done is use the exact same words to mean the exact opposite. And that’s the point of body position, tone of voice, and the words not being the most important thing.

So when you’re talking to your patients, think about how the words that you say are interpreted. Because an amazing thing that happens is patients remember very little of what you tell them. In fact, in several studies, they remember less than 20% ultimately of what you tell them. So another point is the words don’t matter. Once they're going to walk out of there is that they liked you or didn’t like you and they’ll remember that.

So body language is really important too. And these are some things in body language. The very best position when you’re talking to someone is having your hands at your sides. This means I‘m hiding something to some people. So you've got to be very careful about what you do with your hands. That’s okay if you talk with your hands like I’m talking with my hands, but you keep the hand where they can see your hands. It’s really, really important.

But these other examples, this is, I’m not listening. People that cross their arms, I know it’s a position of comfort, you’re sitting there, you’re cold, okay? But your patients might interpret that as you’re not listening to them or you’re closed to what they have to say.

One of the very worst things you can do is put your hand on the doorknob. All that tells the patient is you want out of the room. How many of you have telephones in your treatment areas, in your room? Okay. When I practiced, I never had a telephone in a room. Because all that – when a telephone call comes in and you take it, all that tells the patient is that phone call’s way more important than me. That’s all it tells them. So in my practice, there was only two times I could be interrupted. One is, if I had called another physician and they called me back, I didn’t want to inconvenience them, and the other one is my wife or my son but the house better be on fire to call me. Because there’s really not much that can’t wait a few minutes before I’m out of that room. But the detriment is done when you walk out of that room.

I give you – I’ll tell you a story when my son was born, he was born 6 weeks premature. So this is in 1985 and there was not a drug called Surfactant at that time. So Surfactant now takes premature babies and then – and helps develop inflate their lungs. He didn’t have that. He had a pneumothorax when he was 2 days old. And he got transferred from a hospital where I was a resident and knew everybody in the hospital to a hospital where I knew nobody. And my wife got transferred as well. She had a C-section so she was in the hospital.

The first morning we’re at the new hospital, the doctor walks in and his beeper went off. Okay? So beepers were these things that when I was a resident, you wore it and it told you, you had a phone call and you going out and make a phone call. I know you don’t – young folks don’t know what those are. But that’s what a beeper is. So his beeper went off but he didn’t look at it. And I happened to look at my watch just to see how long he’d been in the room and see what time it was. And he sat down on the edge of the bed after introducing himself to my wife. Why sit down? Sitting down is a position of relaxation. I’m here for you as long as you need me to be there, as opposed to hand on the door knob, which is the opposite thing.

They talked for a few minutes, he examined her wound and then he said can I – can I answer any questions? He allowed her to end the visit, and then he left. I looked at my watch and I said to my wife, “How long do you think he’s been in the room?” She said, “Twenty-five minutes.” Three. The point is your demeanor with your patients will determine the quality of the visit to them. Time is not necessarily a factor. And we live in a world where you’ve got to see every patient in 7.2 minutes to get on to the next patient. But the way that you act in there will determine what they think and how they feel.

So let’s talk about some other things that go on and just – you know, the saying that you only get one chance to make a first impression, well, someone decides within the first five seconds of meeting you, they’ve already formed an opinion about what they think about you in five seconds.

[15:02]

You’ve got to bring it in those first five seconds so that you create a positive atmosphere or that you’re staff creates a positive atmosphere. Those first five minutes are really important. And for every minute that you’ve created a negative impression, it takes twice as long to try and change that impression. So if you’ve had bad visit for 30 minutes, it’s going to take an hour of positiveness to try and change their mind.

And what do we all do? We do what happened at the United Airlines. Everybody’s talking about the crappy service United Airlines give because we’re ten times more likely to talk about bad experiences than we are to talk about good experiences. So you’ve got to bring it in those first few seconds.

So let’s talk about some impediments. First of all, who’s the most important person in your practice? What’s that? The receptionist. The person who greets your patients or the person who talks on the phone. And guess who we pay the least in our practices? And we hire him off the street so you’re starting behind the eight ball, you’ve got to train those people to give the impression that you want to give. So how many people like to walk in a doctor’s office and do sign a sign-in sheet? It’s like going to the deli counter and taking a number, right? But many of us do that.

Now, some of us have reasons why we do it, we do it because we want to chart that somebody’s been there, we want to know what time they came, all those things. I will submit to you, you have other ways of doing that, but it’s very common practice and your patients don’t like it at all because it’s impersonal. And we have offices where we have glass doors and we open the glass door and we talk to the person and then we close the glass door. And what do your patients want to know? They want to know what’s going on behind the glass door because when you’re sitting there as a patient or sitting in an office, you want to know what’s going on behind the glass door, right? So that’s a very impersonal thing and impediment to good customer service.

People want to be greeted and people want you to mention them by name. “Hi, Ross, it’s great to see you today.” Act like you care. I used to tell myself I don’t care if you really care but you got to pretend that you care for every single patient and using their name is really important and you and everyone else in your practice should have a name badge so that somebody knows who you are.

Another thing that patients hate is to wait. How many people like to wait? Nobody, right? Yet in doctor’s offices we are notoriously bad at keeping people waiting and usually it’s our bad planning, it’s not because we have emergencies every minute of every day for most of us but that’s the excuse we give, have your staff tell the patient that you’re running behind. Now, here’s the practicality of it. Your patients are really going to complain to you as a physician that you’re late, but they’re going to wear your staff out about it. And when you go in the room, acknowledge that you’re late. “I’m sorry, Mrs. Jones. I’m late but I’m here now for as much time as you need me.” That’s really all it takes and you’ve diffused the situation.

Telephone is really important. We do business on the telephone every day. How many people have this experience? I call somewhere and they answer the phone and say it’s ABC Company. “ABC Company. Can I help you?” “Hi. This is Dr. Taubman. I’d like to speak to Mr. Jones.” What’s your name again, right? Why does that happen? Because that first few seconds, they are multitasking and changing from whatever they did to answering the phone and they’re not all in when they answer the phone. It is really important to be all in when you answer the phone because nothing’s better for me as a customer than to say, “Hi, Dr. Taubman, how are you today?” They heard my name. Write names down unless you have an eidetic memory and you remember everything. But it helps you on a piece of paper to say, “Dr. Taubman” and you keep using my name in the conversation, really important.

We are not very good listeners in this world. We’re talkers. We like to tell you what we think. God gave all of us two ears and one mouth I think for a reason, but we have not figured out why that is. It’s really important that you listen to what your customer, your patient wants and give them what they want.

The other two things is putting people on hold pisses them off.

[20:00]

And never ask your patient to call you back. It is your responsibility once they made contact with you that you’re going to call them back, really important. How many people have automated answering queues in their office? How many like those? Your customers, yet they’re very common in medical practices. “Hi. This is Dr. Taubman’s office. If this is an emergency, please hang up and dial 911. If you’re a doctor’s office, please press 1. If you’re a patient wanting to make an appointment, press 2.” You know what I do? I’m pushing zero because I’m trying to talk to a human being. I don’t want to listen to a queue because the other problem is my problem is never one of the choices in the queue. And then it asks me at the end if I didn’t hear it, they’ll repeat the whole thing by pushing star. It’s ridiculous but we use them all the time because we think they help us save money. They’re not very good.

When patients complain, they are trying to tell you something. You have to listen to the complaints and the thing at the very bottom is what they really want is for you to fix their problem. They don’t care why it happened, they don’t care how it happened, all they want to do is fix the problem but what do we do instead? We argue with them. We tell them why our processes are the problem. We tell them that this person or that person is the problem. We are not accountable to the patient and it doesn’t really matter if it was your fault or not to the patient. At that point, all they want to know is that you’re sorry and that you’ll fix it. Those are the only two things they care about. So when you have issues, they’ll think about your staff and the mistakes they might make, you are going to be blamed for that because you hired them or you’re working with them and they affect your reputation.

So the next piece of this is about documentation. And this is one of the hardest things for us as physicians to do well especially from a res standpoint. It’s just really hard to do. But the problem is that when it comes to a lawsuit, if it’s not in the record, it didn’t happen. And all you’re in then is a confrontation between what your patients said and what you said and somebody’s going to have to decide that.

So make documentation your friend, not your enemy. So how many people have an electronic health record? Whether it’s at the hospital or in your practice. Most of us, right? Do they help us be more efficient? How many people think they make us more efficient? They help us to provide better care. Are they cost-effective? I don’t think so.

Because when I started out, we used pencils and papers, so, they were pretty cheap. Does it help improve billing? Maybe, because they were designed as ways to dump lots of information into a note so you got a higher level of an E&M visit, right? So if it’s all these bad things, why are we using them? This is the reason. Because the government – we don’t have to. But the government paid you $40,000 to do it. And nobody says you have to use electronic record. Now, you could argue that there’s penalties if you don’t use them and things like that.

But here’s the deal, they are not very helpful and they’re really bad risk documentation tools. Because what we do is for to be efficient is cut and paste, right? So we’re cutting and pasting stuff. The problem is I can show you one of our malpractice claims where our doctor removed the K-wire from the second toe on seven consecutive visits by cutting and pasting. And there was no note about putting it back in.

If I can ask you 100% of telephone or email or text that you take from your patients need to make it in the chart – documented in the chart, of any conversation related to care. It’s really important. So I said before that patients don’t remember much. So this study was done – your patients forget 40% to 80% of what you said immediately upon leaving the office. So what words you used are not very helpful.

[0:25:00]

So use materials, written materials that you can give them that reinforce what you say. So I want to finish up by talking about electronic communication. It’s awesome. How many of you have your cellphones with you? Okay. They’re really cool. They allow you to communicate instantly. They allow you to send pictures, all kinds of things. They’re really awesome.

But there’s a problem from a res standpoint with them. And these are all the potential problems. So let’s start with this. I need somebody who’s 30 or younger. So if I text you, how fast should I expect to get a response? It depends on who you are. So what if I’m your patient.

Female Speaker: I tell my office, but with my patient I want the 24 hours over that.

Ross Taubman: Okay. So you’re really smart. But if you think about how you text with people, most people expect a very rapid response. Okay. If you’re texting about their care and you’re in the operating room for nine hours, you’ve already messed up your communication with the patient because you’ve missed their expectation. So you have to set expectations like this young doctor did, by saying this is how quickly you will get a response. Alright. So you need to have a policy and think about it.

The other big issue with texting I can tell you is there is not a very easy way to send a secure text. There are secure text systems like TigerText. However, the sender nor receiver both have to be in the same system. I would submit to you if you’re texting with your office staff that you need a system like that to text.

But there is not a secure way from a HIPAA standpoint to text with your patients. There is not one currently. So it’s a problem. So most people are violating HIPAA security laws by texting with their patients. It’s not a violation for the patient to text you. The problem is once it makes it to your hardware, now, you’re subject to the security rules. And that’s the problem. Alright. So let’s finish up here.

First of all, what the customer perceives or wants is what’s important. Meeting those expectations is your dilemma as a physician. Secondly, communication is the root of how you are going to stop having problems with your patients or misperceptions with your patients. So you’ve got to develop those skills.

Young folks have a problem because you’ve not developed the communication skills nearly to the level that people in my generation did. Because we had to talk to each other. We didn’t text. We didn’t have email. We didn’t have any of those things. And if you think about – if you try and text my 85-year-old mother-in-law, you just lost your patient. Because she’s not talking to you that way. You’ve got to meet your patients’ expectations.

What you write down in your note is really important. So accurately capture what happened. For you young folks, I’ll give somebody a prize if you can not only tell me what that song is but can sing it. And lastly, when you’re communicating electronically, if you’re going to use email, it has to be in a closed portal. Not over an open source like Comcast or AOL or any of those Yahoo or Gmail. That is not the way you communicate medically. They do it through your closed portal. Thank you.