This talk is on staying out of trouble, and I'm going to point out, first of all, that there are many pitfalls that you will encounter when you first go out and practice. I'm only going to cover the first two, personality clashes and online reputation, and I'll thank Judy for reminding me to put the first one in about personality clashes. Malpractice will be covered in depth tomorrow. I think we've just covered in relative depth. Kickback and Stark will cover elsewhere, and regulatory abuse is also covered in some of the other talks. So the first thing that I want to talk about is personality, and you are going to be entering into a very new world of employers when you take on your first job. Many of you will work for hospital administrators, for large group administrators, and no longer are most of you going to end up in a situation where there's maybe two or three or four where the people who are your bosses and your senior people and your supervisors are your neurosurgery colleagues. And so you are going to be working with different kinds of people who are going to be directing your day-to-day life on some level. As residents, you know, you may feel somewhat the heavy hand of your faculty and your chairs, but they're still neurosurgeons, and on many levels, they still think and approach patients and patient care and day-to-day life more like you than many of these other individuals who you're going to encounter. Most of these people have very different training than you do. Their training, some of them are going to be considerably younger than you, because to get a master's in public health or get a master's in MBA takes about a year or 18 months. Many of these people will have risen to high levels of influence, and they may be a decade younger than you. That is not an easy nut to swallow, okay? They have very different expectations. Your training, as some of our speakers, including Reg, is that ours is a calling. Many of us, you know, we may have said, okay, yeah, we can make a good living as a neurosurgeon, but we've gone into neurosurgery because we feel some level of passion about caring for patients and treating diseases such as brain tumors and pediatric hydrocephalus. Hospital administrators, large group administrators, they have gotten to where they are because they have a very different calling, okay? They have different expectations about your job. And one more thing is that they speak a very different language, okay? We talk about empathy and diseases and curing and helping and quality of life, and they are talking about contribution to margin, length of stay, acuity index, bottom line, you know, Excel spreadsheets and things like that. So the language that they speak is very, very different. I mean, to the point that when you admit a patient to the hospital or care for a patient, your work is in the realm of ICD-9s, which are what your diagnosis is, and CPTs, which is what you bill for the procedure. The hospital talks DRGs. And the DRG system, which is what the hospital gets reimbursed on, is not a parallel system to either of the systems that you probably don't know how to use yet but will know how to use. So their entire language is very different. If you don't think that this is a potential pitfall, the first day you walk on the job and every day after that, then you don't have your eyes open, so please open them now. So the rules of engagement are your boss is your boss. It doesn't matter if they speak a different language. It doesn't matter if they're 10 years younger than you. It doesn't matter whether they don't know the first thing about caring for subarachnoid hemorrhages or about how to stabilize a cervical spine injury in the emergency room. Your boss is your boss is your boss. And therefore, you have to make sure that when you're having conversations with them about patient care, about length of stay, about policies and procedures, that you honor that. That doesn't mean that you're not a patient care advocate, but you have to honor the fact that they're the ones that sign your paycheck and decide whether your contract's going to be renewed, et cetera, et cetera, et cetera. So don't burn your bridges. Maybe your kids are in school and you want to stay in that community, so you may have to find a way to live with them and work with them and find a way to do what's right for the patients, but also work with these individuals. Learn to listen carefully, because while they do speak a different language and while they are bottom line thinkers and all the rest of it, they did choose to be in the business of health care. They didn't choose to be in the business of investment banking. Listen to them and then try to understand what their language is and try to never speak out of frustration or anger. If something that they say or some meeting that you have really bothers you, just keep the lid on it. And if you need to walk out of the meeting, like you just said, go on your cell phone or whatever else or excuse yourself and go to the ladies' room or the men's room. Then you can always come back and address it later. And learn to speak the administrative speak so that when you are doing your patient advocacy things that you understand their language so that you can meet on common ground. Okay, so that's my spiel about personalities. I hope I saw a few of you open your eyes and laugh and wake up, so hopefully you heard the message. Okay, so the second part that I want to address is about the internet. So this is an important quote. The internet never forgets. Everything you say and do in the virtual world can have an impact on your reputation in the real world. And I'm looking out here and I know what ages you all are and I know what your presence is on the internet. These are pictures of neurosurgery residents. Their faces have been covered. Some of you may know some of these individuals. When I showed this with those residents in the audience, everybody knew who they were. And I probably, if I'd known you guys beforehand or had this list, I could have gone onto your Facebooks and probably 50% or more of you, I could have found pictures like this of you guys on the internet, okay? Does anybody really want Bill Caldwell, who may be hiring you at University of Utah, to see these pictures of you? Do you want me, who may hire you as my next junior at my multi-specialty group, to go online and when they Google you, see these pictures of you? Probably not. So just think about that as you're traversing your day-to-day life. It's really all too easy these days with these little smartphones that we all have and that I've seen you all playing with during moments when maybe you're a little distracted to use these phones for things that they shouldn't be used for. I mean, when my daughter had her graduation party from high school and her friends wanted to come over and have a few drinks, and we were a little bit wary of it, but none of them were going to drink. We collected two things from every kid that walked in the house that night, and it was only six of them. We collected their car keys and we collected their cell phones. The last thing I needed was to be a neurosurgeon in the community and have pictures of underage kids drinking in my house, going up on Facebook. So we collected their cell phones and we collected their car keys. If you take a picture of a patient, even if it's a picture like this, that is not identified Can anybody in the world tell me who this patient is? Is it Mr. Smith or Mrs. Jones? Can you even tell me whether it's a male or female? Do you know if you take this picture on your cell phone and somebody sees that picture on your cell phone, you have violated a HIPAA regulation? Did you know that? So don't do it. Do not use your cell phone to take any clinical pictures, ever. Okay? It's illegal. Don't do it. All right. So whether you like it or not, your online reputation is becoming the main prism through which we will be known to colleagues, to friends, to patients, to prospective employers. And with this realization comes the recognition that we can no longer afford to be passive observers of our online reputation. In the digital age, negative online content has very far-reaching legs and a devastating impact. Patients are using what they can find out about you on the web to discuss your reputation. The first time a patient walked in and told me how old my kids were, this is when they were little, I almost, like, fell over. I mean, this was, like, almost 20 years ago. They knew everything about me. I once had a patient who came in and said, I really like you, Dr. Benzel, and I really think you'd do a good job of my surgery, but I'm really disappointed that you're not board certified. Well, I can assure you it was in 1999, and I had been board certified for two years. So why did this patient say that? Because they went to one of these sites, and the site erroneously had me listed as not being board certified. Now, because this patient came in and told me this, I contacted the site, and it took me six months and 10 emails, and finally three calls to the company before they made the correction. Okay? So things appear about you on the Internet, and they — there's no problem if they get it wrong. Okay? A single negative blog post can spark a reputation crisis, and it's important to listen, identify, and engage your online influences, because if you aren't keeping track of this, rest assured other people are. See, these are the top rating sites, and most of the people, once they get out and practice, if you Google yourself, almost all of the first things that show up are Vitals, Yelp, Great MDs, Angie's List, ZocDoc, Google's Health Grades. It's like, you know, I chair a meeting, or come and teach this, or write a manuscript that, you know, people read, and still the first two pages that come up are these things. Right? So, I mean, this is what people are going to see, because most people don't get to the third or fourth page of your Google search. Eighty percent of consumers go online and read information about doctors. Eighty percent of your patient, your potential patients, are going to go online and look you up. And 52 percent of the patients trust what others have to say about you. And you know it's always that one patient that got pissed off for something that goes online and writes about you, but still people go online and they believe it. So, who you are online is what you are to most consumers, and to some extent to other physicians, because if physicians are referring patients to you from remote areas, they may never know you. And I'm sure that this is true for many of the physicians here. I would say 80 percent of the doctors that refer patients to me, I've never met them. I wouldn't know if I fell over them, because they're not in my immediate geographical area, so they're going online and looking. So the doctor's greatest strength is their reputation. And we spend our entire professional lives trying to create and protect this valuable asset. And in the past, that had to do with the quality of care that you delivered. It had to do with what your patients said about you to their friends and neighbors and at churches and synagogues, and it had to do with how you treated your referring doctors. Unfortunately, in today's world, a lot of it depends on what goes on online. So this is my Google Me, and it just like doesn't come out at all. But there are some things that come up. I mean, if you do, if you're fortunate enough to be named in U.S. News and World Reports or one of those best doctors, they have a way of getting towards the top of your Google list. Most of us didn't get there until we'd been out in practice for a while. And most of the other ones that you see here is RateMD, Doximity, Health Grades. And like I said, I'm pretty active. But most of my Google profile, at least on the first couple pages, those kinds of things. And in the ExecutiveNet survey, it said that 90 percent of executive recruiters conduct an online research of their potential candidates prior to interviewing them. And they always click on images as well as website, okay? And that's where all of these things might come up in terms of your Facebook posts. And I should point out that you can take a picture down off of Facebook. It is still searchable on Google. It will still come up even after you've removed it. It never goes away on the Internet. It may go away on your Facebook page, but it never goes away on the searches, okay? So just keep that in mind as well. You'll also have missed opportunities if you don't have an online presence. You'll not stand out to your patients. Having no reputation can be as harmful as having a bad reputation. And you also miss an opportunity to educate your patients because you can create websites either for your practice or your specialty group or your department where you can help educate your patients on any number of things. I mean, some people are very advanced in this, and they provide post-op instructions online to their patients so their patients can go on board. A new part of the mandate for the Accountable Care Act in patient protection is that the patients can have access to their electronic medical records. So most medical groups and hospitals have to have a patient portal so the patient can have direct access to their medical record. It's a great opportunity to also provide information online for your patients to help them prepare for their surgery, to recover from their surgery, and to make them feel that they have that safety net. So the online can also be an opportunity to educate. If you don't have an online presence, you have no outlet for people to sing your praises, you're not in control of your own brand, you're missing an opportunity to improve efficiency because people can make appointments through a website that you have. They can fill out forms that you need for your office ahead of time so that they're not sitting in your office filling out those forms and wasting time when they should really be spending that time with the patients. And you also might lose out on some recommendations. So how to manage your online reputation? You need to Google yourself on a regular basis. You want to set up a Google Alert so every time something gets added, you can do that. That could become problematic. You might be getting dings all the time, but you should set up a schedule to Google yourself on a regular basis. Correct mistakes and false information when you do discover it. It's not always so easy, but you really should persevere, especially in the case like me when I was said that I wasn't board certified when I actually was. And create your own content when you can. Address any actionable items. Like I said, if they get something wrong, if you create a LinkedIn profile, that oftentimes will rise up higher than some of these other things, and you can, again, control the information that you put on a LinkedIn profile, and you can create your own blog. These are things you can do if you want these things to be what your patients see about you rather than rate MD or health grades. Understand your vulnerability in terms of the internet. Acknowledge the durability of the internet and what you put on the internet, and be very proactive about your online reputation, because it is these days almost equivalent to your reputation on most levels. Only you can control your online reputation. It's increasingly important, and it really does require constant vigilance. If you want some more information, this is a book that was recommended to me by our communications person from the Washington committee. It's short. It's sweet. It's easy to read. And I recommend that you all buy it and read it on your way home tonight. I mean, after the course. And I always have to throw in a little bit of a plug for our online reputation. You can follow us at neurosurgery, for those of you who are Twitter people. And the more people that follow us, the more we can get neurosurgery's message out about things like the conflict of interest and the Sunshine Act. And we do have a blog. You should all be following it. I want you all to get your pens out right now, or your smartphones, and write this down. I expect at least half of you to be following us by the end of the day. And this is a picture that was taken. I'm the one in the dress. This is when I was a first year resident at Brown. This is the type of picture that fortunately is only available as a slide, because this is one I would never want of me on the internet. And this is a picture that was taken. I'm the one in the dress.

personality clashes

online reputation

professional practice

boss authority

patient care