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AAGLAdvancing Minimally Invasive Gynecology Worldwide

Didactic: Post-Fellowship Survival Skills: Professional Development for Your Career in

Minimally Invasive Gynecologic Surgery

PROGRAM CHAIRS

Erin T. Carey, MD, MSCR, Sarah L. Cohen, MD, MPH, Jessica A. Shepherd, MD, MBA

FELLOWS REPRESENTATIVE

Mark R. Hoffman, MD

Ted L. Anderson, MD, PhDLinda D. Bradley, MD

Louise P. King, MD, JDCharles E. Miller, MDKirk A. Shibley, MD

Warren Volker, MD, PhD

Janet Bickel, MDTimothy A. Deimling, MD

Suketu Mansuria, MDShanti I. Mohling, MD

Matthew T. Siedhoff, MD, MSCRKaren C. Wang, MD

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 7.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 4 How to Secure Your Dream Job by Mastering the Basics S. Mansuria ................................................................................................................................................... 6 Contract Negotiation: Technicalities and Legalities of Successful Contract Preparation L.P. King ....................................................................................................................................................... 11 Setting Up Your First Practice: Do’s and Don’ts K.C. Wang .................................................................................................................................................... 15 Creating a Marketing Action Plan for Practice Success – MBA Not Required C.E. Miller .................................................................................................................................................... 20 Making a Splash in Social Media! Becoming an Innovative Power J.A. Shepherd .............................................................................................................................................. 26 Complication Management Outside the Operating Theatre: Limitations of Informed Consent, Patient‐Family Communication and Documentation T.L. Anderson .............................................................................................................................................. 30 Managing Conflicts in the Workplace J. Bickel ........................................................................................................................................................ 37 Gender‐Related Issues in Medical Training J. Bickel ........................................................................................................................................................ 41 Maximizing Your Financial Return W. Volker..................................................................................................................................................... 44 Innovation and Intellectual Property: Protecting Your Idea from Conception to Product Release K.A. Shibley ................................................................................................................................................. 49 Surgical Video Tutorial: Tools to Create a High‐Impact Video Presentation M.T. Siedhoff ............................................................................................................................................... 54 IRCAD Award: Laparoscopically Assisted Transversus Abdominis Plane Blocks S.I. Mohling .............................................................................................................................................. UNA Jay M. Cooper Award: Laparoscopic versus Robot‐Assisted Minimally Invasive T.A. Deimling ............................................................................................................................................ UNA Data Collection in 2015: Creating a Database for Quality Improvement and Research S.L. Cohen .................................................................................................................................................... 57

“TED Talk” Revolution: Lessons Learned from the Greatest (and Shortest) Presentations Ever Given E.T. Carey .................................................................................................................................................... 63 Cultural and Linguistics Competency ......................................................................................................... 67

FELO-600 FULL DAY: Didactic: Post-Fellowship Survival Skills: Professional Development for Your Career

in Minimally Invasive Gynecologic Surgery

Erin T. Carey, Sarah L. Cohen, Jessica A. Shepherd, Chairs Mark R. Hoffman, Former FMIGS Board Member (Fellow Representative)

Faculty: Ted L. Anderson, Janet Bickel, Linda D. Bradley, Timothy A. Deimling,

Louise P. King, Suketu Mansuria, Charles E. Miller, Shanti I. Mohling, Kirk A. Shibley, Matthew T. Siedhoff, Warren Volker, Karen C. Wang

This full-day course will provide a comprehensive overview of key topics in personal and career development for the gynecologic surgeon, both with regard to academic or community-based practice. The target audience for this course is current AAGL fellows or recent graduates; however international physicians or junior faculty will also benefit from participation. The topics covered will include: navigating the job market, negotiating contracts, practice set-up and administration, managing conflict or discrimination in the workplace, transitioning from learner to teacher, setting up a successful research program, mastering presentation skills and collaborating with industry on technologic innovation. There will be several panel discussions and interactive sessions built into this course in order to maximize individual interaction and encourage networking with leaders in our field. A graduation dinner will follow this event to celebrate accomplishments of the AAGL Fellowship class of 2015. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Outline an individualized career path in either an academic or community-based practice; 2) formulate strategies to address clinical questions by incorporating research and innovation into practice; and 3) describe how to maximize and navigate interactions with others, including potential employers, colleagues, co-workers and patients.

Course Outline 7:00 Welcome, Introductions and Course Overview E.T. Carey, S.L. Cohen, J.A. Shepherd

7:05 How to Secure Your Dream Job by Mastering the Basics S. Mansuria • Discovering Job Opportunities • Marketing Yourself • CV Development and Cover Letter • Interview Pearls

7:30 Contract Negotiation: Technicalities and Legalities of Successful Contract Preparation L.P. King • Do You Need a Lawyer? • What to Ask for – Typical Salary for FMIGS Graduates,

Vacation, Coverage Responsibilities • Pitfalls to Avoid • Noncompete Clauses • Malpractice Coverage

7:55 Setting Up Your First Practice: Do’s and Don’ts K.C. Wang • Setting Yourself Up for Success

• Administration, Medical Assistance

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• Templates/Schedule Design • Securing OR Time

8:20 Break

8:30 Creating a Marketing Action Plan for Practice Success – MBA Not Required C.E. Miller • Website Design/Increasing Visibility with Search Engines • Promoting Yourself – Presentations, Increasing Visibility in the Community/Online, Patient Education Materials • Networking/Referrals • Niche Services – Office Based Procedures

8:55 Making a Splash in Social Media! Becoming an Innovative Power for the Future J.A. Shepherd • Social Media: Do’s and Don’ts • Using Twitter, Health Grades to Your Advantage

9:15 Questions & Answers All Faculty

9:25 Break

9:35 Complication Management Outside the Operating Theatre: Limitations of Informed Consent, Patient-Family Communication and Documentation T.L. Anderson • How to Consent and How to Document • Disclosure of a Complication to a Patient • Personal Stress Related to Complications • Medico-Legal Aspects – Managing a Malpractice Claim

10:05 Managing Conflicts in the Workplace J. Bickel • Identifying Your Default Conflict Management Preferences and Becoming More Versatile • Handling Sensitive Conversations with Co-Workers and Personnel • Diffusing Angry Patients • How to Give and Receive Negative Feedback

10:35 Gender-Related Issues in Medical Training J. Bickel • What Are We Learning about the Gender Issues That Remain? • Assessing and Avoiding Situations and Behaviors That Put You at Risk • Discussing the “Undiscussable”

11:05 Difficult Issues in the Workplace – Open Discussion L.D. Bradley, M.R. Hoffman • Ask the Experts about Conflict Issues

11:30 Adjourn for lunch

12:45 Welcome, Introductions and Course Overview E.T. Carey, S.L. Cohen, J.A. Shepherd

12:50 Maximizing Your Financial Return W. Volker • Coding and Billing Pearls: Need to Know for ICD-10 and the “Obama-Care” Age • RVU versus Other Reimbursement Schemes • Office Management and OR Cost Containment

1:15 Innovation and Intellectual Property: Protecting Your Idea from Conception to Product Release K.A. Shibley • Maximizing Interaction with Industry

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• Generating Ideas, Taking Them to the Next Level • Principles of Patents, Prototype Design, Funding Start-Ups

1:40 Surgical Video Tutorial: Tools to Create a High-Impact Video Presentation M.T. Siedhoff • Practical Tutorial on Editing Software • Example of Live Video Editing • How to Design a High-Impact Video Presentation

2:10 Questions & Answers All Faculty

2:30 Break

2:40 Award-Winning Paper Presentations IRCAD: Laparoscopically Assisted Transversus Abdominis Plane Blocks S.I. Mohling Jay M. Cooper: Laparoscopic versus Robot-Assisted Minimally Invasive Hysterectomy: A Randomized Controlled Trial T.A. Deimling

3:10 Data Collection in 2015: Creating a Database for Quality Improvement and Research S.L. Cohen • Designing an Outcomes Database That Meets Your Needs • COEMIG, Redcap Review • Variable Inclusion/Exclusion (How Big to Build the Database) • The Burden of Data Entry – Estimate the Support You Need for Consistent Data Entry

3:35 “TED Talk” Revolution: Lessons Learned from the Greatest (and Shortest) Presentations Ever Given E.T. Carey

4:00 Panel: Questions & Answers All Faculty

4:30 Adjourn

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Erica Dun* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Johnny Yi*

SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Intuitive Royalty: CooperSurgical Sarah L. Cohen* Jon I. Einarsson* Stuart Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Kimberly A. Kho Contracted/Research: Applied Medical Other: Pivotal Protocol Advisor: Actamax Matthew T. Siedhoff Other: Payment for Training Sales Representatives: Teleflex M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Ted L. Anderson* Janet Bickel* Linda D. Bradley Contracted/Research: Bayer Healthcare Corp. Speakers Bureau: Bayer Healthcare Corp., Smith & Nephew Endoscopy Stock ownership: CooperSurgical, EndoSee Corp. Consultant: Allen Medical, Boston Scientific Corp, Inc., Smith & Nephew Endoscopy Royalty: Elsevier, UpToDate Erin T. Carey* Sarah L. Cohen* Timothy A. Deimling* Mark R. Hoffman* Louise P. King Consultant: Spouse: OvaScience, Reprosource Suketu Mansuria*

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Charles E. Miller Contracted/Research: AbbVie, Actavis, Aegea Medical, Bayer Healthcare Corp., Covidien, Gynesonics, Intuitive Surgical Consultant: AbbVie, Covidien, Ethicon Endo-Surgery, Gynesonics, Halt Medical, Intuitive Surgical, Pacira Pharrmaceuticals Speakers Bureau: Ethicon Endo-Surgery, intuitive Surgical, Smith & Nephew Endoscopy Royalty: Thomas Medical Shanti I. Mohling* Jessica A. Shepherd* Kirk A. Shibley Consultant: Olympus Royalty: Advanced Surgical Matthew T. Siedhoff Other: Received small amount of money to train new sales representatives. I also gave a talk on gynecologic anatomy and laparoscopy: Teleflex Warren Volker* Karen C. Wang* Asterisk (*) denotes no financial relationships to disclose.

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How to Secure Your Dream Job by Mastering

the BasicsSuketu Mansuria, M.D.

Associate ProfessorAssistant Director MIS

Magee-Womens Hospital/UPMC

Disclosure

I have no financial relationships to disclose

Objectives

Discovering job opportunities

Generating a cover letter

Developing a CV

“Marketing” yourself

Interview pearls

Job Opportunities

Everyone needs an MIS person!

Start EarlyEnd of first year of fellowship

Departments are slow-everything has to go through about 300 committeesGives you time to negotiate your contract

If you have to be in a certain location get your medical license for that state now

Shows that you are motivatedMinimize delays for your start date/getting onto insurance companies’ providers list

Things to consider:Location, location, locationAcademic/PrivateJoin an established MIS practice vs. Being the Newbie

Job Opportunities

Pro’s and Con’s

Mentorship

“Back-up”

One entity/Group-power in numbers

Able to diversify

Research vs. clinical

Specific disease/conditions

Always in the shadow

Harder to change the “culture”

Referral patterns/Competition

Job Opportunities

How to find a positionLook for advertised positions in the “classifieds”

Journals: Green, Grey, JMIG, Urogynecology, REI, “Throw-aways”

“Societies”: AAGL, AUGS, etc.

Talk to colleagues in REI/Urogyn about open positionsYou often can fill a need that they don’t know they have!

Use your contacts from medical school/residency/fellowship

Use your contacts from THIS MEETING

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Job Opportunities

How to find a positionHeadhunters

May be of limited value given our specialty (not a lot of places specifically looking for an MIS)

They don’t come cheap ($20-30,000)

May have some value if you are looking in a very specific location and are looking for any type of position (ie. academic or private, specialist or generalist)

Job Opportunities

How to find a positionShotgun Approach-just contact EVERYONE

Academics-Send a cover letter and CV to:Chair

Residency Director

Division Director

Resources:http://www.acgme.org/ads/Public/Reports/Report/1

List of all residency directors

APGO has a list of all Department Chairs

Private Practice-Google!

Senior partner/Office managers

Job Opportunities

How to find a positionWhat if you find a job in your dream location, but not your dream institution/practice???

Either hire me, or compete against me!

Nothing to loose

It works

Go after the job you want, not the “name” you think you need

Go for your dream job…switching jobs is not that easy and you usually have to start all over again

Cover Letter

This is their introduction to YOU!

Sell yourself!

What to include:Your educational background

Residency

Fellowship

Additional training (MPH, etc.)

Cover Letter

What to include:Fellowship background

This isn’t MFM or Onc!!!

Details , details, details:

Specific surgical skills/procedures

PSN

SCP

Complicated TLH

Urodynamics

Populations you serve

Prolapse

Pelvic pain/Endometriosis

Fibroids

Cover Letter

What to include:What you have to offer besides awesome surgical skills:

Education

Residents

Pig labs, covering service, staffing clinics

Faculty

Fellows

Research

Grants

On going projects

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Cover Letter

What to include:What your professional goals are

SELL YOURSELF…but be honestSpecialized clinics/services

Clinical/Research

New revenue streams

Urodynamics, office procedures

Education

OB?

CV

This will be your calling card for the REST of your career

Keep it UP TO DATE…everyday

Most universities have a format that they want your CV inAll contain the same basic information

Feel free to get creative with categories (ie. Video Presentations)

Include what is relevant for your level (ie. resident presentations) and edit as your career progresses

No one cares that you enjoy reading, gardening, Parcheesi, knitting creepy cat sweaters

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Marketing

Be a good citizenBe back up/be available for anyone who needs help-at ANYtime

Be a problem solver-don’t pass the buck

See patients promptly-within 48 hrs if possibleHand out your card and phone number like those guys on the Strip!!

Communicate with the referring docsPhone calls

Letters

Send them your business cards

Marketing

Best Marketing Tool-YOU!!!Word-of-mouth advertisement is the best advertisement

Be a great:Surgeon

Person (Bedside manner is KEY)

Doctor

If patients love you, your schedule will always be full (and that gets noticed by the bean counters)

…and make your attending’s life eaasier (shameless plug)

Marketing

Be academically productiveVisibility in meetings

AbstractsPostersVideosSeek out opportunities to help with PG courses/committees

Don’t be afriad to ask!Publish

Original research Throw away journalsBook Chapters

Involvement in AAGL/organizations

“Shadowing” at a program-for residents looking for a fellowship

Marketing

References-pick references who know:You as a person

Your abilities as a doctor

Your “intangibles”

Interviews

This is the time to “flesh out” your CV and cover letterExpand on unique things on your CV or unique skills you have that make you stand out in the crowd

Give concrete examples of how this will make you a valuable asset to the group

everyone likes to teach…you have developed a full curriculum for all levels of residents to improve their L/S skills that has been validated

everyone likes to operate…you have experience in implementing an office based procedure clinic for hysteroscopy/ablation/Essure

We can read what’s on paper…we want to know the person (ie. knitting creepy cat sweaters)My hard and fast rule: “Is this someone I can stand being in the OR with til 1 am?”

Interviews

You are also interviewing them…find out:What they want out of you

Specialist for referralsClinical work horse

Researcher

What are their 3/5/10 year expectationsHow will they support your non-clinical interests (ie. research, teaching, etc.)Will they market you, where do they expect your volume to come from?Interviews are a CONVERSATION!

Make sure they are a good fit for YOU!

9

Thank You

[email protected]

10

Basics of Contract Law and Negotiations

Louise P. King MD JD

Department of Obstetrics and GynecologyDivision of Minimally Invasive Gynecologic Surgery

Director of Reproductive Ethics Center for Bioethics, Harvard Medical School

Disclosures

Consultant: Spouse: OvaScience, Reprosource

• Should you consult an attorney?

• Compensation/Benefits

• Ownership/Partnership

• Malpractice Insurance

• Hours/Duties/Balance

• Non compete

• Should I consult an attorney?

Call Maggie

• Maggie Finklestein JD

• SE Health Care Quality Consulting

• www.sehealthcarequalityconsulting.com

• [email protected]

Compensation

• AAGL survey• 221 graduates surveyed, 164 responded

• Average 3-4 yrs post fellowship

• Median starting salary $216 K

• Median salary at 3-4 yrs $238 K– JMIGS 2015 22(3) 469-74

• Breast Surgeon• 2784 members surveyed, 843 “observations”

• Mean income $330K– AnnSurgOncol 2015 23 (epub)

• Trauma Surgeon• 385 surveys, 172 “suitable” responses

• Mean $229K– JTrauma2000 49(5) 833-8

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Compensation Across Specialities

Medscape 2014 Compensation Survey

Who’s Up Who’s Down


Male vs Female Pay OBGYNs


ObGyn Compensation by Practice Setting


Basics points to emphasize

• Ensure base salary is guaranteed for as long as possible

• Specific requirements re all activities and metrics (collections, productivity, quality, meaningful use) should be included in employment agreement or established written policy

• RVU’s ACOs

Typical benefits

• Health Insurance• Physician

• Family members

• License Fees

• Medical Staff Dues

• Stipend for Continuing Ed• $2500

• Retirement Plan

• Disability

• Vacation/Sick Leave• 3-4 weeks

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Which MDs Take More than 4 Weeks Vacation

Medscape 2014 Physician Lifestyle Report

Ownership/Partnership

• Usually separate “buy-sell” and/or “partnership” agreement

• Signed later on – thus agreement is verbal at outset

• Ask for conditions and cost of buy-in to be included in original contract

• Consideration vs automatic offer

• Timing/method

• Determination of purchase price/time over which paid

Insurance

• Occurrence • Incidents that happen during the coverage year

• Claims made• Claims filed during the coverage year

• Requires a reporting endorsement “tail”

• You MUST establish who pays for the tail and under what circumstance

Outside activities

• Specify ability to participate in • Research

• Publications

• Teaching

• Consulting

• Directorships

• Who will be paid honoria/bonus? If paid to practice how will this benefit physician in compensation formula?

• Intellectual property?

Schedule and call

• Full or part time?

• Admin duties?• Who do you report to? Who reports to you? What

is your role in hiring staff?

• Teaching duties?

• Length of work week/pts per day/week?

• Call?

• Performance evaluation process?

Number of patient visits per week


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Amount of Time Spent with Each Patient


Hours spent on Admin


Non compete/Non-solicitation

• Limit to small geographical area

• No more than 1-2 yrs

• Specify remedy of monetary damages

Review Learning

• Which of the following is typical insurance offered by employers

• A. Claims Made

• B. Occurrence

• C. Claims Made with Tail

• D. Occurrence with Tail

References

• http://www.medscape.com/features/slideshow/compensation/2014

• http://www.medscape.com/features/slideshow/lifestyle/2014

• https://www.acponline.org/running_practice/practice_management/human_resources/employment_contracts.pdf

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Setting Up Your First Practice: Do’s and Don’ts

Karen C. Wang, MD

PRESENTER INSTITUTION

• I have no financial relationships to disclose

• Implement strategies to develop a successful practice

• Utilize support staff to improve efficiency

• Incorporate organizational skills to optimize your schedule

• Establishing precedence to secure operating room time

Setting Yourself Up for Success

Donald Kendall; former CEO Pepsi Cola

“The only place where success comes before work is in the dictionary”

• S: Start without any preconceived notions

• U: Utilize your previous experience

• C: Create a wishlist

• C: Capture the essence of Zen

• E: Endure setbacks and failures

• S: Set short term and long term goals

• S: Seek opportunities

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Determining your niche

• Design clinics according to your preference

– Endometriosis clinic

– Fibroids clinic

– Pelvic pain clinic

– Vulvar diseases

– Pediatric/adolescent gynecology

– Mullerian abnormalities

– Procedure clinic

Administration, Medical Assistants

Helen Keller

“Alone we can do so little; together we can do so much”

Administrative Support

• Managing your schedule

– Updating your calendar

– Arranging meetings

– Facilitate travel

– Scheduling clinic and OR

• Gatekeeper

– Patients

– Colleagues

• Communication and training is vital!

Medical Assistants• Improves efficiency

– Clinic flow

– Initial assessment

– Specimens/procedures/paperwork

– Room turnover

– Patient disposition

• Consistency is important

• Communication and training is vital!

Physician Extenders

• In 2009 49.1% of office based practitioners worked with physician extenders

• Nurse Practitioners

• Physician Assistants

– Office

– Inpatient

– ER consults

– OR assist

– Phone calls (pre and post op, triage)1Park NCHS Data Brief 2011

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Templates/Schedule Design Templates

• Structuring your clinic schedule

• Allot appropriate time

– consults, post op, procedure, problem, annual

• Variety of models

– Designated clinics (consults, post op, pain)

• Important to discuss with office manager

– Space

– Staff

– Materials

Schedule Design

• Multiple factors to consider

– Access to clinic space and staff

– Access to operating room block time

– Availability of assistants

– Other responsibilities

• Flexibility

Example Weekly Schedule

Monday Tuesday Wednesday Thursday Friday

OR Clinic Procedure Clinic

OR Clinic

OR Clinic AdministrativeTime

OR Administrative Time

With time….

Monday Tuesday Wednesday Thursday Friday

OR Clinic Procedure Clinic

OR Clinic

OR Clinic AdministrativeTime

OR Administrative Time

Securing OR Time

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• “Use it or lose it”

• Demonstrate volume consistently

• Be realistic estimating length of surgery

– Case volume

– Complexity

– Turnover time

• Open time Block time

• Releasing your time

– Unfilled, vacation

Materials

• Office equipment

– Procedures (cystoscopy, hysteroscopy, EMB, colposcopy, LEEP, ultrasound)

– Tests

• Operating room preference cards

– Procedure specific

– Instruments, equipment, suture material

• Meet

– Nurse managers (floor, office, OR)

– OR staff (pre op, OR, PACU)

– Anesthesia group

– Office manager and staff

• Get to know other consultants

– Urology

– Colorectal

– General surgery

– Psychiatry

– Physical therapy

– Interventional pain

Seek out mentors

• Division

• Department

• Other institutions

• Other specialties

DO’s

• Conceptualize how you would structure your schedule

• Understand there may be limitations (access to clinic space, OR, assistants, materials)

• Be flexible

• Realize that organization and structure is helpful

• Seek out mentors

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DON’Ts

• Don’t overestimate your abilities

• Don’t forget to utilize your assistants (administrative, medical, physician extenders)

• Don’t be afraid to ask for help

• Don’t get frustrated

• Park M, Cherry D, Decker SL. Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants in Physician Offices. NCHS Data Brief, 2011. Aug (69):1‐9.

19

Creating a Marketing Action Plan for Practice Success –MBA Not Required

Charles E. Miller, MD, FACOG

Past President, AAGL (2007 – 2008)

Past President, International Society for Gynecologic Endoscopy – ISGE (2011 – 2013)

Treasurer, International Society for Gynecologic Endoscopy (ISGE)

Clinical Associate Professor, Department OB/GYN, University of IL at Chicago, Chicago, IL USA

Director of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL USA

Director, AAGL/SRS Fellowship in Minimally Invasive Gynecologic Surgery, Advocate LutheranGeneral Hospital, Park Ridge, IL USA

Contracted/Research: AbbVie, Actavis, Aegea Medical, Bayer Healthcare Corp., Covidien, Gynesonics, Intuitive Surgical

Consultant: AbbVie, Covidien, Ethicon Endo-Surgery, Gynesonics, Halt Medical, Intuitive Surgical, PaciraPharrmaceuticals

Speakers Bureau: Ethicon Endo-Surgery, intuitive Surgical, Smith & Nephew Endoscopy Royalty: Thomas Medical

Charles E. Miller, MD, FACOG

1. List three steps in organizing an effective marketing strategy plan.

2. List two different approaches to building practice volume.

3. Discuss the interaction between segmentation, targeting, and positioning in practice.

At the end of this discussion, the physician will be able to:


1. Which of the following is not a recommended way to effectively build practice volume:

a. Steal share

b. Stimulate demand

c. Acquisition

d. Retention

e. Over promising

Evaluation Question:


• Nordhielm, Christie L.Marketing Management: The Big Picture. Hoboken, NJ: John Wiley & Sons, 2006. Print.

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Overview

• Tools & Responsibility – Ethical Practice in Marketing

• Business Objective

• Marketing Objective

• Source of Volume

• Segmentation

• Targeting

• Positioning

• Product

• Produce as Service

• Marketing Communications

• Pricing Strategy

• Channel Strategy

• Integrate: Marketing Research


The Big Picture


Tools & Responsibility – Ethical Practice in Marketing

• “Do the Right Thing”

• Long term success– Retain patients– Legal risk

• Areas where there is a mismatch between expectation and ability

• Ethical concern must govern– Business objective

• Inappropriate goals may lead to unethical behavior

– Marketing objective• Acquisitions behavior increases risk• Over promising

– Volume• “Steal share” mentality more likely to lead to ethical concerns

– Segmentation, targeting and position• When the segment being targeted is harmed

– Advertising and promotion are notorious areas of unethical behavior


Business Objectives

• Fundamental entity – who are we?– Does not vary whether marketing is directed to referrals or patients– “Brand”

• Core competence – what do we do best?– Skill that we possess that provides a competitive edge

• Strategic asset• Not easily imitated

– Focus on the input – the set of skills producing the asset rather than theoutput – the asset itself

Umbrella vs. Distinct Branding


Business Objectives (cont’d)

• Core business – what business are we in?– The focus is on patient benefit– Provides a blueprint for future business expansion

• Goal– Serves as a decision aid for marketing– Serves to define performance criteria

• Was the goal unrealistic?• Was the strategy ineffective?


Marketing Objective• Marketing objectives

– Acquisition– Retention

• Heart loyalty• Head loyalty• Hand loyalty

Relationship of Investment to Revenues

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Marketing Objective (cont’d)

Why Customers Are More Profitable Over Time

Relationship To Marketing Objectives


Source of Volume

• Steal share vs. stimulate primary demand

• Must evaluate potential competition

Relationship to Marketing Objective


Segmentation

• How we define our market

• Evaluate demographics and behavior, attitude, and aspirations to increase efficiency of marketing

• Must not stereotype– Stereotyping is based on physical behavior; segmentation is based on attitudes– Stereotyping presumes a complete picture of a person; segmentation focuses solely on one or two

variables

Relationship of Type of Segmentation Variable to Reliability and Competitive Advantage


Segmentation (cont’d)

• Segmentation criteria– Variables must generate a large enough audience that can be accessed – Meet consumer expectations– Company is capable of meeting needs

• Main and dynamic segmentation variables– Category variable is the primary benefit that patients seek– Dynamic variable is the variable that allows you to out perform the market leader

Identify Segmentation Variables


Targeting

• Who we will attempt to reach

• A district step from segmentation ‐ a further refinement

• Result of intensive strategic thinking

• Reflects our strategic choices and consumer insights

• Allows further definition of the target patient in terms of attitudes and behavior

• Sets the stage as to how we position our “value added” to the marketplace– A critical link between corporate strategy and execution

Relationship To Marketing Objective


Positioning

• What we will say to them

• A pivotal step– All elements of the marketing strategy coalesce into a single, focused idea– Weds our entity’s core competence, strategic intent, and understanding of the target consumer– The probability of conversion will be highest when the message is tailored to a specific type of

person

Select Positioning

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The 4 P’s – product, pricing, distribution (place), promotion

• 4 basic categories of tactical decisions in a marketing plan

Product

• A bundle of benefits

• Point of contact between the practice and the patient – Contact includes needs, awareness, purchase, and post‐purchase

Product “Life Cycle”


Product and Brand/Brand Equity

• A product is an essential brand building tool

• Brand equity is a strategic asset built through successful marketing

• Investments are made to support brand equity in the form of advertising, promotion, customer service, and product development

• Advantages of branding– Serves as a memory aid– Surrogate for quality information– Basis for differential– Locus for emotion

• Branding cannot add value to the firm if the product does not perform in a consistent fashion


Product Involvement/Attributes: The Link Between Consumer and Product

Product Involvement and the Purchase Process

• Attributes– Search ‐‐ can be evaluated prior to product purchase

and consumption • Most common – price

– Experience ‐‐ can only be evaluated after consumption– Credence – cannot be evaluated

Production ‐ Summary


Product as a Service

• Many types of services are high in credence attributes – as a result other aspects become important – all aspects of the experience before, during, and after service delivery must be controlled

• Defining elements of service– Standardization helps reduce cost– Consistency helps to sell service– Consider memory aids to make the intangible tangible

• Logos• Taglines

– Rule of mouth is important (rule of 10)– Operations is a necessary core competence

• Ideal– Boost low period demand sufficiently to support the fixed and labor costs necessary to meet peak demand

– Key to exceptional service – tight integration of operations and marketing• Danger – marketing over‐promises, operation under‐deliveries

– Target low time demand customers• Customize and dramatize

– Target high need‐for‐convenience• Time –constrained customers

– Move services into backstage/standard quadrant

– Articulate the steps of service delivery• The service is only one of many “touch‐points”


Product as a Service (cont’d)

Service as a Product

Mapping to Customer Experience



• Zone of tolerance– Within the zone ‐‐ perceptions and memories of performance tend to regress toward expectations– Below the zone ‐‐ perceptions fall precipitously– Above the zone – risk – raises future expectations– Key – consistency should come before brilliance

• Customer satisfaction and customer service– No guarantees that improved customer service, increased customer satisfaction, and loyalty =

Increased profitability

• Keys to connection between investment in customer service and profitability– Manage expectations

• “Never make a promise that you can't keep”• Value the core competence• Communicate the core competence

– Manage production • Consistency before brilliance

– Manage the memory• Services are high in credence attributes• Emphasize successes

– Quantify the value of our services– Avoid wishful marketing– Retention – customer service has experience and expertise– Acquisition – customer service can teach and reassure

23



Customer Satisfaction and Profitability


Marketing Communications

• Combines rational argument, emotional appeal, and dramatic presentation

• Adhere to strategic plan– Jeopardize success– Cannot learn from success or failure

• Distinguish strategic vs. executional elements of marketing communications

• Most successful marketing communications campaigns are those that are consistent

• Communications objectives– First step in the communication process– Objective – increase awareness– Alternative channels

• Public relations• Support materials• Word‐of‐mouth• Product placement

• Marketing objective– Basic awareness

• A brand that is new to the market• Increase brand awareness• Emphasize brand name• Short term goal


Marketing Communications (cont’d)

• Marketing objective (cont’d)– Top‐of‐mind awareness

• Brand recognition established• Emphasize public relations to increase word‐of‐mouth

– Information objective• Convey information• May seek to enhance the perceived importance of the information

– Image/attitude objective• Seeks to evoke an emotional response• Utilized with mature brands

– Behavioral objective• No additional steps between exposure to ad and the intended behavior

• Developing communications materials – copy development– Developed by advertising or public relations agency– Evaluating execution

• “BUMP Analysis” – believable, unique, memorable, pertinent

• Media planning and buying– The choice of media drives the creative work and vice versa– Consider all options

• TV, radio, print, website, social media, on‐site events

– If promoting experience attributes• Word of mouth endorsements

– If promoting search attributes• Informational communications



Advertising Spending



Promotion ‐ Summary


Pricing Strategy

Pricing – Sources of Surplus

24


Pricing Strategy

Cost‐Based Pricing: The “Growth Spiral” Cost‐Based Pricing: The “Death Spiral”


Pricing Strategy

Pricing – Summary


Pricing Strategy

Pricing and the Big Picture


Channel Purpose and Definition

• Set of interdependent organizations involved in the process of making a product or service available for consumption or use to the final consumer

• Ultimate purpose ‐‐ deliver benefit to the end consumer


Integrate – Marketing Research

• Links marketer and customer and the competitive environment through information

• Marketers must distill relevant information from vast amounts of data available

• Marketing research– Asses the need for research– Articulate the research question– Determine the research design– Determine the methods and sources of data– Analyze and communicate– Evaluate


Integrate – Marketing Research (cont’d)

• The best return on research investment will come from decisions made on the left in the above figure

• In actuality, most marketing research dollars are spent on aspects on the right in the above figure

• Market research is more valuable when questions are answered frequently

Market Research and the Big Picture

25

Social Networking and Medicine:

Starting the Conversation: An Introduction to Using Social Media

In Healthcare

Jessica Shepherd MD, MBA

Director of Minimally Invasive Gynecology

Founder of HerViewpoint

1

Disclosure

• I have no financial relationships to disclose.

“Our practice doesn’t use social media because…”

✉We don't have control over what people might say about us.

✉We risk HIPAA and PHI violations with social media.

✉There is no return on investment with social media.

✉People don't use social media to choose healthcare providers.

What is Social Media?

Simply put….it’s the way we communicate over technology.

Why use social media?

Branding

Word of Mouth Advertising

Provide Information

Reputation Management

TODAY’S MULTI-CHANNEL JOURNEY

Social Media Platforms?

• FaceBook

• Twitter

• FourSquare

• YouTube

• Pinterest

• LinkedIn

• G+

I love to give presentations.

Speaking at #MCMS

I’m at

Watch my presentation

Here’s a slideshow

My skills include

I’m an attorney/consultant

26

7

Online Social Networking Exploding

• Facebook

– >400 million users worldwide

– 2009 revenue: >$550 million

– 8 billion minutes spent on Facebook each day

– Increasing corporate marketing use

• Twitter

– “Tweets” – max. of 140 characters

– Celebrity usage – Lance Armstrong, Brittany Spears

– Corporate use growing exponentially

– Over 55 million users / month and growing

– Largest user demographic: 35‐49

8

Online Social Networking Exploding

• LinkedIn– Facebook for professionals– Over 50 million registered users

• MySpace

– Similar to Facebook– Less than half the users at over 100 million

• YouTube– Online videos

• Blogs– The original social networking tool

• Non‐provider hosted sites (external sites)– Different legal obligations may arise when a provider hosts blogs and other

media on its own servers

Why should we care about social media?

• More than 40% of consumers say that information found via social media affects the way they deal with their health

• Health care professionals have an obligation to create educational content to be shared across social media that will help accurately inform consumers about health related issues and out shine misleading information

Who’s All Involved?

• 31% of health care professionals use social media for professional networking.

• 26% of all hospitals in the US participate in social media.

• 60 Million Americans exchanged their medical experiences online with each other last year.

• Almost 72 % of patients searched for online information before or after a doctor visit.

• 890 hospitals in the US used social media to engage with their patients

• An estimated 500 million people worldwide are expected to be using mobile healthcare applications by 2015. (Source: Reasearch2Guidance, November 2010)

• There were nearly 17,000 health apps available in major app stores in November 2010, with 57% of them being aimed at consumers rather than healthcare professionals.

• The heaviest use of health or medical related apps is by young adults: about 15% of those aged 18 to 29

What is the Social Media Impact?

•Patients are becoming increasingly more social, and healthcare professionals are using different online tools to reach and educate them.

•Patients are free to publicize their medical condition or experience with a provider

27

Social Media and HIPAA“We already have guidelines; social media is simply another form of communication. It’s no different from e‐mail or talking to someone in an elevator,” Bennett said.

“The safe advice is to assume anything you put out on a social media site has the potential to be public.”

http://ebennett.org/hsnl/ “Found in Cache” Social Media resources for health care professionals

HIPAA & Social Media

• The same rules regarding patient privacy in healthcare apply to social media as well.

• Any information that could potentially lead to the patient’s identity being exposed cannot be shared.

• HIPAA violations are taken seriously

• Get written or verbal consent to use pictures or information/testimonials

Social Media ground rules

Be likable

Be trustworthy

Be transparent

Be approachable

Create value

Brand Recognition

• Same logo, photo and images in all marketing and communications

• This includes the same image on the company website‐ Twitter, Faceboo, LinkedIn, Instagram etc

• Find a niche for your brand and refer to it constantly

• Content strategy is about brand awareness

17

18

28

Social Media workflow

• Create alerts to notify you via email when you have comments on your blog, FB, YT or Twitter

• Use analytics to help identify how people find you – what are the terms they are using to search?

• Be creative! Find ways to create content that is informative

• Post content

• Engage with your followers by responding to every comment‐ good and bad

Start The SM campaign

• Your website is the electronic center of your practice, your digital home, your virtual front desk

• Add one SM piece at a time, we suggest you start with a blog.

• Add a WordPress or Blogger blog to your existing site very easily. Make sure patients can comment on your blog (it’s a conversation!)

• As surgeons, we should love YouTube videos for surgeries but also utilizing Vlogs to introduce yoursellf and your partners in addition to answering questions. Self‐produced is better, more organic

One More Item to the List……

• Practice makes perfect, once you get into the flow, a rhythm will follow

• Have a contract worker help you or a employee a high school or college student

• Hire a ghost blogger for blogging content

• Use content from your professional society –always attribute.

• Find ways to use every piece of content three times: Blog, FB, IG in a different format

Benefits of social media

• Introduce new providers/partners and services quickly

• Greatly reduces marketing costs

• Use in communication about changes in practice and about problems, leading to greater customer retention

• Greater market influence and brand awareness

• Allows marketing of products and services

Start the buzz now!

• Twitter #hashtags:

• #AAGL2015

• #healthcare

• #minimallyinvasivesurgery

• #herviewpoint

• #changethecycle

29

Complication Management Outside the Operating Theater:

Limitations of Informed ConsentPatient‐Family Communication

Documentation

Ted L. Anderson, MD, PhD, FACOG, FACS

Betty and Lonnie S. Burnett Professor Vice Chair for Gynecology

Vanderbilt University Medical CenterNashville, TN


• How to Consent and How to Document

• Disclosure of a Complication to a Patient

• Personal Stress Related to Complications

• Medico‐Legal Aspects – Managing a Malpractice Claim

A Land of Risk

• Potential for things to go wrong

• Opportunity for injury

• “Damage control” should begin before the procedure

• Ongoing process requiring transparent communication

Informed Consent

• Process, not a form

• Dynamic relationship

• Mutual trust

• Realistic

• Transparent

• Ethical principles

Patient Autonomy?

Just because the patient wants it:•doesn’t mean it is appropriate

•doesn’t mean YOU have to do it

•autonomy ≠ pa ent demand

30

Patient Autonomy?

Just because the patient wants it:•doesn’t mean it is not appropriate

•doesn’t mean YOUR way is better

•Paternalism is not the answer

Informed Consent

• Autonomy

• Recognizes right of patient to make informed decisions

• Not to be confused with procedures on demand

• Beneficence

• Actions that serve the best interest of patients

• Not to be confused with paternalism

• Non‐maleficence

• "first, do no harm," or the Latin, primum non nocere.

• More important not to harm patient, than to do them good

Balance

Do you want fries with that?

Recognizes the right to self‐determination

Allows informed decisions about personal matters

…but I’m not going to let you do something stupid

Documenting Informed Consent

• Patient’s medical condition

• Proposed procedure(s) and purpose(s)

• Alternative treatments, including non‐treatment

• Comparative risks and benefits involved

• Downstream consequences

• Complications and sequelae

• Recovery

• Expected outcomes

• Document! Document! Document!

Disclosure of Complications

• When the unexpected happens

• Take responsibility

• Do not be defensive (or offensive)

• Escalate communications

• Plan / corrections moving forward

Disclosure of Complications

Be Available

31

Disclosure of a Complication

• Apologize (be precise)

• When & where error occurred

• Causes, results of harm

• Actions to be taken to reduce gravity

• Actions to be taken to reduce / prevent recurrence

• Keep it simple; grand gestures not necessary

Content‐Related Issues Looking Back:

Pichert JW, Hickson GB, Vincent C: “Communicating About Unexpected Outcomes and Errors.” In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, Hillsdale, NJ: Erlbaum Associates, 2007

Effective Apology (…and ineffective)• I’m sorry ….. (just say it)

• Sincere body language, tone of voice

• Follow through with anything promised

• Beware of:

• The “sorry, but…” apology

• The “sorry you feel…” apology

• The “sorry for my sorry colleagues…” apology

• Any apology with failure to follow through

• Narcissistic apology (“…this is so tough on me…”)

• Patients may be more willing to forgive

• Family/ friends may doubt your sincerity

Disclosure of a Complication

• Who will manage ongoing care• you or someone else (…pt’s choice)

• Describe error review process• reports to regulatory agencies

• how systems issues are identified

• Provide contact info for ongoing communications

• Offer counseling, support if needed

• Address bills for additional care

Issues Looking Forward:

Pichert JW, Hickson GB, Vincent C: “Communicating About Unexpected Outcomes and Errors.” In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, Hillsdale, NJ: Erlbaum Associates, 2007

Financial Consequences

• Do you know all the facts?

• Do you really want to handle this issue for the medical center?

• Do you have authority to make a promise?

• When in doubt, “You raised an important issue… I am not authorized, but will get review…for now, let’s focus on taking care of you/your loved one…”

Disclosure Strategies Balance Beam

Hickson GB, Pichert JW. Disclosure and Apology. [Developed by the Vanderbilt University Center for Patient and Professional Advocacy for the National Patient Safety Foundation, 2007] In: National Patient Safety Foundation Stand Up for Patient Safety Resource Guide. North Adams, MA: National Patient Safety Foundation; 2008;

Pichert JW, Hickson GB, Vincent C. Communicating about unexpected outcomes and errors. In: Carayon P, ed. Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety. Hillsdale, NJ: Erlbaum Associates; 2007, 2nd Edition 2012.

In cases of Uncertainty

Disclose error, assign

responsibility

Fully Disclose error right

away

Facts, limited disclosure, more later

No disclosure / “safe” facts

Principles to Handle the Unexpected• Listen carefully; remain calm, professional (position)

• Ask questions to learn reasons for behavior

• Remain confident in known facts, stick to message

• Understand flooding, when to call time out

• Be ready to handle anger

32

When Pt / Family reacts Angrily

• Anticipate

• Avoid defensiveness (challenging!)

• Consider possible sources of anger

• Acknowledge patient/family’s anger

• Use empathetic statements

• Avoid making excuses, blaming

• If the data are clear, stick to the message (kindly)

• If data are not clear‐cut, offer a referral for a second opinion, or suggest that a second opinion from another physician might be useful

When Pt / Family reacts Angrily

• Use calm, soft voice

• If they make angry assertions with which you disagree, kindly but firmly tell them it is okay for you and them to disagree

• May have to call time out

Personal Stress of Complications Recognize Triggers/Symptoms

Emotional Flooding and What To Do About It.

http://portlandrelationshipinstitute.com/Artcl__Emotional_Flooding.html

• Fight, flight, or freeze reaction

• Many feel intense fear, anxiety and/or rage

• Causes a feeling of “system overload, swamped by distress and upset”

• Changes in heart rate, respiration, sweating, voice

• Controlled expression, chin tightens, set jaw

• Thinking becomes difficult

Personal Stress of Complications

Waterman, et al. Jt Comm J Qual Pt Safety, 2007:33:467‐76. Wu, Albert. Medical Error: The second victim: The doctor who makes the mistake needs help too. BMJ. 2000;320:726‐7.

• Increased anxiety about future errors (61‐96%)

• Fear of punishment (50%)

• Loss of confidence (in self or system) (44‐93%)

• Sleeping difficulties (42‐54%)

• Reduced job satisfaction (42%)

• Harm to reputation (13%)

Important to prevent if possible and know how to cope if/when…

24


33

Predictors of Impact of Medical Error

Engel KG, Rosenthal M, Sutcliffe KM. Residents’ responses to medical error: coping, learning, and change. Acad Med. 2006;81:86-93.

• Patient outcome • The more severe the morbidity the greater the impact

• Degree of personal responsibility• The more responsible, the more damaging the error

25Engel KG, et al. Acad Med. 2006;81:86-93.

• Ultimate Impact• Leave medical profession• Suicide

Nurse's suicide highlights twin tragedies of medical errors –

Kimberly Hyatt killed herself after overdosing a baby, revealing the anguish of

caregivers who make mistakes


• Peers with listening and supportive skills (not counselors)

• Strictly confidential

• Focus: “second victim’s” emotional response (not event details)

• Safe zone of supportive intervention

26

• General awareness about second victim vulnerabilities

• Healthcare leaders & peers are “safety nets”

• Internal rapid response team

• Immediate “emotional first aid”

• Effective “second victim” healing and restoration

Litigation

• MIS “ripe” for litigation (ranks 3rd in reasons)• High level of technology and skill involved

• High level of expectations

• Contributing Categories• Errors in clinical judgment (77%)

• Miscommunications (36%)

• Technical errors (26%)

• Inadequate documentation (26%)

• Administrative failures (23%)

Medico‐Legal System

Definition of Lawyer

a member of a profession

whose sole responsibility

is to protect clients

from other members of the

profession

Medico‐Legal System

34

Medico‐Legal System Signs of a Potential Lawsuit

• Complication has occurred

• Dissatisfaction with outcome

• Request for records

• Failure to keep follow‐up visits

• Failure to pay bills

Often not so much about event as it is:

• Breakdown in communication

• Breakdown in trust

• Perception of caring relationship

Factors Affecting Outcome

• Evidence (missing or inadequate documentation)• NEVER change the record

• Experts (plaintiff vs defense)• Credibility, availability

• Decision of review panel

• Verdict potential (amount and chances of getting it)• May or may not be related to actual damages

• Cost to settle vs try case• You may not have a choice in this

• Personality factors• Mostly yours

Medico‐Legal Process• The investigation

• Injury occurred, cause and effect

• The complaint• Designed to make you seem careless and incompetent

• Discovery• Records, depositions (parties, witnesses, experts)

• Negotiations and settlement• Overwhelming number of cases end here

• Dropped (56%)

• Summary judgment, arbitration, settled (26.6%)

• Trial preparation and trial (14.8%)• Majority of cases tried decided for DEFENSE

Recognizing Source of Stress• You set high expectations & demand best effort

• You are hardworking and conscientious

• You are somewhat compulsive in attention to detail

• You are directive and like to be in charge

• Worked hard and sacrificed to gain your skills, proud of accomplishments

• Lawsuit represents a challenge to competence, integrity & self‐concept

• Feel you have been labeled as a bad doctor

• Worry that everything you have worked for is at risk

• Medicine is collegial

• Legal system is adversarial

• Medicine values promptness and rapid resolution of problems

• Delays are an unavoidable element of the legal system

Coping with Litigation

• What are your priorities?• Does the way you spend your time and energy match?

• Did case identify areas in which you could improve?• Strengthening documentation or informed consent process?

• Interpersonal relationships?

• Perspective with the rest of your professional life• Identify strengths and accomplishments

• Value who you are , not just what you do

• Work to overcome negative attitudes developed• Patients, practice, profession

• Get counseling if necessary

35

It all boils down to communication and documentation

Complication Management Outside the Operating Theater:

36

ASSOCIATION OF AMERICAN MEDICAL COLLEGES

Managing Conflictin the Workplace

11/16/15

Janet Bickel, MACareer and Leadership Development Coach


“I have no financial relationships to disclose.”

Janet Bickel, MALeadership and Career Development Coach

Objectives

Participants will build skills in:

• Becoming more versatile in handling conflicts and differences

• Raising difficult issues with patients, co-workers and personnel

• Soliciting feedback from colleagues

Please Assess Yourself:

*Am I becoming more versatile in communicating with individuals very different from myself?

*Am I getting better at maintaining my equanimity in challenging situations and when I feel devalued?

*Are my understanding of my organization and how to have influence within it becoming more sophisticated?

*Am I continuing to develop a more accurate sense of my strengths and weaknesses?


(many) (blood sucking parasites)

Organizational POLI - TICS

37

*reframe “conflict” as “differing interests”

*see disagreements as opportunities to learn

*question your own assumptions and storylines

*recognize tendencies to overemphasize interpersonal dimensions

*move beyond your “default” to become more versatile

How do we become more skilled at handling conflict? CONFLICT MANAGEMENT STYLESRELATIONAL

CONCERN

Concern for self-interest

Harmonize/

Accommodate

Collaborate

Avoid Compete/

Direct

Source: Thomas-Kilmann Conflict Mode Instrument

Compromise


Your Brilliant Career Trajectory?


Relational Communications Skills • Self-monitoring

- Notice when you're over-reacting- Pause and ask “what hooked me?”

• Inquiry and Listening- Ask questions that encourage the other to reveal more - Listen “generatively”

• Expressing Views/Advocating • Explain your reasoning and intent [eg “This is why I’m

raising this and how I arrived at this conclusion”]


Automatic Listening

•Right/Wrong

•Win/Lose

•Agree/Disagree

•Good/Bad

•Either/Or

Generative Listening

•What could make that possible?

•What could that allow us to do?

•What goals could that idea advance?

•What do you see that I don’t?

•Say more

Raising difficult issues

In preparation ask yourself:

*What are my goals for this conversation?

*What would I most like to communicate?

*What strategy seems likely to prevent defensiveness?

Examples of openers: --“Because our relationship is important, I need to raise what feels like a difficult issue … How do you see this?”

--”Our last interaction left me feeling uncomfortable—I'd appreciate knowing your take on it.”

38


In pairs

Use this opportunity to prepare for handling a conflict you've been avoiding.

--What's at stake if you don't speak up?

--What are your goals in this conversation?


OPEN Blind

Hidden Unknown

Known to self Not known to self

Known to others

Not known to others

Johari Window


Ask trustworthy colleagues for feedback

*In what areas do I tend to over-function?under-function?

Any observations on how well I listen?

Do I present ideas in an effective manner and invite discussion?

How well do I handle challenges to my ideas?

*Do I communicate about problems in ways that facilitate engagement?

*Do I relate better to some kinds of people than others?

See: What got you here won’t get you there by Marshall Goldsmith

Observations about Feedback

*Female employees receive more negative feedback than male employees, and 76% of the negative feedback given to women (vs 2% to men) was ”personal”, eg “abrasive” or “strident.”

*Powerful women received the most inappropriately personal criticism.

*Feedback provides information about others' points of view and offers insights into those you want to influence and engage.

Advice:*Any substantive work draws criticism, so be prepared for

criticism, and persevere

*Learn from those who handle criticism well


Your Brilliant Career Trajectory?


*Build your capacity for competition and complexity

*Differentiate between what you can and cannot influence

*Ask more questions and listen with curiosity

*Study how people interpret their roles

*Discover and build on shared commitments

*Reflect on and learn from surprises and feedback

Closing Recommendations

39

REFERENCESGoldsmith M. What got you here won’t get you there, 2007.Goulston M. Just Listen: Discover the Secret to Getting Through to

Absolutely Anyone. AMACOM, 2010.

Isaacs W. Dialogue and the art of thinking together, Random house, 1999.

Ogunyemi D, et al. The Associations Between Residents' Behavior and the Thomas-Kilmann Conflict MODE Instrument. J Grad Med Educ. 2010 Mar; 2(1): 118–125.

Patterson K, et al. Crucial confrontations: tools for resolving broken promises, violated expectations and bad behavior. McGraw Hill, 2005.

Schein EH. Humble Inquiry: The Gentle Art of Asking instead of Telling. BK, 2013.

Stone D, Heen S. Thanks for the feedback: The science and art of receiving feedback well. Viking, 2014.

40


Gender-Related Issues in Medical Training

11/16/15



“I have no financial relationships to disclose.”


Objectives

Participants will build skills in:

• Understanding the gender issues that continue

to hamper women physicians' development

• Mentoring women to achieve their potentials

• Discussing power- and gender-related issues


Women's Cumulative Career Disadvantages

*Most cultures remain conflicted about how much agency and authority to allow women, eg still expected to defer to men

*Receive more negative feedback than men do

*Less likely to be effectively mentored, sponsored

*Less alignment between their values/responsibilities and organizational demands

*“Tiara Syndrome”: the fantasy that good work will be praised and rewarded

*Women under-estimate their own abilities, eg apply for jobs only if they meet 100% of criteria (for men 60% usually suffices)

What are we learning?

* Young women expect equity, remaining unprepared to handle continuing disadvantages and “double standards”

* A focus on gender can polarize rather than illuminate

• Achieving success appears to reduce women's capacity to see gender discrimination

* What look like “women’s issues” are system-level problems

He’s confident

He’s analytic

He’s authoritative

He’s good at details

He’s open

He follows through

He’s passionate

They’re networking

They’re debating

She’s conceited

She’s cold

She’s bossy

She’s picky

She’s unsure

She doesn’t know when to quit

She’s a control freak

They’re chitchatting

They’re catfighting

41

Cognitive shortcuts are built into the brain

-Our mindset largely determines what we notice

- We ignore evidence contradicting our assumptions and “cherry pick” data that confirms our opinions.

-We over-estimate what we know about others and the extent to which others agree with us.

NB: Perceptual bias is most likely to occur when evaluators are under time pressure and when they lack specific decision-making criteria

See: D Kahneman's Thinking Fast and Slow

What can women do to be perceived as both strong and “likeable”?

*hold themselves to high standards of behavior

*never diminish themselves or others

*focus on shared goals and common missions

*become a versatile and relational communicator

*keep expanding their network


To excel as mentors of women:

--be prepared to bolster a mentee's belief that she can achieve big goals.

--watch for opportunities to coach women to respond ”I can do this” rather than ”I'm not ready”

--assist women to expand their professional networks and recommend great role models

--nominate women for growth-promoting opportunities

--if a woman does not take full advantage of an offer of professional support, rather than giving up on her, keep the door open

--What gender-related issues are you most aware of in the workplace?

--How are you handling these?


*Anticipate the types of tough issues likely to arise

*How might you tap into the other person's values and commitments?

*Any questions you can ask that might help the other think in a new way?

*Conduct a risk/benefit analysis, i.e. what's at stake if you do/don't speak up?

*Stay curious

*Keep building relational communication skills

[See: M. E. Dankoski, J. Bickel, and M. E. Gusic. Discussing the Undiscussable

with the Powerful. Acad Med. 2014; 89:1610-13].

To Become Adept with Power-related Issues


“Difficult” Conversations• the “what happened” conversation:

We only know OUR version of what happened

• the “feelings” conversation:Deal with emotions or nothing will be satisfactorily resolved

• the “identity” conversation:What does the situation imply about our competency, integrity etc?

Source: Douglas Stone, Difficult Conversations: How to discuss what matters most. Penguin, 1999.

42


In pairs

Use this opportunity to prepare for a conversation you've been postponing.

--What's at stake if you don't speak up?

--What are your goals in this conversation?


Increasing your Organizational Effectiveness

REFERENCESBabcock L. Women don’t ask: negotiation and the gender divide. Princeton U Press, 2003.

Babaria P, Abedin S, Nunez-Smith M. The effect of gender on the clinical clerkship experiences offemale medical students: results from a qualitative study. Acad Med. 2009;84: 859-66.

Bickel J. How men can excel as mentors of women. Acad Med. 2014; 89:1100-02.

Bickel J. Why do women hamper other women? Journal of Women's Health. 2014; 23: 265-67.

Burgess DJ, Joseph A, van Ryn M, Carnes M. Does Stereotype Threat Affect Women in Academic Medicine? Academic Medicine. 2012; 86:506-12.

Carnes M. Deconstructing gender differences. Academic Medicine. 2010; 85:575-577.

Dankoski ME, Bickel J, Gusic ME. Discussing the Undiscussable with the Powerful. Acad Med. 2014; 89:1610-13.

Ibarra H, Ely R, Kolb D. Women Rising: The unseen barriers. Harv Bus Rev. 2013; 91: 61-66.

Kahneman D. Thinking Fast and Slow, 2013.

Sandberg S. Lean In: Women, Work, and the Will to Lead, 2013.

Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss what Matters Most. 1999.

43

Maximizing Your Financial Return

K. Warren Volker, MD, PhD

Disclosure


I. Coding and billing pearls: Need to know for ICD‐10 and the ACA age.

Why. . .ACA (Affordable Care Act)

. . .What does it mean to you?

Affordable Care Act passes

November 7, 2009

44

Healthcare Reform

The Affordable Care Act – In March 2010, Congress passed and the President

signed into law the Affordable Care Act, which puts in place comprehensive health insurance reforms that will hold insurance companies accountable, lower costs, guarantee

choice, and enhance quality health care for all Americans.

www.whitehouse.gov/healthreform/timeline

It Passed, Now what?

www.healthcare.gov

Facilitate the purchase and sale of qualified health plans

Provide for the establishment of a program to assist qualified small employers in facilitating the enrollment of their employees in qualified health plans

Make only qualified health plans available to qualified individuals and qualified small employers on or after January 1, 2014

Health Insurance Exchanges

Plans sign‐up October, 2013Plans go live January 1, 2014

. . . Consumerism of the Healthcare Dollar

Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified to reflect the quality of care they provide so that providers who provide higher value care will receive higher payments than those who provide lower quality care. Effective January 1, 2015

2015 Quality‐Based Reimbursement Becomes a Reality

ICD 10 becomes a reality

45

Went Live October 1, 2015

It’s a State of Mind

History of ICD‐9‐CM

• World Health Organization (WHO) developed ICD‐9 for use worldwide

• U.S. developed clinical modification (ICD‐9‐CM) Implemented in 1979 in U.S.

• Expanded number of diagnosis codes

• Developed procedure coding system

ICD‐9‐CM

• ICD‐9‐CM Diagnoses –used by all types of providers

• ICD‐9‐CM Procedures –used only by inpatient hospitals

• Current Procedural Terminology (CPT) –used for all ambulatory and physician procedure reporting

ICD‐9‐CM is Outdated

• 30 years old –technology has changed

• Many categories full

• Not descriptive enough

Reimbursement and Quality Problems With ICD‐9 vs ICD‐10

– Example –fracture of wrist Patient fractures left wrist A month later, fractures right wrist

– ICD‐9‐CM does not identify left versus right –requires additional documentation

– ICD‐10‐CM describes Left versus right

– Initial encounter, subsequent encounter

– Routine healing, delayed healing, nonunion, or malunion

46

Benefits of Adopting the New Coding System

• Incorporates much greater specificity and clinical information, which results in Improved ability to measure health care services

• Increased sensitivity when refining grouping and reimbursement methodologies

• Enhanced ability to conduct public health surveillance

• Decreased need to include supporting documentation with claims

Some Resourcesfor ICD ‐10 New Coding System

• General ICD‐10 information

• http://www.cdc.gov/nchs/icd.htm

• ICD‐10‐CM files, information and general equivalenmappings between

• ICD‐10‐CM and ICD‐9‐CM

• http://www.cdc.gov/nchs/icd/icd10cm.htm

II. RVU versus other reimbursement schemes.The Compensation Game

Compensation Models

Depend upon how you are contracted

Relative value units (RVUs) ‐ are a measure of value used in the United States Medicare reimbursement formula for physician services. RVUs are a part of the resource‐based relative value scale (RBRVS)

Salary – less common in surgical specialties, fixed income, military, IHS, Federal Clinics

Performance Based – usually combination of salary with bonus

Risk Based – usually higher income model, “eat what you kill”

Value‐Based – future of compensation

Compensation ModelsRange of Income varies:

Nine of the 15 surveys reported average OB‐GYN salaries of between $270,000 and $300,000 per year. For example, the study by staffing firm Merritt Hawkins reported an average OB‐GYN salary of $282,000 per year. The lowest reported salary in that survey was $220,000 per year, while the highest was $360,000

work.chron.com/average‐obgyn‐salary‐6923.html

47

Comparative Income for Urologists

work.chron.com/salaries‐urology‐specialists‐2671.html

Urologists reported average earnings of $305,000, according to a 2012 survey. Sixteen percent of the doctors who responded to the survey reported earnings between $300,000and $349,999, while 14 percent earn more than $500,000annually.

Current and Future Income Expectations

You are running a marathon – not a race

Practice Models

Private PracticePHO (Physician Hospital Organization)ACO (Accountable Care Organization)Insurance Based & SponsoredGovernment EmploymentMilitaryAcademicNon‐profit Federally Funded Medicaid ClinicsIntegrated Health Systems ***I’m in this model

III. Office management and OR cost containment. OR cost containment.

Journal of Clinical Anesthesia (2010) 22, 233–236

Editorial

What does one minute of operating room time cost?

IV. Personal finance pearls.

Handout Provided

Thank You!

48

Innovation and Intellectual Property

protecting your idea from conception to product release

Tony Shibley M.D.

Fairview Health System

• Consultant: Olympus

• Royalty: Advanced Surgical

• Generating ideas and taking them to the next level

• Principles of Patents

• Collaboration, funding and maximizing interaction with industry

Innovation in Surgery

• Successful innovation in surgery is a collaboration between research, industry and physicians utilizing a cluster of new technologies to advance care.

• Innovation can be “disruptive” or “sustaining”

• Continuous innovation is the foundation upon which surgery has and continues to progress.

• Intellectual Property Law protects this process

Intellectual Property Lifecycle

• Idea Formation

• Protect and Patent

• Product production

• FDA Approval

• Sales and Marketing

Idea Formation

• Ideas find you if you are paying attention

• "Mater Artium Necessitas"

• Don’t assume that it has been done before

• No one is better prepared to problem solve than you!!

49

“People tell you not to take any chances and there aren’t any answers… but when I see

the signs I jump on that lightning bolt”--Jake Bugg

• AHA Moment - A moment of sudden realization, inspiration, insight, recognition, or comprehension

Perseverance

• Seize the moment

• Investigate- patent search at USPTO.gov

Protect Your Idea

• Describe your invention in great detail on paper in a bound notebook with numbered pages. Include detailed drawings.

• Do not share your idea without a nondisclosure agreement.

• Find a lawyer who specializes in patents and intellectual property.

To get an Effective Patent Colloborate!!!!

• “Stay in your lane” Get expert legal advice!

• This is not like doing your own taxes.

• Would you defend yourself in a malpractice case?

Non-Disclosure agreement

• Also known as a Confidentiality agreement

• Nondisclosure Agreement (NDA) is first line of defense in protecting confidential data, inventions and trade secrets

50

What Exactly is a Patent?

• A patent for an invention is the grant of a property right to the inventor, issued by the United States Patent and Trademark Office.

• Right to exclude others

A Patent is Not

• A license to practice the invention

• Enforceable by the government

US Pat. 6293874 B1

• Novelty

• Non-obviousness

• File first

• Formal requirements*

• Patent types*

Patent Requirements

What Qualifies as Patentable?

• Any person who “invents or discovers any new and useful process, machine, manufacture, or composition of matter, or any new and useful improvement thereof, may obtain a patent”

Utility (US6490999 B1)

Plant Patents (US20120311744 A1)

Design(USD590868 S1)

Patent Types

51

The America Invents Act - AIA

• Full name: Leahy-Smith America Invents Act• Signed into law on September 16, 2011• Possibly the most significant change to US

patent law since 1836• Changed the law from “first to invent” to “first

to file”• The most consequential provisions went into

effect on March 16, 2013

19

Old U.S. First-to-Invent System• The act of invention was divided into two parts:

– Conception – the formation of the inventive concept in the mind of the inventor; and

– Reduction to practice – the actual performance and testing of the invention or filing of a patent application.

• Enabled one who conceived earlier but filed a patent application later than another to sometimes prevail in getting a patent.

• Contained a liberal one-year grace period for an inventor to file a patent application after public disclosure of the invention.

20

AIA First-Inventor-to-File System

• Generally, the first person to file a patent application is entitled to the patent rights.

21

Filing for Patents

• “First to file”

• Provisional patent application

• Non- Provisional Patent application becomes the published patent

Best Practices Under the AIA

23

• Always File First!!!

• Consider the AIA as a strict First to File System

• Avoid “publishing ahead” wherever possible

• File a patent application before disclosing anywhere whenever possible

• File as early in the development process as possible

• Evolving String Provisional Filings

• One way to improve your odds of getting an “Effective Filing Date”

Sources of Finance and Support

• Business Angels

• Venture Capitalist

• Medical Companies and Multinationals

• Research and Development Companies

• Government- Grant or Small Bus loan

• Crowdfunding

* Universities

You need a management team behind project,

They won’t give funds to a surgeon.

Often steal ideas and never develop

Probably the best way to go.

Often quite good.

Pain in the ***.

Unproven

52

Key Points in Increasing Value

Concept File a Patent

Application

Conduct a very wide

patent search

Proof of Principal

Approved Patent

Manufactured Product

Working Prototype

RegulatoryApproval

(FDA)

Get Distributors

Achieve Sales

Targets

Free

$ Free $$

$$$Free$$$$$$$

In Summary

• Refine and document your idea

• Investigate for originality

• Get a patent attorney

• Get a developemt partner to raise valuation and maximize opportunities

Idea Finished Product

• United States Patent and Trademark Office. N.p., 1 Dec. 1994. Web. 24 Aug. 2015.

• "Financial Funding for Inventions." Financial Funding for Inventions. N.p., 13 Nov. 2012. Web. 26 Aug. 2015.

• http://www.wired.com/2013/03/america-invents-act/

• http://www.uspto.gov/aia_implementation/bills-112hr1249enr.pdf

• Advanced Surgical Concepts. Pneumoliner. Digital image. N.p., 10 Oct. 2014. Web. 26 Aug. 2015

• "Patterson Thuente Pedersen, P.A.| Minneapolis Patent & IP Law Firm." Patterson Thuente. N.p., n.d. Web. 23 Aug. 2015.

53

Surgical Video Tutorial: Tools to Create a High-Impact Video Presentation

Matthew Siedhoff, MD MSCR

Minimally Invasive Gynecologic Surgery, DirectorFellowship in MIGS, Director

University of North Carolina at Chapel Hill

• Other: Received small amount of money to train new sales representatives. I also gave a talk on gynecologic anatomy and laparoscopy: Teleflex

•“Why” : Understand the uses and value of surgical videos in education and career advancement

•“What”: Recognize the types of surgical footage that are effective for various types of instruction

•“Where”: Learn the venues where video can be used as an extension of your academic and clinical practice

•“How” : Know the factors which create effective video presentations in different settings and the principles of basic surgical video editing

Why Video?

Education: others and your own

Career advancement

Why Video?

• ‐How we learn in surgery

– Try something reasonable and it works

– Try something reasonable and it doesn’t work

– Learn from what others have learned

• Surgical learning is both practice and observation

Why Video?

• Surgical success is in the details, the “tips and tricks”

– E.g. ovarian suspension during endometriosis resection, internal iliac ligation in myomectomy

• Laparoscopy is ideal for broad dissemination of technique

54

Why Video?

• Watching others’ videos

– Incorporate new techniques once you have core skills (“I can do that!”)

– Remind yourself the steps of an uncommon procedure or you haven’t done in a while (e.g. presacral neurectomy)

– Perform procedures you’ve never done before (e.g. laparoscopic cerclage)

Why Video?

• Displaying your own videos

– Enhancing talks

• There is medicine in what we do and a cognitive aspect to our practice, but we are primarily a procedure‐driven specialty—what better way to learn than by seeing?

• Even if the primary aspect isn’t technique, can still provide context and engage the audience

• Improve understanding for non‐GYN audiences

Why Video?

• Learning by seeing – e.g. driving needle through tissue:

• Right the needle (A‐B‐C)• Pronate wrist• Penetrate perpendicular to tissue• Supinate wrist• Grasp point B with left hand• Follow the curve of the needle out of

the tissue• Grasp point C with right hand

Right needle(A-B-C)

Pronate wrist“Rainbow”

Penetrate perpendicular to

tissue

Supinate wrist“Smile”

Grasp point B: Lt HandFollow curve of needle out

Grasp Point C: Rt Hand

B

C

Why Video?

• Displaying your own videos

– Critique yourself (sports reel)

– Enhance your CV with talks, abstracts and video articles

– Show others what you can do

55

What Videos?

• Rare interesting cases

• Illustrative cases

• Demonstration of relative anatomy

• How to get yourself “un‐stuck"

• Complications

– How they can occur

– How to manage them

Where to use your videos?

• Talks

• SurgeryU

• Journals

– JMIG video articles

• Abstract videos

– AAGL Global Congress

• Your own website, YouTube, etc.

• AAGL EndoExchange listserv

How to use your videos?

• Basics

– Turn on the video anytime you think something might be interesting or record every case

– Take the video off the tower immediately after the case

– Have a good organization system


• Talks

– Talk through what’s happening, orient the viewer over and over

– You don’t have to show every step of the operation

– Narrate like a sportscaster

– Pause if needed

– Be careful about embedding

– Present off your laptop


• Formal video publication

– Create a storyboard

– Intro slides (don’t have to read to people)

– Best videos use multiple cases, highlight anatomy,

– Don’t use music

– Write a script and speak clearly

Let’s Practice

• Editing basics

– Accelerate

– Fade transitions

– Freeze frames and slides

56

Data collection in 2015: Creating a database for quality

improvement and research

Sarah L. Cohen MD MPH

Division of Minimally Invasive Gynecologic SurgeryBrigham and Women’s Hospital


1. Understand impact of database research

2. Be able to organize your data

3. Learn how to answer your research question

4. Know where to go for support

Why collect data?• Learn your own outcomes

– Patient counseling

– Self improvement

• Research purposes

– Analyze outcomes relative to patient‐specific factors or intervention

Examples of studies you can do with a database

• Study trends

– Frequency of robotic or LSC surgery?

• Effect of intervention

– Suture type on cuff dehiscence?

• Survey or follow‐up studies

– Pregnancy, sexual quality of life after surgery?

• Health care disparity

– Who is getting what intervention?

Database Research

• Are these types of studies “poor quality?”

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Utility of Database Research

– As a first step

• Gather data for future work

• Better define the problem

– When not feasible to perform randomized or controlled experiment

• Rare outcomes

• Ethical concerns

• Logistics – time/cost

Levels of Evidence: What can we do with a database?

– Case studies, series of rare events

– Case:Control

– Retrospective or prospective cohort

Cohort studies get a bad wrap Examples of Cohort Studies

Well designed cohort study is better than a poorly designed RCT

• Can control for many design issues in analysis stage

– Baseline differences

– Can not control for unknown confounders (randomization helps with this)

Limitations of Cohort Studies

• Incomplete or inaccurate information on pertinent variables

• Records not designed for the question at hand

• Loss to follow‐up

*These issues may be differential between groups under study

58

Getting started: Choose your Research Question

• Think about your patient population, procedures, what sorts of studies may you want to do?

• Peruse the literature, attend meetings – what topics seem pertinent, need more data?

Getting started: Study Design

• Define patient population

– Source of patients

– All patients who have X procedure or condition

• Inclusion/Exclusion criteria

• Prospective or Retrospective?

– Prospective: more time and labor intensive, may have better variable collection

Getting started: Study Approval

• Most every study needs IRB approval

– Even retrospective data

– Often expedited

– Need to document indication for data collection and the reason why it is not necessary to obtain patient consent to use their medical records

Need IRB help?

• Contact your institution’s IRB administrators

• Good clinical practice (GCP)

– International standards for ethical human research

– Courses offered at many institutions

– Online resources

Finding your source patients

• Billing records

• EMR may have search functions

• OR/clinic schedules

–Check with others doing research, how are they finding cases?

Next: Start collecting information!

• Considerations:

– Variable inclusion,

• More is better but where do you draw the line?

– Definitions and clear instructions

– Preferred format for statisticians

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Variable inclusion

• Look at similar studies that are published

–How did they report outcomes

• Ex: complications, blood loss, OR time

–What variables were included

• Table 1: often lists baseline variables

Variable inclusion

• Demographics

– age, SES

• Baseline characteristics

– BMI, PMH/PSH

• Perioperative characteristics

• Other• Antibiotic, drug use (GnRH, Vaso)

• Suture/Energy type

• Surgeon training/volume

Data entry tools

• Microsoft Excel or Access

• REDCAP

– Web based, secure

– Can administer survey

– Can create database

– Useful for multi‐site projects

– Can query database

Reliable Data Entry• Get help!

– Estimate time to complete one patient record

– Premed or medical students – can advertise with their interest groups

– Volunteer or paid research assistant

Reliable Data Entry• Oversight:

– Audit random data to confirm correct definitions, performance

• Create key with clear, specific definitions

– What constitutes intraop, postop complications?

• Clavien Dindo scale

• Standards from similar literature

Formatting Data Entry: Tips

• Numeric values, with key (0, 1)

• How to denote missing information (.)

• Any complications, extreme outcomes

– include explanation note to make review easier

60

Cleaning the data

• Goal: find errors before running the analysis

– Sort data, look at all outliers, high/low values and complications

– Scan for errors

– Re‐read all op notes for major complications and your primary outcome measures

Working with your statistician

• Tell them what you want

– Helps them design analyses and choose correct tests

– Create an outline of your Tables, what variables you want and how you want to compare them

Working with your statistician

Table 1‐ baseline differences between groups, with or without test of significance

Table 2‐ primary outcomes between groups

Table 3 – regression analyses

Subgroup or descriptive analyses?

Finding Statistical Help

• Basic analyses can be done if you have background in biostatistics/epidemiology

– For complex studies it can be very helpful to have an expert review – it is an art form!

• Anyone in your department/hospital doing research? Who do they work with?

• Local school of public health? Grad students interested

Where to find funding?

• Local grants: department, hospital

• National Organizations

• NIH

• Industry

Where to find funding?

• Database work can be low cost

• Budget your needs

– Epidemiologist, study design consult

– Data entry

– Statistical analyses

61

• USPSTF Levels of Evidence

• STROBE Guidelines

• Good Clinical Practice

• REDCAP

• ACOG Reading the Literaturehttp://www.acog.org/Resources‐And‐Publications/Department‐Publications/Reading‐the‐Medical‐Literature

• AAGL How to Publish

• Green Journal Guidelines for Authors

• Funding sources

– ACOG, NIH, industry

62

“TED Talk” Revolution: Lessons learned from the greatest (and shortest)

presentations ever given

Erin T. Carey, MD, MSCR

University of Kansas Medical Center


• Review errors with current presentation practices

• Highlight the components of a great lecture

• Review how to implement ‘TED’ skills into a medical presentation

Current Presentation Practices

• Transvaginal or endorectal ultrasonography may reveal:– Endometriomas– Internal echoes, solid masses– Requires a skilled radiologist and ultrasonographer to detect rectovaginal disease, deep

infiltrating disease

• Computed tomography (CT) scanning may reveal: – Endometriomas can appear as cystic masses– Appearances are often nonspecific

• Magnetic resonance imaging (MRI) may reveal:– Very small implants – Can distinguish the hemorrhagic signal of endometriotic lesions due to its very high spatial

resolution– Performs better than the CT scan in detecting between muscles and abdominal subcutaneous

tissues– Accurately detects rectovaginal disease and obliteration in >90% of cases when

ultrasonographic gel was inserted in the vagina and rectum– High specificity for endometriomas (high signal intensity on T1‐weighted images and low

signal intensity on T2‐weighted images)

Imaging modalities for deep infiltrating endometriosis

63

• Depending on the theory you buy into, different treatment options are recommended:

– Müllerian remnants “metaplastic theory”• May explain culdesac disease, uterosacral/broad ligaments as well as adolescents shortly after

menarche• Surgical excision of the remnant

• Coelomic metaplasia – Assumes substances released by the endometrium are transported by blood/lymph systems,

inducing endometriosis – Accounts for the extra‐pelvic sites of disease

• Retrograde menstruation “Sampson’s theory”– Implantation and metaplasia surgical excision and management of early disease– Sampson’s theory is based on the importance of progression but fails to explain why

progression to advanced disease occurs in only some women.

• Iron‐induced oxidative stress– Target HNF‐1β overexpression in endometriotic foci

• Stem cells– Adult progenitor stem responsible for the regenerative capacity– Hormonal/medical management

Pathogenesis matters

Death by text

64

– Establish the status quo

– Contrast to ‘what could be’

What message do you want your audience to hear?

• Slides should be prepared last

• It should not be the presenters notes

Slide consistency is important

• Make the slides appear as part of the same presentation

But not too consistent…

• Use different styles to transition topics

Less is more

65

Present a new idea or an old idea in a new way

Manage your time

• 45‐60 minutes are the average grand rounds presentation

• Break this up into two or three segments, fractionating your presentation into a few smaller ones with main ‘messages’

Practice Practice Practice End with a call to action!

Rossini Lucio G.B, Ribeiro Paulo A.A.G, Rodrigues Francisco C.M., Filippi Sheila S, Zago Rodrigo de R., Schneider Nutianne C, Okawa Luciano, Klug Wilmar A. Transrectal ultrasound ‐ Techniques and outcomes in the management of intestinal endometriosis. Endoscopic Ultrasound. 2012. Vol: 1 ; 1. Pages: 23‐35.

https://unknowntoexpert.com/public‐speaking/top‐5‐tedtalks‐give‐great‐ted‐talk/

http://blog.ted.com/10‐tips‐for‐better‐slide‐decks/

Duarte, Nancy. Slideology: The Art and Science of Creating Great Presentations. O'ReillyMedia, cop. 2008 1 vol. (274 p.) Sebastopol, CA.

When preparing a medical presentation:

• A. Tell personal stories to connect with the audience.

• B. Prepare the slides as the initial step in the presentation process.

• C. Use a high volume of text to communicate the message.

• D. Wing the presentation by preparing the morning it is due.

• E. Loosely adhere to time recommendations for an invited presentation.

66

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

67

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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