SMCMA Physician

What I’ve Learned after 35 Years in Medicine

I have learned so much over the past 35 years from my colleagues.  As Isaac Newton said, “If I have seen further, it is by standing on the shoulders of giants.”  I completed my Physical Medicine and Rehabilitation Residency at Stanford in 1986.   I started my private practice in 1986, joining two medium-size, multi-specialty groups in the Mid-Peninsula.

In 1991, I started my own private practice specializing in sports, spine and pain management which became ReMeDy Medical Group.   In 1999 I started SPARCmed, a chronic pain management group that utilizes Functional Restoration to improve patient’s function, integrating medical management, physical conditioning, psychological care, and vocational rehabilitation.

The following people taught me lessons, which contributed to my education as a Physician:

Elaine Lambert, MD 

Electrolyte management of ICU patients.

Canal Wilmot, MD 

Spinal shock and management of Autonomic Dysreflexia.

James Kirn, BS  

Halo Placement on spinal cord injured patients and prosthetics for amputees.

Elaine Date, MD  

EMG/NCV, head injury, spinal cord injury, and stroke patient management.

Rodney Anderson, MD 

Upper and lower motor neuron bladder diagnosis and management.

Mike Berrly 

Determine proprioception sense by assessing the patient’s awareness of moving their large toe up and down.

Art Ting, MD 

Patient referrals are more reliable than physician referrals. Provide immediate treatment to all patients. Provide the best care to all patients regardless of their ability to pay. Provide this care for free if necessary.

Michael Dillingham, MD

Observe the entire extremity for atrophy and biomechanical  abnormalities.

Gary Fanton, MD 

How to exam for ACL laxity using the pivot shift.

Dan Tintor, DC 

Joint mobilization reduces pain. 

Richard Derby, MD

Constantly re-image the needle during spinal injections.

Arthur White MD 

What is the patients interpretation of the meaning of pain? Defining internal disc disruption.

Duc Nguyen, MD

Distinguishing Neurogenic vs Vascular Claudication based on how quickly leg symptoms resolve with sitting.

Robert Watson, MD 

Tell the player, wife, girlfriend, trainer, coach, General Manager, and owner the same thing about the athlete’s injury to avoid confusion.

Ray Tufts, ATC 

Diagnosing Sacral Iliac Disorders.

James Reynolds, MD 

Assess quadriceps strength by leg lunges.

Bernie Wilcosky, MD 

Assess restorative sleep which influences pain perception.

Mark Pratt, PhD  

Patients with depression and anxiety may self-medicate with alcohol.

Steven Feinberg, MD

Asking the patient the cause, meaning, and impact of their pain.  Asking are they satisfied with their medical care. Asking educational level, salary, amount of disability payments, and do they believe in a higher power.

Jerome Schofferman, MD

Patients that have been sexually abused as children are more likely to develop chronic pain as an adult.

Bob Pavy, MD 

Babinski performed with socks off.

George Schmangnoff

Night time spinal pain can indicate malignancy.

Perry Shoor, MD 

Loss of hair on the toes is an indication of vascular insufficiency.

 

I also learned the following business and practice management ideas:

Frank Clohan, Esq  

Indicate production expectations with new medical providers, including how many patients seen per hour and per day.  Indicate billing and collection expectations.  Outline marketing expectations, including which organizations one needs to join to facilitate referrals (i.e. join the San Mateo County Medical Society!!). Ask a potential new medical hire to complete a task (i.e. send you a resume, letter of recommendation, or sample clinic note) by a certain time.  This gives you an insight into their time management and reliability.

Robert Durazzo, MFT

Bipolar patients have a high incidence of substance abuse and their depression is deeper than unipolar depression.

Perry Blackmon, MFT

Anxious patients have a hard time falling asleep.  Depressed patients awake early in the morning.

John Lannin, MD  

Initiation anterior groin pain indicates hip arthritis.

Lauren Denenberg, PT

Deloading relieves discogenic low back pain.

Lorne Eltherington, MD

Scar injections with Lidocaine for pain relief. Clean a very wide field preparing for pain injections. Securing spinal needle with hand resting on the patient to avoid movement.

Felix Chen, MD  

Drug interactions.

Joe Prendergast  

Patients desire what they want, not what they need.

Todd Alamin, MD  

Does the spinal pain occur at the same time as the extremity pain?  If so, the discectomy is more likely to relieve leg pain as well as the back pain.  

Susan Kritzik, MD  

Provide only one week of opiates rather than a month in patients you are concerned about abusing them.

David Smolins, MD  

Opiate equivalencies to Morphine.

Steve Klein, DPM 

Assessing Lateral Plantar neuropathy.

Dimitry Kondrashov, MD

Hopping in place causing pain indicates Pars Stress Fracture.

Roy Lerman MD 

How to perform a Discogram.

William Montgomery, MD

Holding a weight for shoulder X-Rays is equivalent to standing X-rays for knees to assess joint space narrowing, indicating cartilage loss.

 

Kimeron Hardin, PhD

Primary vs secondary gains impact on human behavior.

 

General Observations

Never criticize an employee or colleague in front of anyone else.

Financially give your employees and patients the benefit of the doubt.

Give every patient one do-over for a missed appointment, lost or stolen prescription.

Patients non-compliant with medical care are more likely not to pay their bills.  They are also more litigious and have a poorer understanding of informed consent. Specifically, if a known potential complication is discussed, and if it actually occurs, they will be more likely to blame the doctor for the complication and are less understanding of why it occurred.

If you do not know something, admit it. Do not guess.  Find the answer later.

Do not assume answers for patients.  Ask open ended questions.

Listen to what your employees and colleagues have to say.

Always examine your patient. Human touch is therapeutic.  Do not rely entirely on diagnostic tests. Visualize the area of pain.  

Do not gossip with drug reps.

Perform the least expensive treatment, if comparable to more expensive options.

Always end each office visit with “Do you have any questions?”

Items to Avoid

Special incentives to employees that adversely affect other partners or associates.

Cherry picking patients that will be more profitable, leaving less profitable patients to your associates.

Uneven overhead allocation.  For instance, one partner gets more ancillary staff, but does not pay for it, even though it generates more revenue just for that partner.

Non-democratic leadership roles that are also not based on merit.

Double standards for promotions within a medical group, based on family relationships or personnel preference, rather than on performance.

Criticism of competing physicians care, to elevate your stature and demean the competitor.  This contributes to patient’s anxiety, fear, and anger unnecessarily.

Dr. Mark Sontag is a Physical Medicine and Rehabilitation physician in Redwood City.