The basic rules of questions and answers.

ABSTRACT

Our world is full of basic rules. And life is loaded with questions. The physician executive's life is certainly governed by both items. With a mountain of information, separation of fact from nonfat involves methodical processing. The physician executive must spend vast amounts of time in the pursuit of factual, pertinent information. Equally time-consuming is the application and dissemination of this information. This article offers a physiologic model for understanding the acquisition and dissemination of information and applies the model to the specifics of handling questions from a broad range of people-subordinates, superiors, constituents, customers, etc.

Following a model of medically significant physiologic analogies, the basic rules applying to the processing of information follow these functions: ingestion, digestion, assimilation, response, and, perhaps, elimination.

Ingestion (receipt of information from many sources, such as radio, video, films magazines, texts, lectures and even conversations with authoritative sources).

Digestion (the comparative mental process linking known facts and experiences to the received message).

Assimilation (recognition of decoded message that accepted verified information).

Response, if indicated.

Elimination (unwanted, or unusable information).

A significant portion of the physician executive's time is involved in responding to questions. In the process of digestion of the ingested question or information, we must develop a mechanism of resolution and response to the question by using some of the following steps:

* Calling upon the receivers authenticated knowledge.

* Utilization of appropriate research.

* Noting and referring to an appropriate documented authority.

* Cross-referencing to other sources when information is soft, weak, or of questionable validity.

* Compartmentalizing relevant information for future use.

* Upon resolution of the main question, cataloging and storing any tangential questions for future processing.

Let us now illustrate two models demonstrating these processes. The noninteractional model (figure 1, page 35) is applicable where the information is presented in a fashion (one-way street) whereby we raise our own questions and resolve or answer them. The second model (figure 3, page 36) for demonstration of the processing of information is a more complex and sensitive method of resolution of questions, namely the interactional model (two-way street)-e.g., person-to-person, committees, groups, public gatherings, radio call-ins, etc.

Certainly, all communication skills and modalities play heavily in the resolution of questions. Factors that need to be considered when dealing with verbal communications are:

* Background for the presentation.

* Experiential and educational bias.

* Voice inflection and intonation.

* Body language.

Our novel way of familiarizing oneself with the types of questions asked and assisting oneself in decoding the question (message) is the mnemonic "Basic Rules" in figure 2, right. Each type of question can be answered in a noninteractional manner. Altematively, interaction proceeds until the decoded message and decoded response yield concurrent understanding and agreement, using any of the mechanisms of question resolution.

SUMMARY OF PREVIOUS SCENARIO

Dr. Applegarth has learned that a major national managed care organization is testing the feasibility of moving into the market that his group practice serves. The technique that his informant says the national firm plans to investigate is the purchase of existing practices in the area. Although no contact has been made as yet with Dr. Applegarth's group, such contacts have been made with local physicians and with smaller groups. Although the managed care firm has seemed satisfied with contracts with these physicians and groups, the informant says that its long-range goal definitely is outright purchase of practices and conversion of physicians into employees. Although Dr. Applegarth's group has moved in a small way into managed care, its involvement has been minor and he realizes that the national firm is a real threat. What, he wonders, should he take as a first step in responding to the information he has received?

RESPONSE

Dr. Applegarth's actions will be directed by knowledge of two areas: the local medical environment and his own group.

Knowledge of the environment includes the geographic distribution of providers, accessibility to primary care, the payer base, contractual relationships, and economic factors influencing employers' choices of health care delivery (e.g., predominantly local small businesses versus large multisite national businesses).

Intimate knowledge of his own group is probably more important. How is the group's governance and stakeholdership set up? Are there physicians who are near retirement? Is there significant debt? Would the current culture of the group accept a staff-model culture? If so, at what price?

Thus, first steps for Dr. Applegarth would include talking with the major national managed care organization directly to obtain further information regarding its plans and whether it sees Dr. Applegarth's group as an integral part of its planning. Also, he should use this occasion to reexamine with his group the basic questions, "Who are wet?" and "Does what we do and how we do it make sense?"

Dr. Applegarth's answer to the threat of the national managed care organization will be found in the development of honest responses to these questions. - Dennis W. Spencer, MD, Medical Director, Aetna Health Plans of Oregon, and Medical Director, Providence Medical Group, Portland.

Number of PPOs Increases by 12 Percent

According to a new study conducted b Marion Merrell Dow, Inc., the number of PPO plans grew to 764 in 1993, from 681 plans in the previous year. The largest gains were in the number of insurer-owned plans and in PPO's with "other" owners.

Among the highlights of the findings:

* The number of workers covered under exclusive provider options (EPOs) rose 18 percent to nearly 10 million.

* The average length of stay for medical/surgical inpatient admissions was 4.1 days, unchanged from the previous year.

* PPOs employed an average of 73 full-time and five part-time staffers per plan in 1993. The number of full-time employees rose 8 percent, and the number of part-time employees went up 12 percent.

* Worker's compensation specialty PPOs covered 34 percent more workers in 1993.

* A total of 81 percent of PPOs performed utilization review activities in-house, versus 15 percent under contractual arrangements.

* The percentage of PPOs using drug formularies jumped 6 percent, to 26 percent, in 1993.

* PPOs contracted with an average of 4,985 physicians per plan in 1993, down 8 percent.

* PPOs contracted with an average of 83 hospitals per plan in 1993, down 22 percent.

For a complete copy of the Marion Merrell Dow Managed Care Digest, PPO Edition, 1994, call Kurtis Klein, Market Manager, Managed Care Markets, 816-966-4000.

MANAGEMENT GRAND ROUNDS

In this issue of Physician Executive, we publish a response to a management scenario that appeared in the February 1995 issue of the journal. A new scenario appeared in the April issue, and another will appear in the June issue. To the reader whose response appears here, as well as to those whose responses regrettably arrived after our deadline had passed, we offer our thanks. If you have a scenario that you would like to have considered for the column, please send it to Managing Editor, Physician Executive, Suite 200, 4890 W. Kennedy Blvd., Tampa, Fla. 33609.

New form Increases Adverse Drug

Reaction Reporting

In the late 1980s, the number of reported adverse drug reactions (ADRs) reported at the Kaiser Permanente hospital in Richmond, Calif., was almost nil. Creation of a simple reporting form and physician and nonphysician education has resulted in a veritable explosion of reports. The hospital currently utilizes 40 inpatient beds and serves an outpatient population of about 65,000.

The reporting form has space for patient demographics, the suspected drug, the definition of an ADR, a fist of reactions to be checked off and the reporter's name. The brainchild of Charles Clemons, MD, Chairman of the Pharmacy and Therapeutics Committee, and Patrick Graham, RPh, the reporting form is identical in size to a prescription pad. It easily fits into a physician's coat pocket and is easily accessible for ADR reporting.

More than 90 percent of the forms come from physicians, with additional participation from nursing, pharmacy, radiology, and the quality improvement services. The reporting form triggers a pharmacy evaluation, and the findings are validated by a physician reviewer. Annual analysis involves separate reports from the inpatient ward, the emergency department, and the outpatient clinics.

The form resulted in an increase in reported adverse drug reactions from 7 in 1988 to more than 225 in 1994, with a high of 339 reported in 1992. About 30 percent of these reports were considered significant reactions and resulted in appropriate educational interventions. The form has been exported to many other Kaiser hospitals and praise has been received from the Joint Commission surveyors. - K. M. Tan, MD, Assistant Physician-in-Chief, Kaiser Permanente, Richmond Calif.

Jerry L. Hammon, MD, FACPE, is a health care management consultant in West Milton, Ohio. Warren W. Kaebnick, MD, FACS is a member of the Medical Executive Committee Upper Valley Medical Center, Troy, Ohio.