going to cost. For office visits, Lan- tors have nothing and want nothing have to waste time setting it up in dry suggests that after examining the to do with billings. Landry, possibly alphabetical order," he said. "We patient, the doctor should write the courting paranoia, advises doctors al- always think the alphabetical orderservices rendered on a charge slip ways to assume that they can be ing system is the best way to organto be handed to the medical assistant. stolen from. By understanding and ize things but we know numbers. This way the patient knows the fee keeping in touch with the accounting Once you have the number, retrieval before leaving the office. Non-office procedure they can monitor their is much faster. We know exactly visits should be discussed before the operations. "Be consistently incon- where things should be. It's difficult procedure. "Never fail to mention sistent," says Landry. "Let the med- organizing names. What do you do that the fee assumes normal time and ical assistant know that there's a with McDonalds, for example, in Cape Breton?" Most physicians who that the cost could be higher should chance you might be checking." problems occur." use the numerical system use an alphabetical card index to store oftenHigh collections depend on a high Filing systems ratio of payments on the spot and used bits of administrative informaproper follow-up procedures. With A prime element of any efficient tion about each patient. Once com80% of the patients there will be medical operation is a filing system puters are introduced in offices, the little problem collecting fees, as most that allows for good recording and cross indexing will be accessible on a collections are made at the office. prompt recall of information. As video terminal by merely typing the With the 20% who ignore bills there well, inactive files should be easily name into the computer. This will should be an organized system for removed. A colour-coded lateral probably give numerical filing the getting payment, based on direct tele- filing system will go a long way in edge. phone contact. The AMA offers a achieving these goals. Landry pointed At a suggestion that doctors could taped instruction with collecting tips out the pros and cons of alphabetic have lateral files constructed more for medical aides, which recognizes and numerical colour-coded systems. cheaply than buying metal case ones, the fact that they are not full-time The disadvantage of numerical sys- 43-year-old Dr. Bruce Stewart, a bill collectors and need to have their tems is the need for cross-references. Toronto neurologist, warned that time free for other things. One participant sighed: "Just an- confidentiality could be violated. He Surprisingly enough fraud and other bit of information"; another believes someone used information theft are problems for doctors. It added: "It would be nice if it works." from his files to make obscene 'phone seems it is very easy to steal from Landry defended the numerical ap- calls to patients using his name. He'd a medical practice, since most doc. proach. "It's better because you don't like to see all files locked securely.

Part IV: Patient management The MD Management symposium on patient management could well have been entitled Selling the Doctor. And despite the dissident who said he already had enough patients and didn't want to attract more, those present agreed that patient relations are being more recognized as important. Patients are becoming more critical of doctors and the medical profession in general. Physicians who opt out of medicare are going to have to explain why and show how patients are going to benefit. Be spectacular This is a new state of affairs for medicare, according to Michael Landry, vice president, marketing, of MD Management. "You have to use your imagination. Why not be spectacular? Offer the patients something that's really different," he urged. "Whether you like it or not, you are judged largely on the basis of

how good you appear to be as a doctor and not on your professional ability," stated the program notes. "It's simple - people react to interest, concern, empathy, understanding etc... Showing that you care (or don't care) for your patients can be expressed in many ways - providing a pleasant reception area, recognizing that the patient's time is also valuable, giving your patient undivided attention." Landry told the symposium it's not the time spent with a patient that is seen as important but "how much you concentrate on the patient during that time." Style and content are the critical factors. A 1973 study commissioned by the OMA under retired industrialist Edward A. Pickering lent support to this view. Pickering found that human relations were most important to patients. "Mere competence is perhaps taken for granted and is not enough. Quality of service, of re-

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sponsiveness, is of overriding importance." Medically it is probably fair to say that better doctor-patient relations will lead to better care. From a business point of view, to attract new patients and to keep old ones it is, ironically, more important to appear competent and caring than it is to be competent and caring. "It is a business fact of life." Patients are people In a survey taken by Physician's Management, the 10 most frequent complaints emerged as: the feeling that doctors are more interested in disease than health; doctors fail to keep appointment times; office staff give patients little respect; doctors act like God; doctors and staff give patients no privacy; fees are not explained on statements; doctors abuse investigative techniques; there are inadequate waiting room facilities; of-

fice hours are inadequate; and medical problems are not adequately explained. Note that six of the complaints involve office and staff problems, not medical ones, with the 10th, the explanation of medical problems, far down the list. This more than supports the contention that even though they are being told what's going on patients want and need to be treated more seriously. Other concerns patients have noted are whether their medical and personal records (their secrets) are safe, the soundproofing in the examination rooms is adequate, the staff is trustworthy and there is enough seating in the waiting room. MD Management suggests that doctors assess their own operatioAs to find out where and how they're weak. "It is one thing to know what bothers patients in general and yet another to know which of those irritations apply to your own practice." It's implied that most practitioners would be surprised with the results. "Concentrate on being friendly," says Landry. "In medicine, particularly in high-volume primary care, some days it becomes easy to perceive patients as widgets on an assemblyline conveyor belt. On a bad day it is easy to start acting like a robot." A doctor can attempt to overcome this apparent disregard of patients' feelings simply by concentrating on doing something different each time he faces another patient. One good procedure is to write personal notes about the patient on the inside of the file jacket. When the doctor refers to these notes the patient has the feeling he or she is not just a cipher. A suggestion that aides photograph all new patients with an instant camera and include the photograph in the files was met with derision by some who thought it an unnecessary and probably irritating extravagance. However the MD Management program maintains that there are "tricks" that will help the doctor concentrate on being friendly, sympathetic, sensitive, courteous and respectful. And everyone benefits. The doctor is more relaxed and pleasant, staff more calm and courteous and the patient more positive and cooperative. Environment is as important as treatment since many patients' cures

start in the reception area. They just people reason that since the person feel better being there. "A properly is speaking in public "he must be an designed office will demonstrate your authority." Although it seemed that such sugconcern for the patient's wellbeing, and your staff will work more ef- gestions involved a good measure of ficiently and pleasantly in a people- common sense, they were designed oriented environment than in one to make doctors and staff, many with relatively new practices, more conthat is just functional." What can you put into a reception scious of such concerns. Too often area? Cool colours have a "sedative they're taken for granted and uneffect" and help soothe patients. stated. "I think it's necessary," says Dr. Comfortable, attractive and upholstered chairs are relaxing. Back- Madgwick, "not just to get referrals ground music works well, and it's but to keep patients happy. i've used good to have a centre of attention, just about every technique mentioned something that can be as simple and to keep the patients satisfied. They functional as a picture window or don't only benefit medically but they mural, as weird as a wall-sized aqua- should look on the GP as a friend rium. A children's play room with a when they're in trouble, someone television and toys is an asset: one they can go to to get relief, not just enterprising if not extravagant practi- for medical problems but also for tioner brought in the front end of a psychological ones." fire engine for children to climb over. Provide consumer magazines that Patient information pamphlet have a lot of pictures, like National MD Management suggests that paGeographic, or Canadian magazines. tients be coached through a patient Provide a writing desk and chair, information booklet. Educating pahave an attractive carpet; a prized tients will save time. addition is a waiting-room telephone A short and relatively inexpensive for those necessary but, one hopes, pamphlet can cost about $200 for short calls. To prevent abuse, make about 2000 copies and can explain it a wall phone without a chair near- routine medical problems and ancilby, and keep it in front of the recep- lary services. It'll save unnecessary tion area. questions and calls; some medical Don't be cheap, but be careful management consultants claim that about laying on plush surroundings, the booklets will reduce incoming unless you're dealing with patients telephone traffic by as much as 25%. who want and expect it. If you have "It won't cost money," says Landry an excessively luxurious office, "your confidently. "It'll save money." Besides containing helpful advice patients may think that you make and emergency telephone numbers, too much money," said Landry. the booklet can include sections describing the philosophy of the pracMobiles and muffins tice, office hours, appointments, proOther "patient pleasers" some doc- cedures and times for telephone calls, tors might want to include: mobiles, methods of billing and collection a globe, colouring books, giant procedures, map of area and so on. stuffed animal, old typewriter, and And for those who are opting out, "you can give patients X-ray posi- the book can explain why and show tives when you no longer need them, that the practice is providing somekeep jumper cables in the office in thing special that warrants extra case someone's car won't start, have charges. your nurse set up a breakfast bar in the waiting room... ." Which was The ideal appointment system about the time that the dissident doctor complained, and the rest of A Florida time study program that the session was so abridged that the computerized daily appointment data participants missed a choice item found that if all patients for one day from Robert Levoy. In his book could be persuaded to come in at "The Successful Professional Prac- 9 am and were forced to wait, there tice" Levoy advises the quickest way would be a minimum time loss and to become regarded as an expert is maximum efficiency. But this would to speak in public. It seems that most be intolerable. CMA JOURNAL/SEPTEMBER 9, 1978/VOL 119 525

NL..dL (amoxicillin) AMOXIL (amoxicillin)... A new generation broad-spectrum penicillin. INDICATIONS: Infections due to susceptible strains of the following microorganisms: Gram-negative-H. influenzae, E. coli, R mirabilis and Ngonorrhoeae. Gram-positive-Streptococci, Dpneumoniae and penicillin-sensitive staphylococci. In emergency cases where the causative organism is not yet identified, therapy may be initiated with AMOXIL on the basis of clinical judgment while awaiting the results of bacteriologic studies. DOSAGE AND ADMINISTRATION:lnfections of the ear, nose and throat due to streptococci, pneumococci, and penicillin-sensitive staphylococci; infections of the upper respiratory tract due to H. influenzae; in fections of the genitourinary tract due to E. coIl, R mirabilis, and S. faecalis; infections of the skin and soft tissues due to streptococci, penicillin-sensitive staphylodocci and E. coli: Usual Dose: Adults-250 mg every 8 hours. Children-25 mg/kg/day in divided doses every 8 hours. This dosage should not exceed the recommended adult dosage. In severe infections or infections caused by less sensitive organisms: 500 mg every 8 hours for adults, and 50 mg/kg/day in divided doses every 8 hours for children. Infections of the lower respiratory tract due to streptococci, pneumococci, penicillin-sensitive staphylococci and H. influenzae: Usual Dose: Adults-500 mg every 8 hours. Children-SO mg/kg/day in divided doses every 8 hours. This dosage should not exceed the recommended adult dosage. Urethritis due to N. gonorrhoeae: 3 g as a single oral dose. Patients with gonorrhea, with a suspected lesion of syphilis, should have darkfield examinations before receiving AMOXIL, and monthly serologic tests for a minimum of four months. For chronic urinary tract infections, frequent bacteriologic and clinical appraisals are necessary. Smaller doses than those recommended above should not be used. Stubborn infections may require several weeks' treatment, sometimes at higher doses than recommended above. Concurrent bacteriologic sensitivity monitoring is recommended. Continued clinical and/or bacteriologic follow-up for several months after cessation of therapy may be required. Treatment should continue for 48 to 72 hours beyond the time patient becomes asymptomatic or bacterial eradication is obtained. At least 10 days' treatment is recommended for infections caused by beta- hemolytic streptococci to prevent acute rheumatic fever or glomerulonephritis. CONTRAINDICATION: In patients with a history of allergy to the penicillins or the cephalosporins. PRECAUTIONS:Periodic assessment of renal, hepatic, and hematopoietic function should be made during prolonged AMOXIL therapy. AMOXIL is excreted mostly by the kidney. The dosage administered to patients with renal impairment should be reduced proportionately to the degree of loss of renal function. The possibility of superinfections with mycotic or bacterial organisms should be kept in mind during therapy. If superinfections occur (usually involving Aerobacter, Pseudomonas or Candida), the drug should be discontinued and appropriate therapy instituted. ADVERSE REACTIONS:As with other penicillins, presumably the most common untoward reactions will be related to sensitivity phenomena, similar to those observed with ampicillin. They are more likely to occur in individuals who have previously demonstrated hypersensitivity to penicillins and in those with a history of allergy, asthma, hay fever or urticaria. (See Product Monograph which is available on request).SUPPLI ED: AMOXIL-250 Capsules (250 mg amoxicillin) in bottles of 100 and 500. AMOXIL-SQO Capsules (500 mg amoxicillin) in bottles of 100. AMOXIL-125 Suspension(125 mg amoxicillin per 5 ml) in bottles of 75, 100 and 150 ml. AMOXIL-250 Suspension (250 mg amoxicillin per 5 ml) in bottles of 75, 100 and 150 ml. AMOXIL Pediatric Drops (50 mg amoxicillin per ml) in bottles of 15 ml. AYERST LABORATORIES Division of Ayerat, McKenna & Harrison Limited Montreal, Canada Made in Canada by arrangement with .Reg'd BEECHAM, INC.

The simple statement "time is money" is nowhere more poignantly used than in patient scheduling, nor is it more readily controllable. And remember too that time is as important to the patient as it is to the doctor. In Toronto a company president this year billed a doctor for the time spent in the waiting room. "in the past, disorganized physicians have been able to get away with murder because a poor schedule indirectly makes a doctor look good," states the MD Management program booklet. But a good appointment system that permits a regular flow through the office can easily be set up. The typical system used by more than 80% of physicians in Canada is the stream system, having time divided into 10- to 15-minute segments. There is also the wave system, which combines a first come, first served system and the stream system. Both have faults. No system can neatly fit patients into 15-minute segments, eliminate no shows, prevent work- or walk-ins or lateness. But one system that takes these into account is the modified wave system designed by Dr. Walter Lane, which schedules clusters of patients at several different periods during the day. Wherever possible, these clusters are organized in time blocks of "like" patients (i.e., diabetics, hypertensives etc.). This socalled "cluster scheduling" should improve productivity as well as the quality of care. Dr. Keith Madgwick of Oshawa was one of the doctors who brought to the session his staff, a part-time nurse and full-time receptionist. He too has more patients than he can comfortably handle but says, "I can always learn more on how to deal *with them effectively." And his receptionist-accountant, Mrs. Hazel Benwell, has taken the instructions to heart. "It confirmed one or two things that we had thought about. Most of the things we have been doing," she says, but they may consider grouping patients. "It wouldn't hurt getting pregnant women to know each other. After all they'll be next to each other in the hospital." Whatever system is considered, it is important to know the routine of the individual practice. What is the average time spent on each patient? Landry doesn't think it wise to

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charge for no shows. "It's not good public relations. The patients who don't show aren't likely to pay for the time anyway." He says it's a good idea to phone patients a day earlier to remind them of the appointment; the phone is cheaper than the mail. Since the first contact any patient has with the practice is usually by telephone, it is important to have a good technique for handling calls. Staff should treat each call as an emergency and answer the telephone on the first ring. "Never put someone on hold without first finding out who is calling and the nature of the problem - in a medical office, it could be a matter of life or death." Many telephone calls can wreck an otherwise normal and regulated schedule and ruin relationships with the patient who is being examined. The medical aide therefore must be trained to screen calls "so that only those calls that serve a medical purpose will be put through right away." For callbacks, set aside 10 to 15 minutes during the day for returning calls. And you can save time by having the receptionist dial the calls while you're talking to another patient - although it is not good to keep anyone on hold. Dr. Michael A. Bloomfield, London, Ontario, radiology specialist, says that most of the suggestions confirmed what he had been doing in his practice but he was intrigued by the device that plays music when calls are put on hold, and he may get one. As this session was directed toward general office management and referred to subtle but practical office techniques, it was perhaps not the best fodder for the medical mind. But medical assistants, of whom there was a preponderance in the session, were obviously interested in and sometimes intrigued by the novel approaches to patient management and could see how they applied to their operations. Such a program could provide the ingredients essential to creating a successful practice and improve relationships with patients and staff by reducing stress and helping the office operate at optimum efficiency. The principles outlined in the session apply best to general practices. As Merle Gonsalves, secretary-recepcontinued on page 532

our society. Areas of stress and conflict find ready expression in direct and fresh projections in spontaneous art by children. In telling stories that are stimulated by his artistic projections, the child can give immense help to the adults trying to understand his predicaments." Dr. Fischer's institute has set up "spontaneous art programs" in several schools in the Toronto area, in which disturbed children are given the opportunity to express, in a safe environment and medium, feelings that might otherwise lead to withdrawal or aggression. Dr. Fischer considers that the "considerable disinterest" in art therapy which he so deplores is not just narrow-minded; it is also short-sighted. "Twenty per-

cent of the children in our school system are emotionally disturbed. I believe that 80% of these could be helped within the school, through a variety of therapies, without the expensive institutional care that is so often the only solution nowadays." So far there have been 11 graduates from the Toronto institute, who have been awarded the institute's private diploma and are now facing the awesome task of persuading school heads that art therapy is valuable enough to warrant loosening the purse strings for. After talking to the various individuals active in the art therapy field, I came away impressed by the efforts of individuals and convinced that for those people who are failed by words, producing pictures can be therapeutic in itself, a valuable projective technique and a conduit to the external world. But I was not

convinced that it held a monopoly on any of these benefits, as some of its more vehement defenders appear to claim. In the ideal world of limitless budgets, an art therapist in every psychiatric and educational institution would be a wonderful asset. But as Dr. Lowy from the Clarke said, "We have to allocate our resources according to needs, and we have other modes of recreation, expression and diagnosis." Currently, the only way an art therapist, whether trained or not, is likely to be employed is if the head of an institution has a personal conviction that the therapy is of value. This means small pickings for the graduates of Dr. Fischer's and the various US training institutes and aspiring therapists who have no training - but it also means that the therapist is warmly welcomed into the kind of setting where his or her work can probably be most useful.*

RESEARCH continued Irom page 506 chastizing the Professional Corporation of Physicians of Quebec over a recommendation to establish an intensive care unit in a regional hospital after a site visit by experts. In a letter to the president of the corporation published in the corporation's Bulletin, August 1976, the then minister of social affairs challenged directly the value of ICUs for survival of patients. He also challenged the right of the corporation to make recommendations for the improvement of regional services.

The distrust by government officials of members of the health professions extends to new buildings. Such construction is under the complete control of government officials, from the contracts with architects, engineering firms and builders to supply of materials. Contracts are drawn up by civil servants. Tenders have to be obtained by the hospital and health centre from three sources and submitted to the ministry for approval. Payment for services already rendered has to be resubmitted for approval. This control extends even to the design of laboratories and choice of materials for working

benches and tables, even size and colour of drapes. Amid such frustrations, I remember the bawling out I gave to a so-called expert who came with an earring in his left ear and wanted to force us to use 16 mm formica sheets for our laboratory benches. His only previous experience was that of a small laboratory in a high school. This distrust and total lack of confidence is most oppressive, if not profoundly insulting. A full list of references will be published at the end of Part II of Dr. Genest's article, which will appear in CMAJ Sept. 23.

has happened or what time of the day it is, I don't have to act totally continued from page 528 detached and professional." For Dr. Jerry Green, Willowdale tionist to Dr. Bruce Stewart, a To- nutritional specialist, it was the secronto neurologist, observed: "We ond time he'd attended the course, don't have as many patients as gen- the first being when it was given in eral practices do; nevertheless some the single-day session last year. He of the principles are the same. felt that the same information was covered in the expanded session. Dr. "I left with the thought that I had Green thinks the principles covered to have a more friendly attitude to- in all the sessions are relevant since ward the patients. No matter what most doctors typically are abysmal

businessmen! But he says they're tough to get through to because they are tremendously resistant to new ideas - whether proposed by management analysts or nutritionists. The key point for a physician to remember, says Landry, is that he's the boss, he is running his own practice and he should be at the helm. Physicians tend to react too much to the environment. The system must react to them. Then they can be in complete control. U

ART THERAPY continued from page 497

SEMINARS

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References