With keen listening skills and fast typing ability, these transcriptionists use their training to document medical histories.

“The patient had discomfort anterior to the lateral malleolus. Talar tilt negative. Drawer sign negative.”

What does that mean? Medical transcriptionists know. And because of transcriptionists’ work, the fact that the patient’s sore ankle passed two tests for stability becomes part of his or her recorded medical history.

Medical transcriptionists are experts in the language of medicine. They turn healthcare providers’ spoken notes into well-edited, typed reports. They can recognize–and spell–the names of bones, muscles, procedures, and prescriptions. Their efforts ensure that doctors and other healthcare workers have accurate information about patients.

The chance to learn about medicine is one reason some people are attracted to this occupation. Ample job openings, flexible schedules, relatively short education requirements, and opportunities for home-based work are other draws. On the following pages, you’ll learn what medical transcriptionists do and what their working conditions, earnings, employment prospects, and training requirements are.

Dictation into document

Medical transcriptionists type voice recordings made by physicians or other healthcare professionals into medical reports and correspondence. The documents that transcriptionists produce include discharge summaries, physical examination reports, patients’ history reports, operating room reports, consultation notes, diagnostic imaging studies, autopsy reports, and referral letters.

Transcriptionists usually listen to recordings on a special headset, using a foot pedal to pause the recording when desired. As they listen, they type the text using word processing software. Then, they organize the material into a set format and return transcribed documents to the dictator for review and signature or correction. Finished documents become part of patients’ permanent medical files.

It takes more than careful listening and fast typing to transcribe medical records, though. Medical transcriptionists use their understanding of medical terminology, anatomy and physiology, diagnostic procedures, and treatment to create accurate reports. For example, the medical terms “ilium” and “ileum” sound the same on a recording, but a transcriptionist knows which is correct in a given context: “ilium” refers to a bone in the hip, and “ileum” is part of the small intestine.

Some people confuse the work of medical transcriptionists with that of another transcribing occupation, court reporter. Both occupations listen to speech and type it on a word processor. But while court reporters use a special typewriter to record verbatim reports of legal proceedings, medical transcriptionists are more concerned with the speaker’s meaning than with his or her exact words.

As they work, transcriptionists translate medical abbreviations and jargon into their expanded forms so that records are easy to understand. They check the spelling and meaning of these terms by consulting standard medical reference materials, both printed and electronic.

Experienced medical transcriptionists spot inconsistencies or mistakes, such as misspoken prescriptions, in a medical report and verify the correct information with the dictator. Transcriptionists’ ability to understand and correctly transcribe patient assessments and treatments reduces the chance that patients will receive ineffective or harmful care.

The emergence of speech recognition technology, which translates sound into text automatically and creates draft reports, has allowed some medical transcriptionists to spend less time typing and more time editing for accuracy and clarity. Transcriptionists format draft reports; edit them for mistakes in translation, punctuation, and grammar; and check for possible errors by the speaker. In specialized areas with more common terminology, such as radiology or pathology, transcriptionists are more likely to encounter speech recognition systems. However, use of these systems will become increasingly widespread as the technology becomes more sophisticated.

Medical transcriptionists are careful when transmitting storing the medical records they create. They keep records confidential by following strict legal and ethical guidelines. As more transcriptionists use the Internet and intranets to transmit records, new security procedures are being implemented. Using the Internet to send records will become widespread only when the technology becomes more secure.

Medical transcriptionists who work in physicians’ offices and clinics may have nonrecordmaking duties, such as scheduling appointments, answering the telephone, and handling mail.

Worklife at the keyboard

Most medical transcriptionists work in comfortable office settings. About 40 percent worked in hospitals in 1999 and another 40 percent in physicians’ offices and clinics. Others worked in laboratories, colleges and universities, transcription service offices, and personnel supply services agencies. An increasing number of medical transcriptionists work from home, either as subcontractors for hospitals and transcription services or as independent contractors.

Many medical transcriptionists work a conventional 40-hour week. But many others work irregular schedules, including part-time, weekend, evening, or on-call hours. Self-employed and home-based workers are most likely to have irregular hours and flexible schedules. However, self-employed transcriptionists usually receive no benefits and face a higher risk of job loss than other transcriptionists do.

Working in this occupation presents few hazards. But sitting in the same position for long periods can be tiring, and workers can suffer strains resulting in wrist, back, neck, or eye problems. Transcriptionists also risk repetitive motion injuries, such as carpal tunnel syndrome.

Transcriptionists must meet tight deadlines. And sometimes, their earnings depend on how fast they transcribe. This pressure to work accurately and quickly can be stressful and wearing. But for some, working fast is a job benefit: transcriptionists often say they enjoy the quick, steady pace of their work.

Medical transcriptionists also like seeing tangible results of their efforts. And inquisitive transcriptionists enjoy satisfying their curiosity as they track down the meanings and spellings of the latest treatments.

Earnings for recordmakers

Medical transcriptionists had median hourly wages of $11.67 in 1999. The middle 50 percent earned between $9.70 and $13.54, the lowest paid 10 percent earned less than $8.38, and the highest paid 10 percent earned more than $16.17.

Compensation for medical transcriptionists varies. Some are paid by the hour for their work. Others are paid based on the number of standardized, 65-character lines they transcribe. Large hospitals and healthcare organizations usually prefer to pay transcriptionists by the hour. Most independent contractors and employees of transcription services receive line-based pay. Employers sometimes combine the two methods, paying a base hourly fee and giving bonuses for extra production.

According to a 1999 study conducted by Hay Management Consultants for the American Association for Medical Transcription, entry-level medical transcriptionists had median hourly earnings of $10.32. The most experienced transcriptionists had median hourly earnings of $13. Earnings were highest in organizations employing 1,000 or more workers. Transcriptionists receiving production-based pay earned about 7 to 9 cents per standardized line. Independent contractors, who have higher expenses than their corporate counterparts, typically charge about 12 to 13 cents per standardized line.

Transcription prediction: Job growth

Medical transcriptionists held about 97,260 wage and salary jobs in 1999. Many others were self employed. And employment of medical transcriptionists is projected to grow rapidly through 2008, with demand spurred by a growing and aging population. Older age groups receive proportionately greater numbers of medical tests, treatments, and procedures that require documentation.

A high demand for transcription services also will be sustained by the continued need for the electronic documentation that transcriptionists provide. This documentation is shared easily among providers, third-party payors, regulators, and patients.

Because medical transcriptionists will still be needed to review and edit drafts for accuracy, advancements in speech recognition technology are not expected to significantly reduce the need for these workers. Despite advances in this technology, the software is not yet sophisticated enough to grasp and analyze the complexities of voice and the English language. Skilled medical transcriptionists still will be needed to identify and fix errors created by speech recognition systems and to create final documents.

Speech recognition has been a positive force in improving the efficiency of clinical documentation in limited practice areas like radiology. Giga Information Group projects the speech recognition software market is expected to grow from $100 million in 2000 to $2.5 billion by 2005, with healthcare representing a significant piece of the pie.

As speech systems begin to spread slowly across the healthcare enterprise, a major opportunity exists to extend the technology for the benefit of the other key stakeholder in this productivity equation: transcriptionists.

Due to the continuing shortage of transcriptionists, cost concerns and the persistent increase in amounts of documentation required, pressure is intensifying to limit or even eliminate the use of transcriptionists. Giga estimates that hospitals spend $1,200 or more per month per physician on transcription, and the American Association for Medical Transcription estimates that $20 billion is spent annually on medical transcription services.

In cases when a physician’s encounter with the patient is especially brief or routine, it may be viable to reduce reliance on transcriptionists. Speech recognition, combined with enhancements like templates, structured notes, menu-driven forms and other tools, will allow physicians to complete reports with just a few utterances and a couple of taps of the stylus on a PDA, thus bypassing transcription altogether. At least, that’s the vision.

As the volume of reports continues to climb, hospitals will strive to keep transcription costs low, typically by deploying productivity-enhancing transcription platforms, employing techniques such as incentive pay for transcriptionists–directly or through outsourcing–and enabling transcriptionists to work from home.

Another approach worth exploring is to leverage speech technology for transcriptionists, thus increasing their productivity. By extending the reach of speech technology into the business process of transcription, hospitals can further streamline transcription workflow–after some change in user behavior–advance patient care through improved report turnaround, and impact the payment cycle by facilitating timely coding and increasing free cash flow.

This perspective of clinical documentation is becoming more common, as budget-conscious hospitals replace aging stand-alone dictation systems with integrated solutions designed to increase efficiency throughout the entire clinical documentation lifecycle.

Speech Recognition Innovations

Speech recognition has come in two approaches: front-end, in which the physician directly sees the recognized text on a PC, and back-end, in which the system completes speech recognition and sends recognized text together with the original voice file to an editor for corrections.

With front-end systems, users need to adjust their normal dictation pattern to optimize for higher recognition accuracy. As users dictate, they can view and edit the document as it appears.

Several factors have enabled front-end systems to gain a foothold in radiology. Since radiologists use a relatively small vocabulary of about 50,000 words, the burden to correct and train front-end speech systems for radiology is less. This, in turn, limits the amount of mistakes generated with each report and minimizes disruption to workflow. Radiologists also generate large amounts of dictation per physician, thus providing an easy return on investment (ROI) justification for the dollars spent in acquiring the technology–typically from $5,000 to $10,000 per license.

This environment has not been without challenges. Most physicians are not inclined to devote the hours necessary to train and customize the system to recognize and interpret voices to the necessary level of accuracy. This is understandable, given the rigorous deadline pressures and powerful financial drivers that radiologists have to contend with to maintain a high throughput of reports. Besides the high licensing fee, the software has to be integrated with a hospital’s ADT feed and a document management system, and customized to include hospital-specific voice-activated templates, physician-specific normals (preset blocks of formatted text for repetitive dictations) and physician training. Many hospitals concerned with near-term ROI and changes in physician behavior have stayed on the sidelines.

Since cost and workflow issues block wider acceptance of front-end speech systems, a different approach has emerged: back-end speech recognition. With back-end systems, users dictate at their normal pace into a phone, PC microphone or handheld device; the text is generated behind the scenes on the “back end.” Once dictation is completed, the voice file is processed by the system’s speech recognition engine to generate a text file that the medical editor or transcriptionist edits.

The key advantage to back-end systems is that they allow users to maintain their customary workflow without changing their dictation pattern to accommodate the technology. Physicians can go back to seeing patients without diverting time to clean up dictations. Meanwhile, the speech engine will compare the original text against the edited version provided by the transcriptionist and “remember” the corrections, thus improving recognition accuracy over time.

Recent Changes in Technology

Just as the first iterations of speech recognition technology were designed to make document generation more cost-efficient, so, too, have recent improvements in the technology:

* the integration of comprehensive vocabulary sets for various healthcare specialties;

* more sophisticated engines that can compensate for dead air or distinguish between ambient sounds and voices;

* the incorporation of structured text and templates for documents; and

* the ability to accommodate more input devices.

While the emphasis of back-end speech recognition technologies has been not to alter physician behavior, transcriptionists have had to adapt. The more than 200,000 transcriptionists in the U.S. have trained themselves, over many years, to listen to dictation through their ears and type using their fingers. The back-end speech recognition paradigm requires them to listen to the dictation through their ears, watch recognized text through their eyes and type corrections using their fingers.

Furthermore. there is no integration of process or technology to aid transcriptionists as they toggle back and forth between text files that are generated by speech recognition systems and recordings produced by traditional phone-based dictation.

Improving Workflow

A number of technology improvements hold the potential to allow transcriptionists to reap the benefits of speech technology, while easing the transition from transcriptionist to editor:

Voice and text bookmarking. Bookmarking speech recognition-generated text to match corresponding sections of dictation adds an extra measure of efficiency to the editor’s workflow. An editor now can edit a particular part of the document and hear the corresponding dictation without searching for it using a foot pedal.

Highlighting low-recognition-confidence sections. By presenting editors with multimedia documents that automatically highlight the sections of documents that have a level of recognition confidence below a certain predetermined percentage, editors can directly transcribe such sections without changing their behavior, while accepting the rest of the recognized document as is.

IP telephony. As hospitals upgrade their voice infrastructure to adopt IP telephones such as the Cisco 7900 series, voice can be captured at a higher quality (16-KHz, 16-bit samples, instead of 8-KHz, 8-bit samples with current telephony technology), resulting in improved accuracy for speech recognition with no change in physician behavior. This would also reduce the editing load for transcriptionists.

Saving the original. Storing the original dictated voice as part of the electronic medical record (indexed by all the same metainformation as the text report) is another way healthcare organizations are gaining more and more comfort with speech-recognized documents. It is going to become mandatory that the electronic chart of the future is a multimedia document, not just a replacement of current paper-based information.

Building in productivity tools like dictionaries, normals and word expanders tied to specialty disciplines, which automatically offer to insert a complete word when the first few letters of it are typed, also enhances efficiency.

Of course, transcriptionists will have to adapt their habits to work with reports generated by speech recognition. Changing a deeply ingrained behavior and then ramping up a new behavior to a productive level will be a critical step for transcriptionists to thrive in the new document-creation paradigm.

While still in the middle of an organizing campaign at Somerset Medical Center in Somerville, New Jersey, the New York State Nurses Association stepped in to defend the rights of RNs laid off through the illegal closing of the hospital’s inpatient psychiatric unit. Somerset administrators suddenly closed the unit on October 24, 2003.

“This unit also happened to employ some of NYSNA’s strongest supporters,” said Marvin Moschel, assistant director for organizing of NYSNA’s Economic & General Welfare Program. “More than a dozen RN jobs were lost, with the administration claiming in a memo to staff that it closed the unit because the census was low and the RNs were providing care that was below par.”

NYSNA contacted the New Jersey Department of Health (DOH). In its initial reply to a DOH inquiry, hospital administrators claimed the unit was still open, but DOH inspectors conducted a surprise visit and found the unit closed. As a result, the New Jersey Health Department charged the medical center with violating state law by closing its psychiatric unit without permission from the state, and without adequate justification, fining the hospital $5,000 a day, retroactive to October.

NYSNA then confirmed through inside sources that the RNs on the psych unit were indeed fired because they were union supporters, and learned that the medical center offered some psych nurses a severance package on the condition that they not speak about the issue. Based on unfair labor practice (ULP) charges by NYSNA, the National Labor Relations Board (NLRB) is investigating the firing of one pro-union nurse leader, as well as the closing of the psychiatric unit. A third charge has been filed over threats by the hospital to fire RNs who vote or campaign to unionize.

NYSNA has also contacted the American Nurses Credentialing Center-the organization that grants magnet status-informing them of these events. In theory, a medical center with magnet status has an ideal work environment for RNs, and an applicant’s history of labor relations is an important factor in granting or withholding magnet status. By filing ULPs with the NLRB, NYSNA has put the magnet designation process on hold.

Meanwhile, the medical center’s physicians have asked for the chief executive officer’s resignation over the closing of the psych unit. “The pressure is really on medical center administration now,” Moschel said. “The RNs are standing up for themselves, letting them know that there must be improvements in working conditions and that this must happen through collective bargaining.”

ENDICOTT - ENSCO, Inc. and Endicott Interconnect will manufacture a baggagescreening machine designed to detect explosives. The venture will add 700 jobs ,over the next four years at Endicott Interconnect. The ENSCO-developed SureScan screening system can check up to 1,000 bags per hour for explosives. Technology-development company ENSCO turned to Endicott Interconnect to manufacture the SureScan machines for a commercial market, says Karen Carpenter, director of marketing and communications for Endicott Interconnect Technologies.

Endicott Interconnect will spend $10 million readying its facility to produce the SureScan, she adds.

Endicott Interconnect is a privately held venture of several partners including the Maines family of Maines Paper and Foods and the Matthews family of electronics maker, the Mateo Group. Local investors purchased the IBM microelectronic division’s assets in 2002 as part of a $100 million venture. The company employs 1,900 and had $200 million in annual revenues for 2003. Endicott Interconnect manufactures electronic components, electromechanical equipment, and other electronics used in the defense, medical, and automotive industries, as well as for other sectors.

The ENSCO manufacturing partnership reflects the change the former IBM operation has undergone since the local owners took control.

“We have gone from a computer-focused [business] to a very diversified company over the past year,” says Carpenter.

The company has customers around the world, she adds. Its facilities cover more than one-million square feet. The SureScan manufacturing venture won’t require the addition of any space, says Carpenter.

ENSCO and Endicott Interconnect will begin testing the SureScan machines at airports in the U.S. and Europe later this year, pending approval of the Transportation Security Administration. After approval and testing, the units will be sold directly to airport-operating authorities around the world.

ENSCO unveiled the latest version of the SureScan this month at the Passenger Terminal Expo trade show in Geneva, Switzerland.

Virginia-based ENSCO, Inc. employs 725 at facilities in Endicott, Melbourne, and Cocoa Beach, Fla. and its field offices in Beijing. The privately held company has annual revenues of $90 million.

The demand for certain health-care workers is growing faster than the supply. There are more people needing more health care, and the numbers will only grow. Nevertheless, the public still expects high-quality care.

Geriatric Care

One of the reasons for the demand for health-care workers is the aging baby boomer generation. As a result, geriatric care (care of the elderly) is one of the areas experiencing rapid growth. High demand in that field is likely to continue over the next 30 years.

Julie Kemp-Havican is a social worker/special needs unit coordinator at the Marquette County Medical Care Facility in Ishpeming, Michigan. “I oversee a 30-bed special needs unit designed for people in the middle stages of Alzheimer’s disease or related dementia,” Kemp-Havican says. “Our goal is to provide a stimulating, homelike environment to individuals who are too confused to live independently, but who are not yet ready for a traditional nursing home.”

Kemp-Havican screens candidates for the unit. Once they are admitted, she evaluates their needs and develops care plans for them. As their disease progresses, she monitors their ongoing eligibility for the unit. “I also train all staff in dementia care skills and supervise the staff and the operation of the unit,” she says.

Her favorite part of the job is the time she spends with residents. The staff involves residents in activities like cooking, arts and crafts, and music. They also spend time reminiscing with residents. “It is truly rewarding because those who you work with and help are very grateful to you,” Kemp-Havican says.

Nursing

The U.S. Department of Labor’s Bureau of Labor Statistics (BLS) says nursing is the largest health-care profession. It is also one of the 10 fields projected to have the most new jobs.

Pam Webb is a registered nurse (R.N.) and also has a certification in infection control (CIC). She is the infection control coordinator at Benefis Healthcare, hospital in Great Falls, Montana. “It’s an art, being a nurse,” Webb says. “It’s using your scientific knowledge and balancing it with your communication and organizational skills.”

Webb earned her bachelor’s degree in nursing from Montana State University. She is now working on a master’s degree in public health from the University of Washington.

She keeps patients healthier by preventing infections. That means keeping patients, employees, and visitors from getting infections that can then spread among patients.

“I make rounds in the hospital, identify patients who have healthcare-associated infections, and I look for trends or patterns of infection,” Webb says. “Prevention efforts are very critical to my daily role, so that our patients have the best possible outcomes.”

There are a wide range of specialties within nursing. Nurses can work in hospitals, doctors’ offices, or other medical settings. They can work with children, the elderly, or patients of all ages.

Webb has worked in many different settings as a nurse. Those areas include coronary care, coronary intensive care, and surgical intensive care. She has also worked as a traveling nurse in hospitals around the country.

Webb says that her love of science helped her choose to go into nursing. She also enjoys using her communication and people skills in her job. “Nursing as a profession has been the best possible career I ever could have chosen for myself,” says Webb. “I’ve had opportunities presented to me that I never would have had otherwise, in any other profession.”

Dental Care

As people live longer and keep their own teeth longer, the need for dental care workers is rising. Dental hygiene is one of the 30 fastest growing careers, according to the BLS.

“A lot of people think hygiene is just cleaning teeth,” says Angeline Nichols, a dental hygienist in Lima, Ohio. The practice she works in focuses on nonsurgical periodontal (having to do with the tissue and structures that support the teeth) therapy, a fairly new area of treatment.

“We have an instrument called a probe, and we measure the space in between where the gums attach to the teeth,” explains Nichols. “Once that space gets deeper, the bacteria get down [into it] and will start to destroy the bone, so a lot of our adult therapy is getting under the gums and keeping the teeth clean there. It’s trying to keep patients’ oral health without surgery, because it can get bad enough that they need gum surgery or bone grafting.”

Dental hygienists are only required to have an associate’s degree. However, Nichols suggests getting a bachelor’s degree to allow career growth, including the option of teaching.

Nichols enjoys feeling that her work makes a difference. “I think we’re changing the way young adults and middle-aged adults feel about keeping their teeth,” she says. She explains that while older people accept dentures as a normal part of aging, today’s middle-aged population is learning that they can keep their teeth for a lifetime.

Physical Therapy

Physical therapists are also in high demand. They help people recover from injury or illness. The need for their services is higher among older patients, whose numbers are growing as the population ages.

Penny Reid, a registered physical therapist, works at St. Luke’s Rehabilitation Institute in Spokane, Washington. She treats patients with spinal cord injuries or orthopedic problems. Many people get outpatient physical therapy, but Reid’s clients are inpatients at St. Luke’s.

She spends six to seven hours a day in direct patient care. That includes helping patients with exercise programs and other therapy. The rest of her time is spent on tasks like paperwork and staff meetings. She also supervises physical therapy students working as interns at St. Luke’s.

Patient care is her favorite part of the job. “I wanted to work in a medical field, and chose not to go into nursing,” Reid says. “I enjoy the patient interaction. It’s very rewarding to help people in a tangible way to get back into living their lives.” She also says that the career pays well, and offers a wide range of job choices.

Reid has a bachelor’s degree in physical therapy, and a master’s in applied behavioral sciences. Currently, a career in physical therapy requires only a bachelor’s degree. However, Reid says that is changing. “Most educational programs now graduate their students with a master’s in physical therapy, and many are moving toward a doctor of physical therapy (DPT),” says Reid. “In the next several years, all new graduates will likely have a DPT at the time they enter the workforce.”

IS HEALTH CARE THE FIELD FOR YOU?

Are you wondering if a job in the Health Science Career Cluster is right for you? If you can check off most or all of these items, it may be! (Some items apply to health care in general, while others are more career-specific.)

* I am interested in the sciences, such as biology.

* I enjoy working with people.

* I show respect for people of all ages, backgrounds, and conditions.

* I am strong enough to lift and support patients.

* I am nurturing and compassionate. am patient

* I have strong observation and analytical skills.

* I am able to communicate my findings and recommendations.

Hot Jobs in HEALTH CARE

MEDICAL STAFF ROOTS date back to initial quality improvement efforts of physician leaders such as Ernest A. Codman, a surgeon who led in the initiation of review of the quality of surgical care in the early 1900’s.

Paul Starr noted in The Social Transformation of American Medicine (1) that the American College of Surgeons first took a formalized approach to hospital surgical review in 1919, establishing a voluntary standard that ACS-approved hospitals must affiliate physicians into a “definite medical staff.”

In addition to dealing with the intense financial and competitive elements then dividing organized medicine, the surgeons recognized a need for an organized quality evaluation of surgical services that required a more formal organization of surgeons at hospitals.

These concepts matured to create the Joint Commission on Accreditation of Hospitals (JCAH) in 1951.

The historical development of hospitals from charities sponsored by wealthy patrons to today’s medical centers was not an easy road. Three centers of authority and power emerged:

2. Physicians

3. Executive management

“Instead of a single governing power, three centers of authority are held together in loose alliance,” Starr states. “Hospitals remained incompletely integrated, both as organizations and as a system of organizations–a case of blocked institutional development, a precapitalist institution radically changed in its functions and moral identity but only partially transformed in its organizational structure.”

Medical staff regulation

The initial Standards by the JCAH (now the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) required accredited hospitals to have organized medical staffs.

The medical staff was responsible for overseeing the clinical practice and quality of care provided by physicians at the hospital. While recognizing the ultimate responsibility for patient care in a hospital is vested in the governing board, a de facto delegation of most of these functions to the medical staff exists in hospitals.

External regulation of hospital medical staff functions was very limited until the advent of the federal government payment programs in the 1960s. Additional regulation stemmed from judicial decisions establishing the doctrine of corporate liability of hospitals for the professional negligence of independently practicing physicians providing care at the hospital.

The Darling v Charleston Memorial Hospital (2) and Johnson v. Misericordia Hospital (3) cases clearly established that hospitals have liability responsibility for patient injuries caused by acts or omissions of physicians on the medical staff.

This responsibility exists even if the physician is not employed by the hospital, but while acting as an independent contractor. Fulfillment of some of the regulatory responsibilities of hospitals is accomplished through the effective performance of an organized medical staff.

In particular, this includes:

* Credentials review

* Appropriate privilege delineation

* Quality of care and risk management activities

As hospital responsibilities increased, the ability to get physicians to perform required medical staff functions diminished.

Physician involvement has been, in effect, quid pro quo. That is, in exchange for the hospital providing the essential professional and technical staff assistance, equipment and supplies to support patient care, physicians are expected and required to provide voluntary services in medical staff leadership, service on committees and departments.

Recent developments

Until the last decade, the quid pro quo approach functioned fairly effectively. Volunteer physician services generally fulfilled the primary functions of a medical staff. These activities included:

* Reviewing physician credentials

* Making recommendations for staff appointment and clinical privileges to the hospital governing body

* Reviewing quality of care in committee and clinical department activities

* Participating in hospital clinical services planning

* Providing continuing medical education

* Participating in the accreditation process and other regulatory compliance

The scene changed dramatically in recent years.

Medical staff leadership activities matured into real jobs requiring special skills. Collaborative medical staff relationships often transformed into competitive camps of physicians with differing allegiances.

Medical staffs of the past were often composed of independently practicing physicians. Today, many hospital medical staffs are a mixture of hospital-employed physicians, physicians providing services under exclusive specialty service agreements and independent physicians.

Pressure to produce strong financial results requires medical staff physicians to devote more time to patient service and less time to medical staff responsibilities. All this reduces physicians’ willingness and ability to provide the volunteer medical staff leadership services required by hospitals.

With more complex medical staff tasks, hospital support staff is now handling functions formerly performed by physicians. In some places, intense differences exist between a hospital’s governing board and executive administration policy direction and the views of physicians on the medical staff. All of this strains the internal working relationships.

The process of selecting leaders sometimes compounds the problems. Elections are most often used to choose medical staff officers. Department chairs are generally appointed or elected by the medical staff. Leadership is usually rotated, resulting in inconsistent quality. It is seldom based on a thoughtful evaluation of the leaders’ competency.

This “sharing of the burden” method can give way to organizational disasters. Many tasks are now managerial and few physicians possess adequate management training. This greatly narrows the pool of competent physician leaders who can handle the tasks.

Minor medical staff organizational changes

In recent years, hospitals and medical staff physicians tried to address these challenges through minor evolutionary changes.

Examples include:

* Lengthening the term of office for the medical staff president (In years past, the chief of staff or staff president often served a one-year term. In most hospitals today, presidents serve multi-year terms following a term as president-elect.)

* Offering formal training for medical staff leaders

* Paying the medical staff leader a stipend to offset income lost because of medical staff duties

* Recognizing a clinical department chair as a management function, appointed by the governing body

* Providing funding and training of medical staff administrators so people with proper skills handle medical staff activities

Even with a mixture of these changes, however, most hospital medical staffs continue to maintain ingrained dysfunctional components. Many physicians view leadership positions as a burden. Physicians who may have the talent for leadership eschew the positions. The pool of available, talented and willing physician leaders in many hospitals has decreased to a critical level.

Even in hospitals with a director of medical staff affairs, it is common for a physician who lacks credibility with medical staff members or lacks the talents and skills necessary to perform the job to fill the position.

Nothing better dramatizes these challenges than situations where a corrective action, or the denial, reduction or termination of a physician’s appointment or privileges at a hospital is taken.

These actions are always difficult. Peer physicians acting in a voluntary capacity possessing little if any training in such matters are often reluctant to undertake adverse action involving a fellow physician even if corrective action is apparent. Hospital medical staff structures often hamper more than help in these cases.

Revolutionary approach to medical staff leadership

It may be time for a more revolutionary approach to medical staff leadership.

Two primary goals of a new structure should be:

1. Centralization of responsibility and authority for medical staff activities in a recruited core group of selected and trained physicians

2. A significant reduction in the total time required of medical staff members performing committee and department functions

Reduced committee time cannot lessen ongoing improvements in the quality of a medical staffs core elements. To the contrary, patient care should measurably improve from the changes or they are not worth undertaking. Core elements include:

* Assurances of quality care

* Participation by physician leaders in the hospital’s policy formulation and strategic planning

* Credentials review and privilege determination

* Appropriate corrective action and assistance in external and internal compliance programs

Along with American jobs exported overseas, individuals’ personal data is often sent to countries that lack consumer privacy laws.

A growing number of U.S. medical and financial-services firms are shifting information-processing work to lowerwage countries that lack tough privacy laws, leaving their consumers vulnerable to identity theft and possibly other crimes.

According to Gartner, offshore business process outsourcing services, which typically require the transfer of personal data, grew 38 percent last year to just under $2 billion.

Concerns include overseas call-center workers being able to view or manipulate personal records stored in U.S. data centers and having databases of information on their citizens physically located in a foreign country and operated by a third party.

“Outside the U.S., medical privacy doesn’t really mean anything,” said California Sen. Liz Figueroa, who wants to bar offshore outsourcing of medical and financial records. She is sponsoring bills to require California employers to notify the state and employees if they plan to move 20 or more jobs overseas and to prohibit state contracts from being fulfilled offshore.

Sen. Dianne Feinstein (D-Calif.) has asked the U.S. Comptroller of the Currency to investigate whether banks that process customers’ financial data offshore have safeguards to protect that data from unauthorized use. In Arizona, proposed legislation would bar companies from shipping financial data outside the country without written permission from consumers. A proposal in South Carolina would prevent companies from giving “financial, credit, or identifying information” to a callcenter representative abroad without the individual’s written permission.
Executives who are counting on offshore operations to lower their costs say safeguards are in place to protect individuals’ privacy. Critics say privacy cannot be guaranteed in offshore settings. According to privacy advocates, contract language and security technology are not enough to protect the confidentiality of personal data that has been moved offshore.

For example, last year, a disgruntled Pakistani worker upset about back pay threatened to divulge data about patients at a San Francisco hospital that sent its transcription work abroad, according to Information Week.

Most Vermont politicians and business leaders have long been boosters of the state’s participation in the global economy, arguing that openness to world trade offers bright opportunities for job growth.

Lately, however, Vermonters have been seeing the dark side of globalization. Recent instances of public and private “outsourcing” are heightening awareness that involvement in a rapidly shifting international economy can also lead to loss of jobs in Vermont. Workers at National Life and other firms have learned through bitter personal experience that competition for jobs from lowwage countries is no abstract threat.

So which is it? Does Vermont win or lose from taking part in the global economy?

It’s a bit of both, according to most economists and state officials. But they conclude that on balance world trade does generate significant benefits for Vermont. “It’s easy to identify those who get hurt by globalization,” says Richard Heaps, publisher of the Vermont Economy Newsletter. “Those who are helped aren’t as easy to see. If you can buy your t-shirts for 25 cents less as a result of world trade, you don’t get to be on television.”

The media can effectively dramatize the misfortunes of a Vermonter whose job is outsourced to a call center in India, advocates of world trade note. Not as well pre-packaged for the nightly news, they argue, are the stories of an estimated 11,600 Vermonters who are working for companies headquartered outside the United States.

It’s the actual and potential losses of Vermont jobs to overseas competitors that have dominated discussion of globalization in recent months. In March, there came the revelation that a food stamp initiative undertaken by Vermont and six other Northeastern states has resulted in some jobs being exported to India. Earlier in the year, the Montpelier-based National Life insurance company announced that it was outsourcing 158 information-technology jobs to Keane Inc, a Bostonbased company, that will, in turn, ship some of that work to India.

Many of the affected employees at National Life were devastated by the news. “Workers were weeping at their workstations,” says Tim Abraham, one of those hit hard by the company’s decision.

“Many have not slept through the night since the day of the announcement,” Abraham said at a Montpelier forum in March organized by Congressman Bernie Sanders, a leading opponent of outsourcing. “Many are under the care of physicians. Some have resigned without severance and many are looking to get out from under the grasp of a company that has so crudely dismissed them.”

Abraham, a Killington resident, isn’t just complaining about his own plight; he has formed an advocacy group to address the larger issues and impacts of the economic dislocation associated with global trade.

“As a result of this outsourcing initiative, a significant piece of the fabric, that we in Vermont call community, has been ripped to shreds,” Abraham said. “Life in Montpelier and this state and this nation has changed dramatically because CEOs, hot-shot consultants, clueless economists, and hip-pocket politicians are trading our country’s middle class benefits for corporate profits.”

Heaps and other defenders of globalization acknowledge that Vermont’s integration into a changing world economic system will not be a painless, riskfree process. But they say that retraining programs sponsored by the state will help prepare workers like Abraham for new, and perhaps better, jobs.

“It’s not necessarily the end of the world for these individuals,” says Heaps. “Many of them will move on and find other jobs.

“We at the Agency of Commerce are trying to provide training options for Vermonters who do get displaced,” adds Kevin Dorn, the head of that agency. He suggests that these efforts may enable affected workers at National Life “to compete at a higher level.”

For the sake of the state’s long-term economic health, Dorn continues, economic development officials in Vermont “need to look toward the jobs of the future and help prepare our folks to qualify for them.” That’s a more effective approach, he says, than “looking backwards to jobs that have left the state and that we can’t compete for anyway.”

Vermont would only damage its own economy if it tried to isolate itself from the world economy, state officials argue. “The pace of change keeps accelerating,” Dorn says. “And at the end of the day it’s the ability to be nimble that will attract the greatest amount of investment.”

“One of the strong suits for the US economy, in comparison with Japan and the European Union, is that we’re more flexible,” Heaps adds.

All this may be true, or at least inevitable, in regard to private enterprise, say some opponents of outsourcing. But they draw a sharp distinction between the job-siting decisions of forprofit companies and those made by government agencies.

“As a matter of state policy,” says Burlington Mayor Peter Clavelle, “we have to put Vermont first. We have to adopt policies that support the creation and retention of jobs in Vermont. And one very modest step would be to stop state government from outsourcing contracts and using taxpayers’ dollars to pay for jobs overseas.”

Clavelle, the Democratic candidate for governor, was commenting on the Agency of Human Services’ food-stamp outsourcing move. He was also speaking in response to Governor James Douglas’ support for a World Trade Organization agreement, which, opponents charge, could result in state contracts going to companies in Central America rather than in Vermont. (See accompanying story.)

The City Council in Burlington had attempted in March to pass a resolution that would have prohibited city contracts with contractors who send jobs outside the United States. The council eventually tabled the motion unanimously, despite Clavelle’s support, because of the complicated nature of rule.

The debate over outsourcing shifted to the state government’s role due to Vermont’s $450,000 payment to Citibank as part of a multi-state deal’ intended to update administration of the food stamp program. The New Yorkbased financial giant subcontracted with a company in Wisconsin which then arranged for some of the contracted work to be performed by a firm in India.

Protests over the state’s role in sending jobs overseas led to demands for an accounting of which other Vermont government agencies might have entered into contracts with firms in other countries.

Administration Secretary Michael Smith uncovered only a few such cases, some of which appeared readily justifiable. The Department of Tourism and Marketing, for example, was found to be using British and Canadian firms to promote Vermont as a tourism destination in Britain and Canada.

Smith notes that he has not yet received a report from the state Treasurer’s office regarding functions it may have outsourced.

“But I’ll bet apples to donuts that some of their financial contracts do involve ‘Operations overseas,” Smith says.

In today’s economy, he adds, it is virtually impossible for any large-scale organization, public or private, to avoid arrangments that entail the off-shoring of some jobs.

“If you’re running Microsoft products or just about any type of software, the chances are that if you need help late at night your call is going to be handled by someone in an office overseas,” Smith notes. “These sort of IT integrations are in place throughout our operations.”

The larger point, according to Smith, is that, “Vermont is actively engaged in the global economy and extricating ourselves from it would be very difficult and costly as well.”

It’s not necessarily bad that some administrative functions of the Vermont food stamp program have been shifted to India, adds economist Heaps. The state is presumably saving money by having this work performed at wage rates significantly lower than those prevailing in Vermont, he says.

“So that allows the state to free up money that could be returned to the taxpayers of Vermont or that could be used for other priorities, like maintaining roads and bridges,” Heaps argues.

But it’s not just state government that feels mounting political pressure to keep current jobs in Vermont and to give Vermonters preference for emerging opportunities, regardless of how much more ‘cheaply the work might be done elsewhere.

Southwestern Vermont Health Care, a medical center based in Bennington, recently bowed to both internal and external demands to cease its dealings with an Albany, NY, company with operations in India.

At issue was a growing medical transcription workload that could not be shouldered by the 14 dictation-takers employed directly by the hospital. Instead of relying on the Albany firm, which would have sent some of the new work to India, Southwestern Vermont will seek to fill the available transcriptionist positions through a training program at Vermont Technical College.

SO I WOKE UP AT NOON in the darkness of my room. I went out into the blinding midday light and looked across the street into Tompkins Square Park; there were already a couple hundred kids skating and standing around for the Emerica Wild in the Streets day. Tompkins is this torturous, supposedly “warm-up” spot right on my corner. When I wake up and straggle over for coffee, I usually resent its existence. It’s not until after I drink some caffeine and do some ninja kicks that I’m able to face any kind of social situation.

In the park, the kids were skating the flat bars and some launch ramps–Suski and Reynolds were doing some sweet jumps and Spanky was entertaining his fans. This really wasn’t a demo, though. Emerica got together with Autumn skateshop in the East Village and KCDC in Brooklyn to hold a city-wide skate jam. It wasn’t about what pros were doing what, it was just shredding. Anyone was welcome to skate.

Keeping it green from the Emerica team were: Andrew Reynolds, Leo Romero, Kevin Long, Bryan Herman, Tosh Townend, Aaron Suski, Heath Kirchart, and Braydon Szafranski. Besides the Emerica dudes, Robert Lopez Mont, Billy Rohan, Brandon Westgate, Taji, Harold Hunter, Allan Russell, and Phil Ladjansld were notably ripping on the scene.

AFTER A FEW HOURS AT THE TF, some kind of silent alarm went off and everyone barged down Avenue A to Houston Park. I rode the BMX bike that Jamie Reyes had left in my apartment, with Spanky in tow. He held on to a string attached to my handlebars; it was funny at first, but I had a huge heavy camera bag and the kid refused to push. Spanky is like the new Axl Rose or something–and I mean that in a bad way: “Ohhh, I’m tired, pull me to the demo …” Before the demo, Spanky was wearing a mink coat and kilt! Then he wouldn’t skate until one of his gear roadies found him his scarf. He fell on a Nollie Enward which some kid was filming, so Spanky dove into the crowd and started kicking his ass. He had the worst Satan face, crying “You can’t control me anymore! I’m the number-one skater in the world, better than Muska!” I was pulling him off, like, “Stop Spanky, that’s not your father!”

Besides that one bad apple it was so cool seeing such a huge mob of skaters all skating down the street at once (insert the nostalgic “can’t we all just get along” skateboard writing here).

Houston park is where things got crazy–the six-stair in front was heavily shredded. I got a bat signal from Andrew that said “gnarly status,” so I went over to the Half-Life section where Andrew did the most gangster frontside wallride. It was one of those things that I don’t think anyone has ever done, even though it’s been sitting there as long as the place has been a skate spot. It just solidified the fact in my head that Andrew Reynolds is one of the gnarliest dudes ever born. If Andrew woke up and said “No more gaps or rails, I’m only going to skate vert and do wallrides now,” he’d still be one of the best skaters in the world.

AFTER ANDREW DID THE WALLRIDE three times in a row, I raced over and shot some photos of dudes killing the ledge to bar. Billy Rohan did a big-spin front board, and Leo Romero did a kickflip 50-50 … what it is!

After that I rode my bikeset over to the Brooklyn banks, where dudes were schralping the wallride. As for the rail, Suski Smithed it and Robert Lopez Mont pulled salad grinds and frontside feebles. Most epic … I forget what else happened on the scene there; it was basically just a big crowd of kids siting around watching, and an occasional skater stepping up and getting broke while trying for the glory of a hammer situation.

Over at KCDC Amy Gunther was making me some food! Oh wait, not just me–that’s where the last stop of the day was, as well as a BBQ and a bunch of ramps on the closed-off street. Oh, and raffle tickets were on sale, with all the money going towards John Cardiel’s medical bills. A ton of skateboard companies donated product–it was the hugest stack of boards I’ve ever seen in my life. There was so much stuff that I think everyone who bought a raffle ticket for a dollar got a board.

That about sums up the situation on the scene. After the raffle I got in one of the Emerica ewwyerweird vans and we went to Albany for a demo. Yeah, I roll with the hot crew these days … owww!

In April of this year, McDonald’s CEO Jim Cantalupo unexpectedly died of a heart attack. Two weeks after the company’s board of directors appointed Charlie Bell to succeed him, Bell was diagnosed with colorectal cancer. And, just weeks ago Apple Computer CEO Steve Jobs underwent surgery to remove a tumor from his pancreas.

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These recent events highlight the need for executives to stay proactive when it comes to issues of their health. As one of the most important assets a company has, top executives owe it to their shareholders to take care of themselves.

Although many recent advances in medical science have led to the increased ability to detect and prevent many illnesses, busy executives may still find it difficult to make the time to attend to their health. Seeing a need, South Florida’s hospitals and medical centers have rushed in with a plethora of health care options targeted at busy executives. Armed with an understanding of the time constraints involved with setting appointments for tests and exams, these programs offer streamlined approaches to care. These top-of-the-line health care options include executive physicals offering VIP treatment for total-body health assessments. The technology is often cutting-edge: clinics and hospitals throughout the area continue to update both their equipment and facilities. The following is a round-up of the array of options available for the busy South Florida executive. Stay well.

Aventura Hospital and Medical Center has just completed the first phase of its $130 million North Patient Tower expansion project, part of the hospital’s plan for enlarging and renovating its entire facility. The hospital moved this June into the first four floors of an 11-story building, which includes a new 28-bed, 17,000-square foot, emergency department with all private rooms and two new intensive care units with 42 beds. The second phase, which will open in the fall of this year, will provide an additional 35 beds and a new surgical center with 10 operating rooms (two dedicated to open heart surgery), new registration and waiting areas with enhanced security. There will also be VIP rooms on each floor and two VIP suites with family living rooms.
Baptist Outpatient Center’s Executive Health and Wellness Program offers full examinations in a private, elegant setting. Amenities include a business center with Internet access, continental breakfast, plush terry robes or warm-up suits and 24-hour international patient assistance. Most examinations are completed during a half-day visit to the Baptist Medical Arts Building. The program’s multidisciplinary team provides a comprehensive medical evaluation, with results available on the same day. The physician also sends a follow-up letter to the patient, outlining areas that may need attention and recommendations for follow-up examinations.
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Bascom Palmer Eye Institute landed the top spot in US News & World Report as the best eye institute in the US this year. When asking ophthalmologists across the nation where they would send a family member if price and distance were no object, 78.5 percent chose Bascom Palmer. It is the institute’s third time in 10 years to be ranked No. 1 in the magazine’s annual medical institution rankings. What put Bascom Palmer Eye Institute on top? “The excellence and the care that we provide to each and every patient every day. And it’s the same care for all CEOs and all aspiring CEOs,” says Marla Bercuson, director of marketing. Bascom Palmer is also the University of Miami’s department of ophthalmology. Miami www.bpei.med.miami.edu (305) 243-2020

Bethesda Memorial Hospital has a Benefactors Pavilion that offers a VIP suite that is more like a hotel room than a hospital room. A minimum donation of $50,000 qualifies a donor for a lifetime membership in the Benefactors Pavilion Society, required for access to the suite.
Broward General Medical Center’s new seven-story parking garage is just the first phase in the hospital’s 400,000-square-foot expansion. Scheduled for completion in 2005, the expansion will feature state-of-the-art surgical suites, new critical care units, outpatient facilities, a 38,000-square-foot emergency department and a trauma center, as well as a new Heart Center of Excellence–the hospital’s specialized heart care center. Fort Lauderdale www.browardhealth.org (954) 355-4400

Cedars Medical Center has an executive physical program. It is targeted to international business people, and is offered in conjunction with Kendall Regional Medical Center and Aventura Hospital. An individual can come to any of the hospitals and have a complete physical starting at $795. It is a two-day process, which includes approximately 15 different tests. Miami www.cedarsmed.com (305) 325-5511

The Center for Preventative Medicine and Wellness at Memorial Regional Hospital was designed for busy executives and their families, and focuses on prevention. Lily Gusman, with the center’s Executive Physical Program, says the center believes that “healthy professionals create healthy organizations because they have a healthy approach to commanding the company. If they don’t take care of [themselves], the bottom line of the company suffers.” Special coordinators make all appointments for the patients, and on the day of their exam, a host escorts the patient to and from all appointments. Each patient is counseled by a physician on lifestyle and early detection of health problems. The center claims the cost is the same as a regular physical. The program started a year ago and is especially popular with international executives,
The Cleveland Clinic Florida’s half-day executive physical includes a complimentary lunch and a full slate of examinations and tests (from eye exam to a chest x-ray). Patients are guided from appointment to appointment, with a general practitioner coordinating it all, and a computerized medical record following them. Approximately five days later, patients receive a customized medical report with recommendations. If a hospital stay is necessary, the clinic is attached to Cleveland Clinic Hospital, where the rooms have wood paneling (to conceal medical equipment), refrigerators, closets, desks and Internet access. The hospital was the first in South Florida to acquire the da Vinci Surgical System for heart surgery. It uses a digital camera and robotic arms to enter the chest cavity through tiny incisions, thus avoiding cracking a patient’s ribs and leaving a long scar. The system allows surgeons to work on a beating heart during bypass surgery without the use of a heart-lung machine.
Coral Gables Hospital has one VIP suite, which features a living room, an entertainment armoire with a television and meals that are a cut above the standard hospital fare.
Coral Springs Medical Center has a new Women’s Diagnostic and Wellness Center, designed to meet the health care needs of women at every stage of life. At this new center, women have access to services including mammograms, ultrasound, non-surgical stereotactic breast biopsy (which is performed on an outpatient basis), breast self-exam training, bone densitometry test for osteoporosis, second opinion consultations and obstetrics pre-registration.
Hollywood Medical Center has a program called “Golf Again” for avid golfers with injuries to their shoulders, knees, back, and/or ankles. “Golf Again” is run by Florida-licensed physical therapists with special training in golf-related injuries. By combining a comprehensive physical evaluation with an evaluation of the individual’s body mechanics during his or her golf swing, the therapists develop exercise routines designed to get the patient back on the golf course. The “Golf Again” program consists of an initial evaluation and 16 one-hour sessions held over eight weeks.