Apr 24, 2014
Structured program eases transition from training to practice
By Bahu S. Shaikh, MD, FACP, and Rex B. Mowat, MD, Toledo Clinic Cancer Centers
The practice of medicine continues to evolve rapidly, and a complex set of skills is required to keep up with the pace of change and perform well in the medical oncology private practice setting. This can be quite challenging and overwhelming for new physicians entering the field.
At the Toledo Clinic, we have developed a model for mentoring new physicians entering our practice, led by a senior physician within the group. This pilot project has the potential to be a successful model in launching the careers of future young physicians, streamline their training and speed up the transfer of knowledge required to increase physician efficiency, reduce stress, and improve quality and performance.
Simply put, mentoring helps physicians translate knowledge into wisdom and practice medicine more skillfully.
SIMPLE, STRUCTURED, CONSISTENT
Our program is structured around 12 discussion topics, which are eitherspecific to our practice or inconsistently taught in medical school and fellowship:
- Introduction and history of practice
- Billing and collection
- Hospital rounds and on-call duties
- Work efficiency
- Safety of chemotherapy
- Communication skills
- Continuing education
- Risk reduction
- Financial reports
- Clinical research
When a new physician joins our practice, he or she discusses these topics in detail during weekly face-to-face meetings with the senior physician mentor. The meetings last a minimum of one hour and continue until all topics are covered and the mentee feels comfortable with the information. The mentor identifies areas for further study and sets up meetings with various members of the health care team to facilitate further learning. We suggest that the mentor and mentee meet on a monthly basis thereafter, until the new physician is comfortable with his or her roles and responsibilities. We expect the mentor to be available during this period of time to answer questions as they arise and provide ongoing guidance.
To measure our progress and effectiveness, new physicians are asked to rate each mentoring session at its conclusion on a scale of 1 to 10 and are also encouraged to record any remarks and suggestions for further improvement.
We selected our 12 discussion topics to provide clarity about the new physician’s role and responsibilities, fill in knowledge gaps from oncology training, and affirm our practice’s commitment to high-quality care and patient safety. Every workplace has a shared set of values, unwritten rules, and expectations for job performance which can seem mysterious to new hires, no matter how comprehensive their training—an oncology practice is no exception. The discussions that take place in our mentoring program are meant to demystify our office culture, and are an excellent tool for communicating expectations for our new physicians in a clear and unambiguous way. Some areas which we particularly emphasize include:
» The importance of accurate and timely documentation essential for coding and billing services provided. We describe the appropriate documentation required for each level of service and the selection of the correct code for the level of service. We review the billing codes used for inpatient as well as outpatient oncology services. We also advise our physicians to be very wary of using drugs without J-codes as these may not be reimbursed in the office setting. We use major guidelines from organizations such as ASCO and the National Comprehensive Cancer Network (NCCN), as well as insurance pathways if available, for evidence-based guidance in planning treatment. We discuss the ideal progress notes for inpatient and outpatient settings and share examples of exemplary consultation reports. We emphasize the importance of discussing the differential diagnosis to justify the level of complexity of care provided and the level of service code used for billing.
» The importance of participating with our local Community Clinical Oncology Program (CCOP) to enroll patients on relevant clinical trials. We mentor our new physicians on cancer prevention, cancer control, and cancer screening trials, as these trials are important to our patients and community. We have also established programs to augment junior as well as senior physicians’ knowledge regarding all aspects of cancer care delivery research. It is our goal to groom our new physician partners to take on leadership positions and to lead all aspects of clinical research at local and national levels in the future.
» The importance of team-based patient care and excellent communication. Our new physicians are educated on the roles of the different health care team members, and are expected to apply a team-based approach to patient care as a matter of routine. Since the practice of medicine is also an art form, we encourage our physicians to learn from their mentors the best way to deal with nurses, hospital staff, consultants, colleagues, patients, and families. Team rounds are conducted with the patient’s nurse, as well as selected team members such as the social worker, dietitian, and clinical pharmacist. This results in decisions being made in a timely manner at the bedside so that the patient and family are included, which reduces follow-up phone calls to the doctor’s office during clinic hours. We integrate our nurse practitioners (NPs) into our routine on rounds to improve work efficiency and communications. We have a dedicated “triage nurse” on call during working hours to screen patient calls and decide about the urgency and location where the patient should receive the timeliest and appropriate care. We have a team of nurses who educate the patients regarding the side effects of chemotherapy. We also have specialized staff for billing and coding to review all new chemotherapy orders and ensure they comply with major guidelines and insurance pathways. During their mentoring sessions, new physicians learn how to delegate responsibilities to the appropriate team member and make the most of our team’s knowledge and expertise. We also guide mentees on how to work productively with primary care physicians and hospitals to reduce unnecessary admissions to the oncology service, so that we can preserve our time and resources for those patients that cannot do without our specialized service. Clear communication between the hospital and the office is very important for patients discharged from acute care, and these patients are seen by the oncologist prior to their next chemotherapy treatment.
» The importance of following procedures that streamline practice and enhance customer service. New physicians receive clear instruction on office procedures, expectations, and technology use. Physicians are expected to complete their hospital rounds in the morning and attend to their clinic patients in the afternoon. We discourage verbal orders and use preprinted orders for symptom management and for all chemotherapy orders. We use electronic devices in situations where they benefit patient care, and also for continuing education and informational updates. Consultations are expected to be done within 24 hours for routine consults and as soon as possible for others. Our physicians are expected to communicate with the referring doctor soon after seeing a new patient for consultation, and the consultation report is sent the very next day. We encourage getting a “second opinion” within our group or through an outside physician at a reputable institution. We have developed a list of specialized consultants close to our geographic area so that our patients can utilize their expertise on a timely basis. We discuss these resources and procedures during mentoring sessions, rather than on an ad hoc basis, so that our new physicians are fully prepared to perform their responsibilities at a high level.
AN INVESTMENT IN THE FUTURE OF CANCER CARE
The importance of mentoring for the future of the oncology field is undeniable in light of the expected major workforce shortage and increasing number of current and future patients and survivors in the coming years. Many oncology practices are already under strain, especially as older oncologists are leaving practice and retiring in large numbers. Their skills and experience will be lost forever unless we harness their knowledge and find a way to transfer it to the coming generation of oncology physicians.
Mentoring can also help new physicians to gain the skills, experience, and preparation they need to start their own practices, to ensure the continuation of excellent community cancer centers for our patients who depend on this care. We can teach new physicians how to manage the risks involved in running a practice and develop the necessary skills for such a complex endeavor.