The Medical Association of Georgia Journal by PubMan, Inc.

MAG members weigh in on health care Vol. 106, Issue 2, 2017

Georgia Rep. Cooper & U.S. Rep. Carter exclusives Highlights from FSMB’s 105th annual meeting The latest on federal tort reform and the 2017 omnibus bill What one solo practitioner thinks Case study: Amyloidosis

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TABLE OF CONTENTS VOLUME 106, ISSUE 2

IN EVERY ISSUE

34 Specialty Feature

3 President’s Message

36 County, Member & Specialty News

4 Editor’s Message

43 Prescription for Life

6 Executive Director’s Message 14 Case Study: Amyloidosis – Two sides of a coin 17 Georgia Composite Medical Board 18 Medical Ethics 20 Legal: Proposed federal tort reform 24 Legal: Key 2017 omnibus bill provisions 28 Practice Models 32 Patient Safety

FEATURES 8 The ACA, AHCA or something else – here’s what MAG members think 23 Opinion: American Health Care Act 30 General Assembly: 2017 – ‘The Open Season on Physicians’ in Georgia 41 MAG Medical Reserve Corps 42 Perspective: The most fundamental question

PRESIDENT’S MESSAGE

Our ‘Geraldine’ moment Steven M. Walsh, M.D.

Steve.Walsh@PeriopPartners.com

f I could go 20 years back in time, I’m not sure my fellow physicians would believe what I had to say. Would they believe me when I told them that lawmakers in Georgia had considered legislation that would fine or imprison physicians who failed to check the Prescription Drug Monitoring Program every time they prescribe an opioid? Or would they believe me when I told them about the legislation that would have required physicians to participate in every health insurance plan that is offered by any hospital where they have privileges? And would they take me seriously when I tell them that legislators passed a bill to allow optometrists to inject pharmaceutical agents into and around a patient’s eye? It feels like physicians are under siege. Nevertheless, I still believe that medicine is an amazing profession. As an anesthesiologist, I have had the privilege of seeing the joy and relief on a mother and father’s face after hearing their healthy baby’s cry for the first time following a Cesarean section delivery – knowing that I played a crucial role. Of course, every physician has a similar story to tell. The feeling is amazing. We live longer and better lives because of the advancements that have been made by modern medicine. Unfortunately, this progress has come at a cost – as health care now accounts for 20 percent of the nation’s GDP, which is clearly unsustainable. Efforts to reign in health care costs have resulted in some dramatic changes, which includes physician accountability, patient care and outcomes metrics, physician employment contract requirements, expanding prior authorization with step protocols, payment reforms, and EHR. Controlling costs is a good and necessary practice. But it is one that can carry unintended consequences. EHR is a good example, as a recent study by Colligan Sinsky, M.D., who serves on an advisory board at healthfinch, Inc., estimated that nearly 50 percent of a physician’s work now involves clerical tasks and EHR. This actuality undermines the patient-physician relationship in some troubling ways. Moreover, it takes a heavy toll on the physician community’s health and well-being. Feelings of anger, frustration, misunderstanding, and overcontrol have grown increasingly prevalent. A survey that The Physicians Foundation conducted in 2012 found that there was widespread “pessimism” within the medical profession. And fellow MAG member Faria Khan, M.D.,

discovered that more than half of the physicians in Georgia are affected by “burnout” in the research project she conducted as a member of the Medical Association of Georgia Foundationsponsored Georgia Physicians Leadership Academy. The term “burnout” means one who is “tired or discouraged.” More importantly, people who are burned out become “sloppy and stop making time for meaningful discussions.” Former American Medical Association President Steven Stack, M.D., echoed this concern when he stressed that, “If we truly want happier, healthier patients, we must ensure we have happier, healthier physicians to care for them.” Burnout influences the quality of care, patient safety, patient satisfaction, and physician turnover. The book How to Survive in Medicine: Personally and Professionally by Jenny Firth-Cozens references a survey that found that half of the physicians reported experiencing “reduced standards of patient care” (e.g., taking short cuts or not following procedures), while 40 percent said they felt irritable or angry. It is time for both our profession and society to recognize that physician burnout is a systemic problem and that it is imperative to begin to take steps to begin to correct the problem. First and foremost, we need to draw on the profession’s existing reserves of optimism and courage and resilience. We need to leverage the infrastructure we have developed in our county, district, and state medical societies. We must engage other stakeholder groups, including health insurers, hospitals, pharmaceutical companies, EMR vendors, and patient advocacy groups. And we cannot become dissuaded because such efforts have failed in the past – because we know what the outcome will be if we do nothing. We must be relentless in our efforts to build effective, broadbased coalitions. And if we are truly going to be the leaders of the health care system, we must be able to get past whatever prejudices we feel for other stakeholder groups because there is simply too much at stake for our profession and our patients. You might remember the iconic World War II poster that showed the bandana-clad Geraldine Doyle (aka ‘Rosie the Riveter’) flexing her bicep and proclaiming that, “We can do it.” Well, this is our ‘Geraldine’ moment.

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EDITOR’S MESSAGE

The Medical Association of Georgia 1849 The Exchange, Suite 200 Atlanta, Georgia 30339 800.282.0224 www.mag.org MAG’s Mission To enhance patient care and the health of the public by advancing the art and science of medicine and by representing physicians and patients in the policy-making process. Editor Stanley W. Sherman, M.D. Executive Director Donald J. Palmisano Jr. Publisher PubMan, Inc. Richard Goldman, rgoldman@pubman.net 404.255.5603, ext. 1 Editorial Board Jay S. Coffsky, M.D., Decatur Mark C. Hanly, M.D., Brunswick Barry D. Silverman, M.D., Atlanta Joseph S. Wilson Jr., M.D., Atlanta Michael Zoller, M.D., Savannah MAG Executive Committee Steven M. Walsh, M.D., President E. Frank McDonald Jr., M.D., President-elect John S. Harvey, M.D., Immediate Past President Steven M. Huffman, M.D., First Vice President Lisa C. Perry-Gilkes, M.D., Second Vice President Rutledge Forney, M.D., Chair, Board of Directors Frederick C. Flandry, M.D., Vice Chair, Board of Directors Edmund R. Donoghue Jr., M.D., Speaker James W. Barber, M.D., Vice Speaker Andrew B. Reisman, M.D., Secretary Thomas E. Emerson, M.D., Treasurer S. William Clark III, M.D., Chair, AMA Delegation W. Scott Bohlke, M.D., Chair, Council on Legislation Advertising PubMan, Inc. 404.255.5603 or 800.875.0778 Fax 404.255.0212 Brian Botkin, bbotkin@pubman.net Subscriptions Members $40 per year or non-members $60 per year. Foreign $120 per year (U.S. currency only). The Journal of the Medical Association of Georgia (ISSN 0025-7028) is the quarterly journal of the Medical Association of Georgia, 1849 The Exchange, Suite 200, Atlanta, Georgia 30339. Periodicals postage paid at Atlanta, Georgia, and additional mailing offices. The articles published in the Journal of the Medical Association of Georgia represent the opinions of the authors and do not necessarily reflect the official policy of the Medical Association of Georgia (MAG). Publication of an advertisement is not to be considered an endorsement or approval by MAG of the product or service involved. Postmaster Send address changes to the Journal of the Medical Association of Georgia,1849 The Exchange, Suite 200, Atlanta, Georgia 30339. Established in 1911, the Journal of the Medical Association of Georgia is owned and published by the Medical Association of Georgia. © 2017.

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Protecting your EHR Stanley W. Sherman, M.D.

f there is one thing that government regulations have accomplished, it is pushing most of us into utilizing electronic health records (EHR). While some of us have gladly embraced this and others have not, the regulations hold all of us accountable to protect these patient records. Locking your office door at the end of your day is no longer record security, so Medical Economics devoted its February 2017 issue to cyber security, which I have summarized below: The people who are after your data are called “hackers” and may be as varied as disgruntled ex-employees, the kid next door or, as it has been reported in the news of late, the Russians. Those who are criminals sell your information for identity theft, false billing for services, and forged prescriptions. They most commonly gain entry into your system with a “phishing attack,” where they send what appears to be a legitimate e-mail with an attachment which, when opened, places “malware” on your network – giving them access to your data. Even worse, they corrupt your system with “ransomware” software that encrypts your data, and they may force you to pay them to unlock your system and retrieve your data. Remember that these phishing messages may seem to come from a vendor you use, a colleague, or a place you stayed in the past because they have checked your social media or hacked your friends. These attacks can occur when someone contacts you with a text or phone call pretending to need your password to fix a software issue. How do we stop hackers? The article recommends updating every operating system on all of your devices with security “patches” as soon as possible. If your mobile device has access to your EHR with a mobile app, do not open links or videos from unknown people, do not use unsecured public networks, and use antivirus software. Make sure any office “open network” does not connect to your practice’s secure network, and require your patients to use a password to use your network. Set up your network so that only authorized applications can execute files and unknown programs cannot. Perhaps not every computer and employee needs full access when limited administrative access will do. Always have an updated, off-network backup of your data to ensure you can restore it, which is particularly important in the event of a ransomware attack. Storing your files on a remote server run by a third-party vendor – called “cloud computing” – may also add a higher level of security. Finally, training your employees about security and prioritizing the importance of security within your practice should be the first, and is probably most effective, step that you can take to protect your data. What to do if your practice suffers a breach and is hacked? At the first sign of unusual computer activity (i.e., it’s not known to your usual IT help center or Internet provider) – frequent crashing, slow servers, files that will not open – get professional help. The article recommends calling a lawyer to engage IT forensic experts to maintain confidentiality and prevent potential litigation. Do not hit “exit” and just walk away from your computers. Allow the experts to assess the extent of the breach, which can save you money if the breach is limited. Keep the practice running with a spare, non-system connected computer (or pen and paper,

remember those?). You will need to report the breach to the Department of Health and Human Services and the affected patients; the police and FBI may need to be notified, too. If all this sounds expensive, you are correct. You can consider buying cyber liability insurance of multiple coverage types, which was also discussed the article. Our feature article discusses what a number of our MAG members, coming from different places and practices, think about the present Affordable Care Act system and the American Health Care Act (AHCA) that recently passed the House. Special thanks to U.S. Rep. Buddy Carter for his perspective on this issue. The feature nicely summarizes what the AHCA proposals may mean for Georgia, while our CEO Don Palmissano Jr. offers MAG’s perspective on this legislation. We all owe our thanks to Rep. Sharon Cooper for all of her help in this year’s tough Georgia legislative session, which she reviews in her article. Congratulations to MAG member Kay Kirkpatrick, M.D., on winning her Georgia Senate District 32 race.

Our legal articles include updates on proposed federal tort reform and how the federal health care budget will be spent in FY 2017. Our second issue this year begins a number of new series of articles, including a historical series on doctors who have contributed to the cardiac physical exam by my predecessor and former Journal Editor Dr. John Cantwell, a series on a variety of practice models by Editorial Board member Dr. Barry Silverman, and, hopefully, the first of many future editorial perspectives by Dr. Mark Murphy. MAG President Dr. Steve Walsh addresses physician burnout, as does MAG Past President and current Georgia Composite State Medical Board Chair Dr. John Antalis. Our case reports address opioid prescribing and cardiac amyloidosis. Dr. Jay Coffsky warns of Faustian negotiations. Also please see Dr. Frank Kelly’s letter complimenting Dr. Coffsky for his long-time contributions to the Journal. Finally, we all mourn the loss of MAG Past President Dr. Joe Nettles.

MAG delivers great results during 2017 General Assembly

Georgia Gov. Nathan Deal recently signed a bill (S.B. 47) into law that will allow a visiting sports team’s physicians and trainers to provide care in Georgia without the need to be licensed in the state. MAG was a leading advocate for this legislation. The MAG representatives who attended the bill signing ceremony included MAG Government Relations Director Derek Norton (second from left), MAG President Steven M. Walsh, M.D. (fourth from left), MAG Foundation Georgia Physicians Leadership Academy Class 9 graduate Brad Bushnell, M.D. (with the red and blue tie to the left of Gov. Deal), and MAG Government Relations Associate Bethany

Sherrer (second from the right). The bill’s sponsor, Sen. Chuck Hufstetler (R-Rome), is in the dark suit over Gov. Deal’s shoulder on the left. Gov. Deal also signed a bill that will prevent the state’s Medical Practice Act from being used to require Maintenance of Certification (MOC) as a condition of licensure or to require MOC to be employed by a state medical facility or for the purposes of licensure, insurance panels, or malpractice insurance. Go to www.mag.org for a comprehensive summary of the 2017 legislative session.

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EXECUTIVE DIRECTOR’S MESSAGE

Inclusive, responsible and transparent Donald J. Palmisano Jr.

dpalmisano@mag.org

hen President Donald Trump said that, “Nobody knew health care could be so complicated” a while back, I wanted to go to the nearest mountain top and shout, “Welcome to my world.”

I have had the “opportunity” to watch the national health care reform debate and process play out for more than a decade now. I’m sure that you will recall that in 2010 the Patient Protection and Affordable Care Act (which morphed into the Affordable Care Act, or the ACA) was signed into law by-then President Barack Obama. At the time, health care costs were spiraling out of control. The health insurance market was poorly regulated. And pre-existing conditions served as a firewall for controlling costs by keeping a lot of the patients who needed the most care uninsured. States were also experimenting with high risk pools for patients with preexisting conditions – though without much success, as the costs were too high and the funding was hard to sustain. MAG supported some of the ACA’s key provisions – barring insurers from denying coverage to patients who have preexisting conditions; barring insurers from imposing lifetime caps; requiring all group health plans to provide first-dollar coverage for preventive services; and requiring insurers to cover dependents under their parents’ policies until the age of 26. But MAG was also concerned that the ACA would result in more government and third party intervention; it did not address tort reform; it expanded a flawed and failing Medicaid system (i.e., unfunded mandate); and it created nearly 160 new government oversight panels. When the dust had settled, MAG decided to oppose the ACA. It wanted to see increasing numbers of Georgians covered by health insurance – but not as a result of a health care system that the organization felt would ultimately crumble under its own weight and that would reduce the accessibility of care as insurers narrowed the networks they employ to control costs – a prediction that has come to fruition. Fast forward, and the U.S House of Representatives passed the American Health Care Act (AHCA) in May of this year. 6 MAG Journal

This measure narrowly passed the House along partisan lines, much like the ACA in 2010. The AHCA’s proponents argue that the legislation will empower the individual patient, allowing them to choose the type of plan that best fits their needs rather than one the federal government prescribes. They also point out that patients who have pre-existing conditions will be protected by high-risk insurance pools. And states will be given greater control and flexibility to manage their Medicaid programs. Opponents like AARP, the American Medical Association, the American Hospital Association, and the American Health Care Association, however, have a different point of view. They contend that 24 million people will lose their insurance coverage if this bill become law, especially when it comes to the patients who have pre-existing conditions. And some say that the ACA tax credits and subsidies will be changed in significant ways that will result in fewer patients being able to afford private health insurance. I believe that MAG learned some important lessons during the ACA experience. The physician community was divided, especially along primary care and specialty lines. And as someone who listened with an open mind, I can say that they all had good and credible reasons for advocating the positions they did. There is no doubt that MAG lost members as a result of its ACA position. And while 100 percent isn’t realistic when you have 7,800 members, our goal will be to achieve a consensus position on the AHCA to the greatest extent possible based on what is best for physicians and patients in Georgia. MAG will, therefore, solicit the views of its members with a survey(s) before it assumes any formal position on the AHCA. MAG staff will discuss this legislation with MAG’s leadership teams, applicable task forces, and the issue-specific task forces that MAG President Steven M. Walsh, M.D., commissioned at the beginning of year. We will reach out to the state specialty societies and other key stakeholder groups. And we will monitor what transpires in the Senate over the course of the next several months. One of the primary roles of a state medical society is to find common ground and unite the profession across specialties and practice settings. That’s not always easy, but you have my assurance that MAG will always employ a process that is inclusive, deliberate, and transparent.

NCI Designated Comprehensive Cancer Center

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The ACA, AHCA or something else, here’s what MAG members think By Tanya Albert Henry

n May 4, the U. S. House of Representatives passed the American Health Care Act (AHCA), a bill that is designed to “repeal and replace” the Affordable Care Act – and legislation that would change the country’s and state’s health care systems in significant ways. The American Medical Association’s president, Andrew W. Gurman, M.D., issued a statement that said that, “The [AHCA] will result in millions of Americans losing access to quality, affordable health insurance and those with pre-existing health conditions face the possibility of going back to the time when insurers could charge them premiums that made access to coverage out of the question.” Meanwhile, the Medical Association of Georgia’s (MAG) staff is busy evaluating the bill’s provisions, which it will then review with MAG’s physician leaders. Only time will tell what happens with this legislation in the Senate, but the Journal asked physicians in Georgia what they believe needs to change to improve the health care system – whether the vehicle is the ACA or the ACHA or something else. Need bigger networks One of the most common concerns for physicians in Georgia is that while it is true that a lot of patients have obtained insurance under the ACA, the system hasn’t necessarily been very easy to use. For starters, there isn’t an adequate network of doctors in a lot of communities. And, in fact, there is just one statewide ACA plan – Blue Cross and Blue Shield of Georgia, Inc. 8 MAG Journal

This is especially troubling for patients in rural areas, says John Crew, a health care consultant and principal with Strategic Healthcare Partners, which includes 66 MAG members in southwest Georgia. “[ACA] Plans are being sold in these areas, but the subscribers then realize that they cannot use these products in their own communities,” Crew explains. “With a population of more than 43,000, there are just five community-based physicians, and no hospitals, in the ACA exchange plan that is sold in Coffee County.” He also notes that the exchange plans have no oversight or parameters when it comes to access, and the law offers no incentives for insurance companies to expand and develop their networks. Crew states that, “There should be requirements about network adequacy and a mechanism to report inadequacies to DHHS [the Department of Health and Human Services].” He also believes that insurers that offer plans that have inadequate networks should be fined, and there should be network stabilization requirements to prevent health plans from arbitrarily modifying their networks during a subscription year. “Competition is critical for any market, including the ACA health care exchange,” remarks Crew, while concluding that, “Having just one health plan available adversely affects rural America.” Deductibles, mandates & Medicaid High deductibles and co-pays are also a barrier for patients who need medical care, according to general surgeon Stephen Jarrard, M.D., who practices in the far northeast corner of the state at The Tiger Clinic in Tiger.

“Many patients are excited to ‘finally have insurance,’ but then they realize that they have a $3,000 to $5,000 deductible,” Dr. Jarrard reports. “This essentially means that they don’t have insurance until they spend $3,000 to $5,000. That’s deceptive.” Networks and deductibles are problematic in metropolitan areas in Georgia, too. In fact, otolaryngologist Jeffrey M. Gallups, M.D. – the chair of the Ear, Nose and Throat Institute in Atlanta – believes that the ACA has failed on these and many other fronts. He declares that, “There’s no access to care in our specialty, there are high deductibles, and no one wants to pay for someone else’s health care costs.” To improve the system, Dr. Gallups says patients should be able to buy health insurance across state lines. He also wants to see an “any willing provider” statute passed to require health insurance carriers to let providers become part of the carriers’ networks if they meet certain requirements.

ACA repeal or revision? A 2016 survey of more than 400 primary care physicians that was conducted by researchers from Johns Hopkins School of Medicine, Massachusetts General Hospital, and the University of Pennsylvania Perelman School of Medicine found that about 15 percent would like to see the Affordable Care Act repealed, while nearly 75 percent favor revising the existing law. The following results highlight how the physicians who were surveyed feel about different health care reform options… • 69% support increasing the use of health savings accounts

Dr. Gallups supported the ‘Empowering Patients First Act’ that U.S. Health and Human Services (HHS) Secretary Tom Price, M.D., proposed in 2015, when Dr. Price was a member of the U.S. House of Representatives – representing Georgia’s 6th Congressional District.

• 67% support a public insurance option to compete with private plans

That legislation would have allowed patients to contribute more to health savings accounts, expanded tax-deductible contributions, and required HHS to provide a grant to each state for high-risk insurance pools to subsidize health insurance for high-risk populations and individuals.

• 59% support tax credits for Medicaid-eligible people to purchase private insurance

Beyond networks and deductibles, MAG President-elect Frank McDonald Jr., M.D., MBA, a neurologist with The Longstreet Clinic in Gainesville, says that the ACA’s “individual mandate” (i.e., requiring individuals to purchase health insurance or be subject to a tax penalty) also has not worked – keeping in mind the AHCA would do away with this requirement.

• 43% support expanding Medicare to people who are 55 and older (versus the current minimum of 64 and older)

“It seems as though many patients have calculated that it’s cheaper to pay the penalty than buy coverage on the ACA exchange,” Dr. McDonald says. “The problem, of course, is that without an individual mandate, people will not buy health insurance until they get sick.”

• 29% would like to see the use of highdeductible health plans increase

If the ACA does ultimately get repealed or replaced, Mary L. Wilson, M.D., the president and executive medical director of The Southeast Permanente Medical Group, says, “An emphasis should be placed on maintaining the health insurance coverage gains that have been made since the ACA was enacted, as well as continuing the ACA’s affordability agenda.” Dr. Wilson adds that, “We need federal financing for coverage for low and moderate income people, and we need some basic federal rules – such as protection for consumers with pre-existing conditions and a framework for essential health benefits.” She also notes that, “In return for more flexibility, the states – which are best positioned to understand their residents, geography, and provider and plan landscapes – should be accountable for gains in coverage and health outcomes.” Meanwhile, Medicaid expansion is a big concern for family physician Thomas Bat, M.D., the CEO of North Atlanta Primary Care in Alpharetta. He believes that expanding a program that “lowers the quality of care” is unwarranted.

• 62% support paying physicians based on value rather than volume

• 47% would like to see their state expand the Medicaid program

• 42% would like to see private insurance deregulated

Source: ‘A View from the Front Line Physicians’ Perspectives on ACA Repeal,’ The New England Journal of Medicine, February 9, 2017.

“Medicaid should be the insurer of last resort, not the fall back plan for every patient in the state,” Dr. Bat says. “My practice’s experience with Medicaid has been poor, including no payment on many claims, unsustainably low fee schedules, and extremely-narrow networks that result in an overutilization of the ER.” Dr. Bat would, instead, like to see Medicaid become a “highly managed” system that provides “premium support” for low income patients. He suggests that, “We should give our patients choices and responsibilities. We must move low income patients into real health insurance plans and get the government out of both health care and the health insurance business.” Dr. McDonald – who believes that “society has an obligation to help its most vulnerable citizens, including the poor, the elderly, and those with pre-existing conditions, get access to health care” – suggests that “the government should provide catastrophic coverage on a sliding scale based on an individual’s net worth.” www.mag.org 9

Dr. Jarrard says that lawmakers also need to look for ways to reduce prescription drug and third party payer administrative costs – “other than simply cutting physician reimbursement.” He asks, “What other profession takes care of people the way we do with the hope of getting paid at a sharply discounted rate and then feels lucky if they do? Try paying your attorney that way: ‘You charged me $7,500, but I am only going to pay you $2,650.’ See how that goes.” Dr. Wilson agrees that Congress must take steps to address what she sees as “unjustified prescription drug price hikes,” explaining that, “We are on an unsustainable path. Competition from generic drugs will help, and Medicare also has a role to play. But we need more help from market forces to lower prescription drug prices.” Bogged down by paperwork Regardless of what happens with the ACA or the AHCA (or any other legislation), physicians in Georgia are calling for lawmakers to reduce the enormous administrative burden that has been placed on them and their practice staff. For Dr. Wilson, “The biggest regulatory barriers we face are the ones that inhibit us from optimizing our multi-specialty group practice model and our advanced health information technology. Medicare has many rules that require that care and communication to be done on a face-to-face basis when we already have all of our patient’s information electronically available at our fingertips, and when we can already communicate with her or him electronically via telehealth tools and secure messaging.

Georgia by the numbers According to an article that appeared in The Atlanta Journal-Constitution on May 5… • About 1.8 million Georgians who are under the age of 65 have pre-existing conditions • About 46 percent of Georgians had employerbased health insurance in 2015 • Some 500,000 Georgians have an ACA health insurance plan • About 2 million Georgians are covered by Medicaid, including low-income kids, pregnant women, the elderly and disabled Sources: Kaiser Family Foundation and Avalere Health

these requirements are largely arbitrary and generally unrelated to providing quality care,” Dr. McDonald notes. “In addition to MACRA, we have to contend with ICD-10. And before MACRA, we had the PQRS and the EHR Meaningful Use program. Before that, it was E&M coding.” He is convinced that, “These regulations are driving physicians out of solo and small group practices and into large groups that have enough staff to deal with the regulations, a trend that affects the balance and accessibility of care across specialties and practice settings in the context of the entire state.”

“We’d like to see Medicare provide physicians who practice in accountable models, and who report  quality measures, like Medicare Advantage, with more flexibility to deliver care conveniently and safely in “Regardless of what happens with more settings, including virtually – in the ACA or the AHCA, physicians the patient’s home.”

Dr. Jarrard is more-than-familiar with the challenges that are posed by these reporting requirements. He explains that, “As a small, private practice, we simply cannot afford to hire staff for the sole purpose of reporting, but that almost seems to be what is required at this point. And matters will only get worse if [the government] continues to add requirements.”

According to Pamela Miller, a vice are calling for lawmakers to reduce president with IMPACT Management the enormous administrative Services – which serves six independent physician associations burden. ” and a statewide physician-only accountable care organization in  Dr. Bat remarks that his practice does, in Georgia that is composed of 465 fact, already have staff teams that are exclusively focused on data entry physicians (most of whom are MAG members) – “Physicians tell us and collection (i.e., rather than patient care). But he says, “It is just plain that the biggest federal regulatory obstacle they face is remaining upwrong. The unfunded ACA mandates have stifled innovation and increased to-date on policy and payment processes and methodologies.” health care and insurance costs. “ The system needs to be streamlined, she says, stating that, for example, “Some physicians have questioned why an entirely separate He adds that, “HHS should suspend all of the regulatory rules until process has been established for the ACA, rather than dovetailing with they are proven to work, and it should only institute these rules if it is Medicare or other government programs already in place to utilize willing to fund the costs associated with them.” existing administrative resources and networks of providers.” Dr. Gallups concurs, stating that he has not seen any evidence that For Dr. McDonald, complying with the Medicare Access and CHIP submitting “massive amounts of data” to regulators has improved the Reauthorization Act of 2015 (MACRA) – and its Merit-based quality of care. Incentive Payment System (MIPS) – is at the top of the list of today’s With that in mind, he hopes that the medical profession’s messages will most pressing challenges for physicians. resonate and that Congress will take steps to “reduce the regulatory “I am fortunate because I am with a large practice that has staff that burden that take so much of the physician’s time,” stressing that, “We helps me comply with today’s regulations, but that notwithstanding, want to treat patients, not serve a bureaucracy.” 10 MAG Journal

Antitrust and consolidation Another priority for physicians is antitrust reform. “I can show you two doctors who have practices across the street from each other and there will be a 30 percent differential in what an insurer pays for the same CPT code,” Crew says. “But if these doctors told each other what they were being paid, they would wind up being sued for antitrust.” Crew maintains that, “This is one of the biggest reasons more than 50 percent of physicians in Georgia are employed by health systems, and this is why a lot of physicians have thrown in the towel.” Dr. Bat can’t see a path to a sustainable health care system without antitrust reform, and he is convinced that the consolidation of entities that employ physicians hurts the overall health care system. He says that, “Hospitals shouldn’t be allowed to ‘own’ physicians or require them to use the highest-cost level of care, and we should favor the higher-quality, lower-cost options over hospitalizing our patients to the extent it’s possible.” Dr. Bat concludes that antitrust reform should be the “number one priority” for both Congress and the U.S. Justice Department. Striking the right balance There is widespread agreement among physicians in Georgia that there’s plenty to fix when it comes to the health care system. The challenge, of course, is reaching a consensus on how we get from here to there. A 2016 nationwide survey of more than 400 primary care physicians found that 15 percent would like to see the ACA repealed, while nearly 75 percent would like to see it revised, according to a study that was conducted by research teams at the Johns Hopkins School of Medicine, Massachusetts General Hospital, and the University of

Pennsylvania Perelman School of Medicine that was published in the New England Journal of Medicine. And in 2015, a survey of more than 1,600 physicians from around the country that was conducted by the Kaiser Family Foundation and The Commonwealth Fund discovered that nearly half (48 percent) viewed the ACA “favorably” while the other half (52 percent) viewed it “unfavorably.” This research also found that there were strong links between physicians’ opinions and their political affiliations. So nearly 90 percent of physicians who identified themselves as a Democrat viewed the ACA either “somewhat favorably” or “very favorably,” while nearly 90 percent of Republicans viewed it either “somewhat unfavorably” or “very unfavorably.” Dr. Wilson is convinced that, “If people are healthier when they become eligible for Medicare, Medicare’s financial future will be much brighter. If we treat those individuals with models of care and coverage that leverage technology and care team relationships, we can help them better manage their own health. “We need to encourage healthy people to get and stay covered before they get sick if we no longer have an individual mandate. Right now, the general uncertainty about the future of legislation at the federal level sends a discouraging message to health plans, providers, and consumers.” For Dr. Bat, deciding on what kind of health care system we ultimately want to have is a good and responsible starting point for solving some of the aforementioned problems. He concludes that, “Congress needs to listen to its constituents and decide if it wants to promote a single-payer, Medicaid-for-all system or whether it wants to promote a system that is based on free market principles – because we are trying to find a middle ground, and it’s not working.” ¨

MAG member wins election to becomes 5th physician in legislature Medical Association of Georgia (MAG) member Kay Kirkpatrick, M.D., won a May 16 runoff election for the Georgia Senate District 32 to become the fifth physician to serve in the current General Assembly. “The Medical Association of Georgia is extremely proud and congratulates Dr. Kirkpatrick on her victory,” says MAG President Steven M. Walsh, M.D. “MAG would also like to thank and applaud every physician who supported her throughout her campaign.” Dr. Walsh stresses that, “MAG’s strategic plan has and will continue to call for more physicians to be elected to the General Assembly, so this was a significant development – and what I hope, and believe, is the beginning of a trend.” He adds that, “It is imperative for physicians to have a voice in the state’s legislative process, so I hope that Dr. Kirkpatrick’s election inspires other physicians to run for elected office.” Dr. Kirkpatrick’s website says that, “Now more than ever we need leaders with health care knowledge to help Georgia manage the upcoming repeal and replacement of Obamacare. As a physician with years of experience in direct patient care, Dr. [Kirkpatrick] is uniquely qualified to support HHS Secretary Tom Price and restore the physician-patient relationship.” Dr. Kirkpatrick is a Republican – and she received 57 percent of the vote. Dr. Kirkpatrick was an orthopedic surgeon in the Atlanta area for more than 30 years, she served as the president of Resurgens Orthopedics, and she is a member of the MAG Medical Reserve Corps – which is prepared to respond to natural disasters and disease outbreaks in the state. Dr. Kirkpatrick also serves as a pet therapy volunteer team leader at the Ronald McDonald House through its ‘Happy Tails Pet Therapy Program.’ She earned her medical degree from the University of Louisville. Georgia Senate District 32 stretches from east Cobb County to Sandy Springs. Dr. Kirkpatrick will succeed Sen. Judson Hill (R-Marietta), who ran for the 6th U.S. Congressional District seat that was vacated by Rep. Tom Price, M.D., when he was nominated (and later confirmed) to become the Secretary of the U.S. Department of Health & Human Services. Go to kayforsenate.com for Dr. Kirkpatrick’s website.

www.mag.org 11

What the AHCA means for Georgia? On May 4, Georgia Health News ran an article – ‘The effect on Georgia: House OKs health plan’ – that reported that the American Health Care Act (AHCA) would change the health care system in important ways… • “Georgia and other states would have more control over health care – its rules, spending and benefits…” • “The [AHCA] would allow states to get waivers to create insurance regulations much different from the current [ACA] requirements.” • “[The AHCA would] move the Medicaid program, which covers about 2 million Georgians, into a ‘block grant’ format. That would limit federal spending and let states set their own eligibility and benefit rules.” • “[Georgia] may have to consider cutting [Medicaid] benefits and eligibility in order to meet increased budget pressures from funding the program, said Bill Custer, a health insurance expert at Georgia State University.” • “Under the [AHCA], states would have more power – and more responsibility, including on setting up ‘highrisk’ pools and other insurance rules.” • “…at least 700,000 residents would be added to [Georgia’s] uninsured rolls under the legislation (based on a CBO estimate that the law would lead to 24 million people losing coverage by 2026).” • “The [AHCA] would eliminate the opportunity for Georgia to expand Medicaid…could mean continued financial trouble for some rural hospitals in the state, experts say, because these facilities treat many lowincome uninsured patients.” • “The effects of the [AHCA] will focus mainly on people who buy insurance individually or as a family. Those in jobbased plans would largely be unaffected by the changes.” • “The [AHCA] would allow insurers to charge older consumers as much as five times more for coverage than younger people. [The ACA] permits a 3-to-1 ratio. States would also be allowed to seek waivers to allow insurers to charge older consumers even more than five times younger ones. [That and] other provisions could raise premiums for people older than 30, while those under that age could see lower rates.” • “The [AHCA] would provide $138 billion through 2026 to help states and insurers lower premiums and set up high-risk pools to cover those with pre-existing conditions. States could get federal permission to let insurers return to their pre-ACA practice of charging more to customers with pre-existing medical problems. The [AHCA also] includes a newly proposed $8 billion intended to be spread over five years to states that back out of this part of the ACA.”

12 MAG Journal

• “[The consulting firm Avalere] finds that the funding in the [AHCA] would not be nearly enough to cover all enrollees in the individual market today who have some form of pre-existing chronic condition.” • “The [AHCA] would get rid of the ACA’s requirement that people have health coverage or face a tax penalty. It also would eliminate the mandate that employers with at least 50 employees provide coverage to their workers.” • “In place of government-subsidized insurance policies offered exclusively on the ACA marketplaces, the bill would offer tax credits of $2,000 to $4,000 a year, depending mainly on age. A family could receive up to $14,000 a year in credits. The credits would be reduced for individuals making over $75,000 a year and families making over $150,000. But Georgians in high-cost markets, such as rural communities, might receive less favorable treatment because the financial help they get would no longer consider the higher cost of premiums, according to the Georgia Budget and Policy Institute.” • “[The CBO] said the [AHCA] would trim the federal budget deficit considerably, The New York Times noted. Insurance premiums would spike next year before settling lower after a decade.” • “States could also seek waivers that would allow insurers to sell plans that don’t include all the essential health benefits under the ACA, which are: outpatient care, emergency services, hospitalization, maternity, mental health and substance abuse, prescription drugs, rehabilitation services, lab work, preventative care and pediatric services.” • “Insurers could offer ‘skinny’’ coverage plans, without such benefits as coverage for substance abuse treatment, maternity and prescription drugs.” • “The [AHCA] would end the additional help that individuals earning less than roughly $30,000 a year receive to cover their out-of-pocket costs. More than half of the enrollees on the ACA exchanges receive these cost-sharing subsidies.” • “The [AHCA] would also eliminate the taxes the ACA levies on health insurers, prescription drug makers, device manufacturers and others.” • “[Georgia] Sen. Chuck Hufstetler told GHN that ‘Georgia would get significantly less [Medicaid funding] than other states because it didn’t expand Medicaid.’ He said that the [AHCA’s] pegging Medicaid funding to perenrollee spending would hurt the state as well.” • “Under ACA repeal, the CDC would lose $890 million of funding annually, 12 percent of the Atlanta-based agency’s budget.” Editor’s note: MAG sponsors ‘Georgia Health News,’ which can be found at www.georgiahealthnews.com.

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CASE STUDY

Amyloidosis: Two sides of a coin By Soroosh Kiani, M.D., and Wissam Jaber, M.D., Division of Cardiology, Emory University School of Medicine

Case 1 Mr. WA is a 76-year-old patient with no significant prior medical history who presented to his primary physician with a complaint of three months of lower extremity edema. He was referred to our clinic for further evaluation. His exam was significant for stable vital signs, jugular venous distension, lower extremity edema, and a large palpable liver. His electrocardiogram demonstrated sinus rhythm with first-degree AV block and low voltage in the limb leads. His echocardiogram demonstrated a severely reduced ejection fraction (30 percent to 35 percent), dilated atria, thickened valve leaflets, moderate tricuspid regurgitation, mild to moderate mitral regurgitation, and significant left ventricular hypertrophy characterized by bright, echogenic myocardium and severe diastolic dysfunction. He was started on Carvedilol 3.125 mg bid, Lisinopril 2.5 mg daily, maintenance diuresis with Furosemide 40 mg daily, and was sent for a left and right heart catheterization. His catheterization demonstrated normal coronary arteries, Cardiac Index of 2.0 L/min/m2, high mean central venous pressure (19 mmHg), mild pulmonary hypertension, and highnormal wedge pressure. There was a high clinical suspicion for infiltrative disease, so endomycoardial biopsies were taken and sent to pathology. Congo red stains revealed apple-green birefringence upon polarization, characteristic of amyloid protein deposition, and genotyping revealed mutant TTR (Val-142-Ile variant) amyloid protein. He was subsequently diagnosed with atrial fibrillation and started on oral anticoagulation using Apixaban. His course remained indolent, and he was referred to hematology/oncology to be evaluated for additional therapeutic options. He was subsequently offered referral for screening to participate in various clinical trials. He continued to require increased doses of diuretics, with worsening renal function. Lisinopril and Carvedilol were stopped to avoid hypotension, and because of the lack of proven benefits in congestive heart failure related to cardiac amyloidosis. Case 2 Ms. WC is a 47-year-old female with a past medical history of easy bruising and a positive rheumatoid factor. She had been suffering non-specific malaise, recent 10 pound weight loss, shortness of breath, cough, and ankle edema for two to three weeks – at which time she presented to her primary physician who discovered bilateral pleural effusions via a chest X-ray. She underwent right-sided diagnostic and therapeutic thoracentesis at a different institution, which was productive of one liter of transudative fluid. While in recovery, she became hypotensive 14 MAG Journal

and tachycardic and was admitted to the hospital. Her exam was notable only for decreased breath sounds at the bases of her bilateral lung fields. A chest CT demonstrated moderate pleural effusions. Routine laboratory workup was significant for hyponatremia, thrombocytosis, and an elevated INR. A metabolic workup – including TSH, iron studies, and serum cortisol – were unrevealing. She had nephrotic range proteinurea (6.99 g/24 hours) and microscopic hematuria. She was not able to tolerate diuresis due to hypotension and her pleural effusions continued to re-accumulate, eventually requiring bilateral pleurodesis. Serum protein electrophoresis demonstrated an elevated serum free lambda light chain and monoclonal spike with an IgG lambda paraprotein. A bone marrow biopsy at that time was consistent with Multiple Myeloma, and a kidney biopsy was positive for AL-type amyloid protein. She was discharged home and re-presented approximately three weeks later as a transfer to our institution with reoccurring shortness of breath and reaccumulation of her right pleural effusion with two right sided chest tubes placed. She had also reported new spontaneous bruising under both eyes. Her vitals were notable for tachycardia and an O2 saturation of 96 percent on 4L NC. Her ECG demonstrated sinus rhythm with low limb lead voltage and poor R-wave progression in the precordium. She had a transthoracic echocardiogram that demonstrated severe LVH, mildly reduced EF (45 percent), and diastolic dysfunction with restrictive physiology – consistent with cardiac amyloid. Her subsequent course was characterized by recurrent cardiogenic and septic (secondary to VRE) shock, respiratory and renal failure requiring continuous renal replacement therapy. She was subsequently started on bortezomib, cyclophosphamide, and dexamethasone therapy with poor clinical response. After a discussion with her family, she was transitioned to comfort care and hospice. Discussion The initial differential for a newly identified restrictive cardiomyopathy is broad, encompassing a large number of underlying disorders including cardiac amyloidosis. The term amyloidosis refers to tissue deposition of misfolded low-molecular weight serum proteins. These proteins adopt an aberrant secondary structure – characterized by antiparallel beta pleated sheaths – that tends to be stable and favors fibril formation. By far, the most common, albeit not exclusive, sources of cardiac amyloid proteins that lead to disease are monoclonal light chains (in AL Amyloidosis) and hepatic Tetrameric Transthyretin Protein (in TTR Amyloidosis)1,2.

AL Amyloidosis AL Amyloidosis results from the deposition of fibrils composed of monoclonal immunoglobulin light chains. The majority of cases are due to deposition of the variable region of the lambda light chain3,4. The production of these proteins is typically secondary to plasma cell dycrasias, most commonly Multiple Myeloma. However, Multiple Myeloma is the underlying cause of only a minority of cases of AL Amyloidosis1. The disease typically presents by the sixth decade of life, though this can be variable5. The natural history of AL Amyloidosis with cardiac involvement tends to be one of severe and rapidly progressing disease6,7 – affecting the heart and kidneys most often, though almost any organ system (other than CNS) may be involved4,8. Even in patients who are younger who have less comorbid illness, and who have less ventricular wall thickening compared to those with TTR amyloidosis (see below), patients with AL Amyloidosis have a far worse prognosis that is out of proportion to the degree of amyloid infiltration1,5,7. ATTR Amyloidosis Amyloid protein consisting of Tetrameric Transthyretin (TTR) is derived from one of two sources: deposition of wild-type TTR (leading to so-called “Systemic Senile Amyloidosis”) or mutant TTR proteins. Cardiac deposition of senile amyloid protein has been reported in close to 50 percent of patients over the age of 60 at autopsy, it increases in prevalence with age, and seems to have a significantly higher prevalence in African American males – though it rarely causes clinically-significant disease9,10. Less ubiquitous are mutant TTR proteins, resultant from any of a large number of mutations in the gene coding for TTR that seem to result in fibril formation and deposition and that may affect the heart or nervous system or both7,10-12. Regardless of the source of TTR amyloid protein, the clinical presentation is similar and typically characterized by heart failure with slow progression6,7. Compared to patients with AL Amyloid, the prognosis is much more favorable with a median survival of 75 months from diagnosis, compared to 11 months for those with the AL variant, despite patients being older with a greater degree of cardiac amyloid deposition1,7. Diagnostic Approach The approach to diagnosing cardiac amyloidosis beings with a thorough history and physical. Cardiovascular complaints are common. Shortness of breath in the absence of demonstrable pulmonary edema is the most common presenting symptom. Otherwise, patients tend to exhibit signs and symptoms of elevated right heart pressures including peripheral edema, ascites, and early satiety. Patients may also complain of atypical angina and, commonly, syncope13. Systemic symptoms that may also manifest are many, though are less commonly associated with TTR amyloidosis14. Examples include polyneuropathy (paresthesias, autonomic dysfunction), macroglossia, and carpal tunnel syndrome13. Symptoms related to small-vessel disease include periorbital bruising, purpura, and claudication13.

The physical exam is characterized by signs of right heart failure, including elevated JVP, occasional S3, though the S4 is typically absent (due to the high incidence of atrial dysfunction)15, hepatomegaly, peripheral edema, and periorbital purpura (i.e., “raccoon eyes,” which is more common with AL Amyloidosis)1. Non-invasive testing in these patients begins with an ECG, which may demonstrate low-limb lead voltage, the so-called “pseudoinfarct” pattern (characteristic anterior Q waves), and evidence of conduction system disease (though any of these findings are present in only a minority of cases)16. Indeed, a low voltage-to-LVmass ratio (determined by non-invasive imaging) may be a more sensitive and specific finding of amyloid in these patients17. Echocardiogram is the initial non-invasive test of choice in the workup of suspected amyloid. Of note, different types of amyloid are not distinguishable on echocardiogram. Classically described findings include increased wall thickness, diastolic dysfunction, and the so-called “speckled pattern” (characterized by bright echo-lucent “speckles” visualized in the myocardium of patients with amyloid), which is present in approximately one fourth to one third of patients18,19. Echocardiograms of patients with more advanced disease may demonstrate large, poorly functioning atria, ventricular septal thickening, progressive LV thickening, valve leaflet thickening, and progression to restrictive physiology18,19. Perhaps more revealing is the presence of the so-called “inverse strain pattern” (increasing strain from the base to the apex) that is seen in patients with amyloidosis and not otherwise significantly associated with other forms of hypertrophic cardiomyopathies20,21. Advanced tomographic imaging with cardiac magnetic resonance imaging (cMR) can be particularly helpful, especially in distinguishing amyloid from other hypertrophic cardiomyopathies. Anatomic findings on cMR are similar to those of the echocardiogram. The presence of Late Gadolinium Enhancement (LGE) on cMR is particularly useful to distinguish cardiac amyloid and demonstrates reasonable sensitivity and specificity, and it can have a high positive predictive value22,23. Ultimately, biopsy of tissue samples that stain positive for amyloid protein is the gold standard in diagnosis. There are multiple stains for amyloid available for use. These include Congo Red (which yields green birefringence under polarized light and is considered the Gold Standard), as well as less commonly used stains, including Thioflavin T (yellow-green under fluorescent light), Sulfated Alcian Blue, and amyloid typespecific immunohistochemical stains5,26-29. A positive biopsy from any tissue, along with characteristic cardiac findings, is sufficient to establish the diagnosis of cardiac amyloidosis26. Common sources of tissue include the abdominal fat pad (ease of access and relatively low risk for complications), bone marrow (which may also help discern the presence of an underlying hematologic dyscrasia), and the endomyocardium30-32. Endomycoardial biopsy is nearly 100 percent sensitive and considered to be safe to obtain in expert hands26. www.mag.org 15

Therapy Typical evidence-based therapies for systolic heart failure have not been shown to confer benefits to these patients and, indeed, may lead to harm given the reduction of inotropy in the case of beta blockers, hypotension in the case of ACE inhibitors and ARBs, and direct toxicity (due to interaction of the drug with amyloid protein) in the case of calcium channel blockers and digoxin19,33-35. These therapies should be used judiciously and with caution under expert guidance. Heart failure symptoms are best managed with diuretics and supportive care in these patients. Anticoagulation is particularly controversial in the cardiac amyloid population. On the one hand, there is data to strongly suggest that patients with cardiac amyloid – especially those with AL type – are at particularly high risk for thrombotic events36. However, there is competing concern for higher bleeding risk associated with amyloid vasculopathy. Evidence-based strategies in this arena are lacking and, thus far, consideration of the particular risk and benefits of anticoagulation on a case-by-case basis seems to be the better part of valor. Interestingly, though, conduction system disease – as well as syncope and malignant arrhythmias – do manifest in a subset of patients, data to support implantation of pacemakers and/or implanted cardiac defibrillators to prevent sudden death are lacking37-39.

Phase 3, as well as an open label extension, trial for patients with FAP (clinicaltrials.gov ID: NCT01737398, NCT02175004, respectively). None of these agents is currently being investigated for cardiac amyloidosis per se, however these agents may hold promise for treatment of cardiac disease should they prove beneficial in patients with FAP. Conclusion Cardiac Amyloidosis is a disease that is predominated by two subtypes: AL and ATTR. While both are characterized by amyloid infiltration of the myocardium, they differ substantially in their demographics, manifestations, clinical course, and therapeutic options. Distinguishing between the two has important prognostic and therapeutic implications for our patients.□¨

References Please go to http://bit.ly/2p1RjpQ for a complete list of references for this case report.

MAG HOD news and notes

To date, no therapy has shown to provide significant reversal of amyloid deposition from affected myocardium. As such, treatment of the underlying cardiomyopathy is typically cardiac transplant. Patients with Systemic Senile Amyloidosis classically have disease limited to the myocardium, making this condition more amenable to transplant. However, these patients tend to present later in life, which may limit their eligibility. Patients with mutant TTR proteins have typically required a combined heart and liver transplant to eliminate further production of the mutant protein. Data for this strategy suggests that in properly selected patients outcomes may be favorable40. Because the AL subtype typically manifests as a multisystem disease with an underlying malignant pathology1,13, these patients are (except for in the rarest cases) excluded from consideration of transplant. In a limited subset of patients with AL amyloidosis who can tolerate it, chemotherapy with or without stem cell transplant may be pursued in an effort to eliminate the plasma clone41-43. Though not thoroughly investigated, more recent data suggests that therapy with regimens that include bortezomib may hold promise for improved outcomes in patients with AL42,43. There are several new investigational agents aimed at targeting TTR proteins in patients with Familial Amyloidotic Polyneuropathy (FAP). Tafamidis, a small molecule drug that stabilizes TTR protein and prevents amyloid protein formation, has been approved for use in Europe and Japan44,45. In addition, anti-sense RNA agents against mRNA coding for TTR have been under investigation, including ALN-TTR0246, which is currently in Phase 3 trials for patients with FAP (clinicaltrials. gov ID: NCT01960348). Likewise, a novel first-in-class therapeutic, ISIS 420915, is in 16 MAG Journal

The Medical Association of Georgia (MAG) will hold its 2017 House of Delegates (HOD) meeting at the Hyatt Regency in Savannah on Saturday, October 21 and Sunday, October 22. HOD meeting attendees are encouraged to contact their county medical society (if applicable) to determine if it has already reserved a room for them at the Hyatt. That notwithstanding, HOD attendees can contact Anita Amin at anita@jlh-consulting.com or 404.299.7700 for assistance with lodging. MAG is also encouraging county medical society and specialty society leaders and member physicians to nominate the individuals and organizations they believe deserve to be recognized for their contributions to the medical profession for MAG’s annual awards, which will be presented during a dinner that will take place in concert with the HOD meeting at the Hyatt on Saturday, October 21. Nominations must be submitted using an online nomination form by 5 p.m. on Friday, July 28. Contact Mandi Milligan at mmilligan@mag.org to obtain the 2017 MAG awards nomination form or with any questions.

GEORGIA COMPOSITE MEDICAL BOARD

Highlights from FSMB’s 105th annual meeting By John Antalis, M.D., Georgia Composite Medical Board John Antalis, M.D.

he Federation of State Medical Boards (FSMB) held its 105th annual meeting in April. Seventy medical boards convened to reach consensus on a wide range of health care issues and regulations, including the opioid abuse epidemic, antitrust concerns, and physician burnout. Georgia was an active participant. Keeping in mind that Georgia Gov. Nathan Deal is considering an opioid bill that passed in 2017, it is worth noting that FSMB has crafted a model policy, ‘FSMB Guidelines for Chronic Use of Opioid Analgesics,’ over the last two years with input from 20 organizations – including the American Medical Association – and based on medical literature, state and federal policies, and the ‘CDC Guidelines for Prescribing Opioids for Chronic Pain.’ These guidelines stress that… • During an initial evaluation, physicians should determine if opioids are clinically indicated and they should assess the risk of prescribing them • Physicians should adequately monitor their patients for opioid use and adjust or wean them from their medication when it is clinically indicated • Once the decision is made to treat a patient with opioids, the physician should make sure their patient clearly understands the full extent and consequence of the drug’s use and obtain their informed consent • If a patient’s opioid dose is increased, the prescribing physician should fully document the reason for doing so with a clear explanation of the risks – and physicians should always consider alternative treatment modalities • Physicians should avoid relying on opioids to treat a patient’s chronic pain unless it is related to cancer or palliative or end-of-life care or if other, non-opioid modalities are “clearly” not effective • Physicians should use their state’s Prescription Drug Monitoring Program (PDMP) and other tools FSMB’s House of Delegates voted to establish a task force to study PDMPs, evaluate how mandatory use impacts patient outcomes, and assess the feasibility of better incorporating PDMPs into EMR systems. There was also a consensus for FSMB to promote greater cooperation among the states to enable physicians to more easily access PDMPs across state lines. Another FSMB priority is the landmark 2015 U.S. Supreme Court North Carolina Dental vs. the Federal Trade Commission

decision. The North Carolina State Board of Dental Examiners (NCSBDE) – which consisted exclusively of dentists when the case was filed and acting on dentists’ complaints – issued ceaseand desist orders to block non-dentists from offering teeth whitening services, saying the procedure could only be performed by licensed dental practitioners. The FTC filed an administrative complaint, alleging that that the NCSBDE’s actions constituted an anticompetitive and unfair method of competition. The NCSBDE moved to dismiss the FTC complaint based on what it asserted was state-action immunity, but the high court ruled that the NCSBDE was not immune from the Sherman Act (i.e., “If a state wants to rely on active market participants as regulators, the state must provide active supervision,” which it apparently didn’t do in this case) – and a dental hygienist and consumer were added to the NCSBE. While Georgia provides this kind of oversight, the GCMB is nonetheless assessing how the ruling affects Georgia to ensure it is operating in a manner that is consistent with the ruling. It is also worth noting that the North Carolina case led to the passage of a bill (H.B. 952) in Georgia that allows the governor to approve or veto any rule that is proposed by a licensing board that will be submitted to and recognized by the secretary of state. Physician wellness and burnout was also discussed at the FSMB meeting. According to Chris Bundy, M.D., MPH, with the Washington Physicians Health Program, more than 50 percent of physicians reported at least one burnout symptom. In addition, the Mayo Clinic has reported that nearly 40 percent of U.S. physicians who were surveyed in 2015 reported depressive symptoms. Key personal triggers that contribute to physician burnout include one’s high achievement orientation, difficulty setting boundaries, delay of gratification, and materialism. Practice triggers include workload and time constraints, lack of autonomy, a culture of incivility, and ineffective leadership. Burnout can also lead to increased drug and alcohol use. There also appears to be a disconnect between physicians’ values and their health care system’s requirements. In an era that’s so reliant on electronics, it is troubling that collegiality among physicians is diminishing. One of the FSMB speakers noted that in the past older physicians would mentor their younger counterparts – and the local medical society was a great place to foster these relationships. So the loss of peer-to-peer collegiality may be exacerbating physician burnout. The good news is that the FSMB is raising the issue’s awareness with the state boards and developing resources to help physicians. Dr. Antalis served as MAG’s president in 2004-2005. www.mag.org 17

MEDICAL ETHICS

What they don’t know won’t hurt them, will it? By Brittany N. Chandler, fourth-year medical student, and Richard L. Elliott, M.D., PhD, emeritus professor of medical ethics, Mercer University School of Medicine

edical ethics is interpersonal, and the interpersonal nature is reflected in its core principles. Autonomy speaks to the right to make one’s own decisions – free from the intrusions of others. Beneficence requires physicians to act for the benefit of others, and nonmaleficence prohibits physicians from causing harm to others.

bit.”1 She described the patient as a “retard” because he looked at the IV needle, even when he knew it made him queasy.1 When the medical assistant pointed out a rash on the patient’s genitalia, the anesthesiologist warned her not to touch it and made another nasty comment: “[you might get] some syphilis on your arm or something. It’s probably tuberculosis in the penis, so you’ll be alright.”

The principle of social justice requires physicians, and society in general, to distribute the risks and benefits of medicine to others in a fair manner. Thus, it is difficult to conceive of medical ethics without the “other” or patient. So how are we to think about ethics when the patient is not present?

The gastroenterologist also made slanderous comments and did not discourage the anesthesiologist from making questionable/offensive comments, even when she announced that she was going to write a diagnosis of hemorrhoids in the patient’s chart, despite not seeing any hemorrhoids. The patient took this tape to court and was awarded $500,000 for defamation, punitive damages, and medical malpractice.

Medical students recite an oath to abide by as a future physician. This obliges them to respect their patients and not allow the personal beliefs or characteristics of their patients to interfere with the medical care they deliver. However, it seems that as the student becomes resident, and resident becomes attending, these oaths sometimes become a distant memory. This amnesia can create an environment or culture in which doctors are in danger of having a flippant attitude towards patients’ rights. An example of such an environment that has drawn national attention is the operating room. How are patients treated when they are anesthetized and unconscious, unaware of what is being said about them? Unfortunately, what happens in such situations does not always conform to the conduct that is required by the oaths we have taken. At a physician’s office in Reston, Virginia in 2013, a male patient presented for a routine colonoscopy and decided to turn his phone recorder on so he could remember the postprocedure instructions that were given to him. However, the patient forgot to stop the recorder and put the phone in his pants pocket. The patient’s pants traveled with him to the procedure room and his phone recorded the entire procedure, including what was said by the anesthesiologist, gastroenterologist, and medical assistant. What the patient heard when he replayed the recording was troubling. After the patient was sedated, the anesthesiologist remarked that, “After five minutes of talking to you in pre-op, I wanted to punch you in the face and man you up a little 18 MAG Journal

A similar case involved a woman who purposely recorded her operation.2 The patient hid a recording device in her hair after a tense pre-operative appointment with her surgeon. The patient had been in severe pain from a hiatal hernia, but she was told by her surgeon that she would have to wait two months for surgery. When she expressed frustration, he asked, “Well, who do you think you are?” Anxious about what might happen in the operating room, she decided she would want proof if anything went wrong during surgery. Indeed, something did happen, but it wasn’t what she expected. After she was sedated, the surgeon began the operation by telling the medical staff that, “She’s a handful. She had some choice words for us in the clinic when we didn’t book her case in two weeks.” Another doctor pointed out the appearance of her belly button, something she had always been self-conscious about: “Did you see her belly button? [laughter ensues].” The anesthesiologist referred to her as “always the queen,” and the surgeon called her “Precious,” saying, “This is Precious over here, say hi to Precious over there,” which the patient saw as racially offensive. The surgeon and the medical staff made comments about touching her, taking photos, and Bill Cosby – suggestive of sexual remarks. Angered by what she found on the recording, the patient sent a complaint letter along with the recording to the hospital

administration. Unfortunately, the hospital’s response was inadequate: “We reminded the OR staff and physicians to be mindful of their comments at all times, [but] Harris Health does not believe further action is warranted at this time.” The Oath of Geneva requires physicians to “maintain the utmost respect for human life” and “practice [their] profession with conscience and dignity.”3 The Hippocratic Oath requires physicians to “remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”4 Can the physicians and nurses mentioned in the cases above honestly say that their actions showed respect for human life at all times? Are we to show respect and compassion only when the patient can hear us? Or can we ignore disrespectful comments on the basis of “What they don’t know won’t hurt them?” We need to choose our words carefully, whether our patients are aware of them or not. What we say can influence those around us. If the M.D. in the OR disparages a patient, it makes it easier for the rest of the OR staff to disparage the patient. Therefore, if we allow ourselves to express such negative opinions of patients and/or not challenge others who express such opinions, it could undermine the quality of care the patient receives. Further, what we allow ourselves to say can shape our own beliefs and affect the way we view and care for patients. From an ethical perspective, even what we say out of earshot of the patient can diminish care and violate the principle of nonmaleficence.

and another set of values when we believe we are not being observed. If we are to continue to be leaders in health care, we must ensure there is only one culture of medicine – where the ethical standards of our profession are upheld by ourselves and others we influence at all times, maintaining the trust patients expect from us.¨ As always, the authors invite your questions and feedback. Contact Dr. Elliott at elliott_rl@mercer.edu. References 1

Jackman T. Anesthesiologist trashes sedated patient – and it ends up costing her. Washington Post. June 23, 2015. https://www.washingtonpost.com/local/anesthesiologist-trashes-sedatedpatient-jury-orders-her-to-pay-500000/2015/06/23/cae05c00-18f3-11e5-ab92-c75ae6ab94b5_ story.html?tid=a_inl&utm_term=.dbb59c7199b3. Accessed November 30, 2016.

Wang Y. Patient secretly recorded doctors as they operated on her. Should she be so distressed by what she heard? Washington Post. April 7, 2016. https://www.washingtonpost.com/news/ morning-mix/wp/2016/04/07/patient-hid-recorder-in-her-hair-as-surgeons-operated-on-hertheir-words-left-her-deeply-distressed/?utm_term=.1e000534a3bb. Accessed November 30, 2016.

WMA declaration of Geneva. WMA. http://www.wma.net/en/30publications/10policies/g1/. Accessed December 1, 2016.

Definition of Hippocratic oath. MedicineNet. http://www.medicinenet.com/script/main/art. asp?articlekey=20909. Accessed December 1, 2016.

Just one way MAG creates value for you.

Some look for humor in clinical situations to relieve stress, to bond with other members of the team, and/or to distance ourselves from “difficult” patients.

MAG protects you and your patients during Georgia’s annual legislative session.

We formulate negative views of these so-called difficult patients, and humor can give us emotional space and make it easier to work with them. Yet trust is the cornerstone of our relationships with our patients, and the aforementioned cases create doubt in patients’ minds about our trustworthiness – that what we really think about them is different from what we say to them.

MAG’s 2017 priorities included network billing and adequacy, Medicaid payment and administration, MOC & patient safety.

Making jokes about patients is clearly for our benefit, not theirs (although, when appropriate, humor can be rewarding for both the doctor and the patient). Further, when physicians engage in such behavior, the signal is given to other staff, and sometimes to physicians-in-training, that some forms of disrespect for patients are acceptable as long as the patients do not know about it.

Call 678.303.9261 or visit mag.org/membership to join or renew.

This creates a hidden culture of medicine, where we follow one set of values when we are in the presence of our patients

www.mag.org 19

LEGAL

Proposed federal tort reform: The Protecting Access to Care Act By Daniel J. Huff, Esq., partner, and Christian P. Dennis, Esq., associate, Huff, Powell & Bailey, LLC

ort reform often refers to legislation that modifies procedural and substantive requirements that are related to personal injury litigation. It may also include limitations on collectible damages. Tort reform differs between jurisdictions, and medical malpractice reform is a special subset of tort reform. Proponents often argue that tort reform will reduce provider insurance premiums, the cost of litigation, and frivolous lawsuits. Medical malpractice reform also has the benefit of reducing health care costs. One commendable goal of medical malpractice reform is the elimination of “defensive medicine” – treatment decisions based on legal consequences, not patient care. Opponents cite a lack of evidence supporting the claims of proponents and allege that tort reform creates barriers for harmed parties to receive their day in court, as well as denying them their right to a jury trial. Over great debate, many individual states have introduced some form of tort reform legislation with varying degrees of success. The federal government, however, has not been able to pass medical malpractice reform legislation. Past failures have not prevented members of Congress from introducing bills. During the current term, lawmakers have introduced at least seven tort reform bills,1 including the Protecting Access to Care Act (PACA, H.R. 1215) – which applies directly to medical malpractice litigation. Protecting Access to Care Act Despite the title’s inferences, the PACA does not directly regulate access to care. Ideally, the bill would allow medical providers to exercise better independent clinical judgment in providing care to patients with less fear of legal liability, thereby improving care. In its current form, the bill also does not affect EMTALA requirements. The real purpose is not reflected in the bill’s title. Its stated intent is to “implement reasonable, comprehensive, and effective health care liability reforms…”2 In fact, the PACA establishes substantive and procedural parameters for medical malpractice lawsuits. Application The PACA applies to demands, claims, and legal actions against a health care provider.3 It applies to civil actions brought in state court or federal court or pursuant to an alternative dispute resolution4 so long as it concerns medical care or goods. In all instances, patient coverage must have been “provided in whole or in part via a Federal program, subsidy, or tax benefit” for the

20 MAG Journal

bill’s provisions to apply.5 Practically, the bill would apply to most patients, as many are covered by Medicaid, Medicare, plans that are subsidized by the Affordable Care Act, or plans that are provided by an employer that receives a tax benefit. Procedural Implications The PACA is a hybrid of enacted tort reform proposals and laws across the country. One aspect is a restrictive statute of limitations and statute of repose to time bar lawsuits. Georgia generally requires a person to file a medical malpractice lawsuit within two years of learning of the injury but no more than five years from the date of treatment.6 The PACA is more restrictive on patients and requires the filing of a medical malpractice lawsuit within three years after the date of injury causing act.7 After a person discovers or could have discovered the actual injury,8 the person has one year to file a medical malpractice lawsuit – subject to the three-year requirement. Similar to Georgia, the bill has special considerations for minors who are under the age of six.9 Some states, like Georgia, also require an expert affidavit that includes an expert opinion, which must reflect breach of the standard of care.10 These affidavit requirements aim to reduce frivolous lawsuits prior to costly and time-consuming litigation. The PACA does not have an affidavit or certification requirement. However, the measure would not abolish Georgia’s affidavit requirement because it allows states to have additional and more stringent reforms. Substantive Impact Two of the most controversial mandates of the PACA involve the amount of compensation for an injury or loss of life (“damages”) that a plaintiff may collect. The other controversial provision involves the fee an attorney for a plaintiff may collect. Notably, there is a distinction between what a jury awards a plaintiff and what the law allows the plaintiff and their attorney to collect. The latter refers to the actual amount of money a plaintiff and their attorney receives. Limits on Damages The PACA does not limit the amount of economic damages that a jury may award a plaintiff.11 The bill does, however, limit noneconomic collectable damages to $250,000.12 So under this legislation, a jury may still award multimillion-dollar verdicts with respect to noneconomic damages – though the bill caps the amount that can be collected at $250,000. This limitation applies regardless of the number of parties, actions, or separate (continued on page 22)

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www.mag.org 21

(continued from page 20)

claims brought.13 This provision is similar to Georgia’s 2005 tort reform act that placed a $350,000 cap on noneconomic damages in medical malpractice cases, keeping in mind that in 2014 the Supreme Court of Georgia unanimously held that this medical malpractice cap violated the constitutional right to trial by jury.14 Other states have enacted limits on damages that have either been overturned or have yet to be challenged. Consequently, if the proposed bill is enacted in its current form, there is a high likelihood its limitations on damages will be aggressively challenged in the U.S. Court of Appeals and possibly be heard by the U.S. Supreme Court. In addition to the amount of damages that could be collected, the bill also grants the court the authority to restrict and redirect attorney contingency fees.15 It also caps the percentage an attorney representing the plaintiff may collect, regardless if the recovery arises from a judgement, settlement, or other alternative dispute resolution.16 Fair Share Rule States differ in their attribution of liability concerning multiple defendants, with some utilizing joint and several liability doctrine and others using several liability doctrine. Joint and several liability is a phrase that is often used in civil litigation that many people do not understand. Concisely, joint and several liability means that a victorious plaintiff that has sued multiple defendants may seek full recovery of a judgment against any single defendant, and the defendant from whom damages are sought will be responsible for the entire judgment amount – regardless of their proportional fault. The defendant may subsequently seek reimbursement or contribution from co-defendants for their proportional share. The PACA does not take this approach. Instead, the bill proposes to utilize several liability, whereby each defendant is only liable for their share of damages proportional to their percentage of responsibility, as determined by the jury. Under this doctrine, the plaintiff can only collect the proportional damages from each named defendant. Overall, the PACA is an ambitious attempt to reform and effectively diminish medical malpractice actions in all courts. Importantly, it is unknown whether this bill will become law or resemble its present form if enacted. If it does become law, it will face judicial scrutiny, constitutional challenges, and other challenges regarding interpretation and applicability. As of April 2017, committees in the U.S. House of Representatives considered this bill and it made it out of committee, but it had not made it to the floor for a vote. There are many variables that may prevent the bill from being enacted as law, especially considering where the bill is in the lawmaking process. Finally, it is too early to rely on the verbiage of the bill, as there is a good chance the provisions and requirements may change. Despite its many uncertainties, the Protection Access to Care Act keeps the discussion surrounding tort reform active. ¨

Huff and Dennis are with the Atlanta law firm of Huff, Powell & Bailey, LLC. They defend civil lawsuits on behalf of hospitals, physicians, product manufacturers, businesses, corporations and other professionals. Huff and the firm tries several jury trials each year. Contact Huff at dhuff@huffpowellbailey.com. 22 MAG Journal

References 1.

Bills introduced in the U.S. House of Representatives include the Fairness in Class Action Litigation Act of 2017 (H.R. 985), Furthering Asbestos Claim Transparency Act of 2017 (H.R. 906), Lawsuit Abuse Reduction Act of 2017 (H.R. 720), Protecting Access to Care Act (H.R. 1215), Stop Settlement Slush Funds Act of 2017 (H.R. 732), Sunshine for Regulations and Regulatory Decrees and Settlements Act (H.R. 469), etc.

Protecting Access to Care Act, H.R. 1215, 115th Cong. § 2 (2017).

H.R. 1215 § 9 (2017).

Id.

O.C.G.A. §§ 9-3-71 to 73. Note that there are special timing considerations for lawsuits arising out of treatment provided to children.

H.R. 1215 § 3.

Id. § 3(a).

10.

See O.C.G.A. § 9-11-9.1.

11.

H.R. 1215 § 4(a). See Id. § 9(5) (defining economic damages as “objectively verifiable monetary losses incurred…” such as medical expenses and loss earnings).

12.

Id. § 4(a).

13.

Id.

14.

Atlanta Oculoplastic Surgery, P.C. v. Nestlehutt, 286 Ga. 731 (2010).

15.

H.R. 1215 § 5(a).

16.

Id. § 5(b). An attorney representing the plaintiff may collect no more than forty percent of the first $50,000 recovered, 33.3% of the subsequent $50,000.

MCG at Augusta University names new dean – David Hess, M.D. The Medical College of Georgia (MCG) at Augusta University (AU) recently announced that David C. Hess, M.D., is its new dean. Dr. Hess – who has been the chair of the MCG’s Department of Neurology since 2001 – served as the interim dean and executive vice president since the beginning of 2017. Dr. Hess has a medical degree from the University of Maryland School of Medicine, while he completed a residency in neurology and a cerebrovascular fellowship at MCG before joining the school’s faculty in 1990. He is board-certified in internal medicine, neurology, and vascular neurology. Dr. Hess has conducted research on new therapies to improve stroke outcomes, including use of bone marrow-derived multipotent stem-cell therapy and the potential of successive, vigorous bouts of limb compressions following a stroke to trigger natural protective mechanisms that reduce damage. Dr. Hess received both MCG’s Outstanding Faculty Member Award and the AU Research Institute’s Distinguished Research Award in 2012. He has been named one of ‘America’s Top Doctors’ for the past 16 years. Dr. Hess is a member of the Medical Association of Georgia and the Richmond County Medical Society.

OPINION

American Health Care Act By U.S. Rep. Earl L. “Buddy” Carter

Rep. Buddy Carter

t’s no secret that the health care system I worked in for more than 30 years is being crushed by Obamacare. The law has failed to deliver on its promise of affordable, quality care. Instead, one-size-fits-all mandates and taxes have driven up costs and eliminated choice for Americans. Across the country, premiums are skyrocketing – on average 25 percent for Americans who are trapped in an Affordable Care Act (ACA) exchange – and 16 of the 17 counties that I represent have only one insurer offering an exchange plan. Throughout Georgia, 96 counties have just one insurer to choose from. That isn’t even a choice at all. Even more alarming, Aetna has said that it will quit all Obamacare exchanges in 2018. Obamacare is crumbling by the day. On top of this, 4.7 million Americans have been kicked off their health care plans and $1 trillion in new taxes have been created. This burden is falling on patients, families, and job creators. I recently hosted roundtables across the First District of Georgia with local small business owners. They reaffirmed that our job creators are being hammered by this failed law and they need relief, especially in rural areas. That is why I am thrilled the House recently passed the American Health Care Act (AHCA) with my support to resuscitate our health care system and deliver the choice and control patients need and deserve. This legislation provides patient-centered reforms to create a free market health care system that is accessible and affordable. Under the AHCA, Washington will no longer dictate that Americans must purchase coverage they don’t want and can’t afford by eliminating penalties attached to the individual and employer mandates. The bill also guts Obamacare by dismantling its taxes while strengthening Medicaid and lowering premiums. There are several aspects of the bill that will work to lower premiums, but a big part is allowing states to redesign their own insurance market to expand choices and provide affordable options. These decisions will be better made at home than by bureaucrats sitting behind a desk in Washington. The AHCA could lower premiums for Americans by up to 50 percent for those buying insurance on their own and outside the exchange. The bill also creates a Patient and State Stability Fund and a Federal Invisible Risk Sharing Program. This provides states with $138

billion to design their own programs. This funding supports mental health and substance abuse, newborn care, and a federal invisible risk pool. It also works to protect Americans with pre-existing conditions. For patients with pre-existing conditions, the AHCA explicitly prohibits insurance companies from denying or not renewing coverage, from rescinding coverage, from excluding benefits, or from raising premiums on those who maintain continuous coverage. It also ensures young adults can stay on their parent’s plan until they are 26. Individuals and families are empowered by this legislation. It will nearly double the amount you can contribute to a Health Savings Account and expand how it can be used. Additionally, the AHCA ensures that Americans can afford health care by providing a monthly tax credit to those who don’t receive health care through work or a government program. The AHCA is now under consideration in the Senate. As it works on the AHCA, the House is moving forward with other critical health reforms that could not be included in the AHCA because it’s being considered under a budgetary process that dictates specific guidelines. While this process ensures the legislation can pass with a simple majority, it prevents certain provisions from being included. For example, legislation has already passed in the House to lower health insurance costs and take the first step toward allowing the purchase of insurance across state lines. The Small Business Health Fairness Act allows small businesses to band together across state lines to negotiate with health insurance providers. Small businesses should have the same ability to negotiate with large insurers just like larger businesses. Additionally, the Competitive Health Insurance Reform Act provides anti-trust scrutiny to the health insurance industry. This protects consumers from consolidation in the health care industry to restore competition. The passage of the AHCA in the House is a big win in the fight to repeal and replace Obamacare, but we have a lot more work to do. As I’ve always said, it’s a strong first step – but it won’t be the last. Rep. Carter represents Georgia’s First District, which includes much of the southeastern part of the state. He is in his second term in Congress. Rep. Carter is a pharmacist.

www.mag.org 23

LEGAL

Key 2017 omnibus bill provisions By Julius W. Hobson Jr., Polsinelli PC

ongress recently completed action on H.R. 244, the ‘Consolidated Appropriations Act for FY 2017’ [P. L. 115-31]. This bipartisan legislation, which funds the federal government for the balance of the fiscal year, passed the House by a vote of 309-188 and the Senate by a vote of 79-18. The president signed the bill into law on May 5. The following is a summary of the key health care provisions that are included in this legislation. Department of Defense • $60 million for peer-reviewed cancer research for cancers not addressed in the breast, prostate, ovarian, kidney, and lung cancer research programs.

• $300 million for peer-reviewed medical research program for: acute lung injury, antimicrobial resistance, arthritis, burn pit exposure, chronic migraine and post-traumatic headache, congenital heart disease, constrictive bronchiolitis, diabetes, dystonia, early trauma thermal regulation, eating disorders, emerging infectious diseases, epidermolysis bullosa, focal segmental glomerulosclerosis, Fragile X, Guillain-Barre syndrome, hepatitis B and C, hereditary angioedema, hydrocephalus, immunomonitoring of intestinal transplants, inflammatory bowel diseases, influenza, integrative medicine, interstitial cystitis, malaria, metals toxicology, mitochondrial disease, musculoskeletal disorders, nanomaterials for home regeneration, non-opioid pain management, pancreatitis, pathogen-inactivated dried cryoprecipitate, polycystic kidney disease, post-traumatic osteoarthritis, scleroderma, sleep disorders, spinal muscular atrophy, sustained-release drug delivery, tinnitus, tuberculosis, vaccine development for infectious disease, vascular malformations, and women’s heart disease. • The bill also addressed DOD/VA efforts to develop, procure, and deploy an interoperable EHR solution. Financial Services and General Government

• $114.8 million for federal drug programs under the Office of National Drug Control Policy. • Section 726 requires health plans participating in the Federal Employees Health Benefits Program to provide contraceptive coverage and provides exemptions to certain religious plans. Department of Health and Human Services • ACA: Eliminates funding for the Independent Payment Advisory Board. Continues requiring the Administration to operate the ACA Risk Corridor program (i.e., one of the ACA’s three premium stabilization programs) in a

24 MAG Journal

budget neutral manner by prohibiting funds to be used as payments for the program. • Rural Health Care: $156.1 million, an increase of $6.5 million. • HRSA: Supports funding for Title VII health professions programs and grants to medical schools and teaching hospitals to develop innovative educational materials related to substance use disorders and pain management. • Nursing Programs: $229.4 million, the same as FY 2016. • Training in Primary Care Medicine: $38.9 million, the same as FY 2016. • Oral Health Training: $36.6 million, an increase of $800,000. • Children’s Hospitals Graduate Medical Education: $300 million, an increase of $5 million. • Maternal and Child Health Block Grant: $641.7 million, an increase of $3.5 million. • Community Health Centers: $1.4 billion, $900 million less than FY 2016. • 340B Drug Program – HRSA to brief lawmakers on the status of the secure website within 90 days of enactment. Provides an additional $1.5 million for telehealth. • CDC: $6.2 billion, including $394 million for the Zika virus. • $160 million for Preventive Health/Health Services Grants. • NIH: $34.0 billion, an increase of $2 billion. Centers for Medicare and Medicaid Services

• Critical Access Hospitals: The agreement continued to note its concerns about the proposal to eliminate critical access hospitals (CAH) status from facilities located less than 10 miles from another hospital and reducing the reimbursement rate from 101 to 100 percent on the hospitals to properly provide care to local residents. The agreement directs CMS to take steps to limit the negative impact of the proposed rate reduction on these hospitals. • Agency for Healthcare Research and Quality: $324 million, $10 million less than FY 2016.

This article was sponsored by Sidney Welch, the chair of Health Care Innovation at Polsinelli. She counsels physicians, physician practices, and health care technology clients in transactional, regulatory, administrative law, and litigation matters on a national basis. Go to www.polsinelli.com/professionals/swelch for additional information. Contact Welch at 404.253.6047 or swelch@polsinelli.com. Paid editorial submission.

• • • •

www.mag.org 25

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PRACTICE MODELS

Solo practice: It’s all about the patient By Barry Silverman, M.D.

n the past decade, there has been tremendous growth in the variety of practice models that physicians employ. This has been driven by the economics of medicine, insurance companies and managed care, EMR requirements and other government regulations, student debt, and generational changes – including the Greatest Generation, Baby Boomers, Generation X, and Millennials. The Editorial Board of the Journal of the Medical Association of Georgia determined that it would be worthwhile to ask some physicians in the state who use different practice models to write about their experiences to help MAG members make informed decisions about the practice model they employ. We asked these physicians to consider the following questions… • When you went into medicine, what were your interests, how did you visualize your future, and have you achieved your goals? • Did you choose your practice model based on financial considerations (e.g., school debt, income potential, lifestyle, and meeting your family’s needs)? • Do you feel like you are in control of your schedule? Is the amount of time you are on call a major problem? Is the number of patients you see reasonable (i.e., can you still deliver good patient care)? • Do you feel like you are truly responsible for your patients’ care – or is management and/or other physicians actively involved? To what extent do PAs direct patient care at your practice, and how do you feel about that? • How much time do you spend managing your practice? Does your perspective matter when it comes to practice management decisions? Does practice staff answer to you or management? How good is the patient scheduling process at your practice, and does your practice contact your patients in person or does it employ “robo” calls for scheduling, test results, etc. • Are you able to generate enough income to meet your overhead expenses, including up-to-date office space (and your EMR system) in a good location? • Do you handle all or most of the patient management? 28 MAG Journal

Do you have your own nurse or are you supported by a group of nurses? Does your nurse(s) handle phone calls, patient concerns, prescriptions, etc.? • How much vacation and other time off do you have? How many hours do you work every week? Do you work a lot of hours because you love working or does the practice control your schedule? • Do you believe that you are earning an income that is commensurate with your skill set and experience? • Have you experienced any burnout, and how enthusiastic are you about medicine compared to when you graduated from medicine school? The following is the first in a series of individual perspectives that will appear in the Journal. It was written by John A. Goldman, M.D., who is a rheumatologist in Sandy Springs. Solo Practice

Government mandates and insurance company profiteering have put the solo rheumatologist in the intensive care unit and facing life support. We are constantly pushed to do more for less – distracting us from our patient’s needs. Community rheumatology provides the highest quality care at the lowest cost. As a solo practitioner, I challenge anyone to compare the individualized care that I provide to my patients to what is offered by large corporations and systems, especially emerging “big box” medicine. Many government-mandated purveyors of health care treat solo practicing physicians as marginal clinicians who need to be regulated on a continuous basis. While they don’t practice medicine, they act omnipotent and are oppressive with their prescriptive policies that disregard my 40-plus years of experience in the medical profession. I have been using a great patient-centered electronic health record (EHR) since 1998, but I’m subject to government penalties since it’s not “certified.” In addition, my requests for waivers have been denied. Forcing me to use a “compliant” EHR simply doesn’t help my practice or my patients. Great care requires intimate, one-on-one physician-patient interaction – not the check-the-box exercises that are designed to help the federal government and other insurers control costs.

I provide sophisticated complex rheumatologic care to individual patients – not populations. I shouldn’t be forced by regulators to have a “care for population” mentality. I also should not be compared to those who attempt to care for large populations using a deeply-flawed government quality calculus and monitored extenders. As we care for our patients, we are constantly insulted by the government bureaucracy, we are subjected to insurance company roadblocks, and we have to contend with pharmacy benefits management (PBM) companies. As we try to find the best way to get our patients the proper medication they need, we are stymied at every step. When we try to prescribe FDA-approved medications, insurance companies (through their PBM) tell us we need to use the compendium and require us to use nonFDA approved medication. And when we want to use a medication from the compendium, we are told that it isn’t FDA-approved and they deny the request. We are required to use time-consuming computer approval forms, we aren’t given a telephone number to call when care is denied, we are subjected to lengthy appeals, we have to contend with policies that ignore treatment efficacy and patient safety, and insurance companies make it difficult to get peer-to-peer communication – which are often done by a physician who is in a different specialty – and then generally denied anyway. Cigna once told me that after I finished a peer-to-peer communication, I would be required to conduct a secondlevel one. And then some 10 years ago, Aetna either did not pay me or underpaid so many times I “fired” them. UnitedHealthcare has deemed me to be a “quality” physician – yet not worthy of being a “premium” physician. Rheumatologists address a wide array of complex conditions, but I felt like all the insurers want me to prescribe is aspirin. Humana once told me told me that an ultrasound I had been using since 2010 wouldn’t be approved unless I had 500 monitored studies. This message was delivered through its imagining approval surrogate, ‘HealthHelp.’ More recently, Humana clawed backed payments without identifying the patients or the reason. When I tried to find out why, the call center I got was in the Philippines, and once I finally got a call center stateside I was told I would receive a letter of explanation – but that never happened. I’m lucky if I get a $3 co-pay from Medicaid, so I have curtailed the number of Medicaid patients I see. Meanwhile, workers’ compensation won’t pay if I make a rheumatology diagnosis, so I’ve moved them into the “see you later” category.

Every business needs to make enough income to cover its costs. Unfortunately, the deck is stacked against physicians in this country. I have lost a lot of legacy physician colleagues who have quit rather than practice with the aforementioned issues and practice environment in mind. I have submitted resolutions to MAG’s House of Delegates to stop physician abuse, to find ways to allow legacy physicians to practice, to promote a Physicians’ Bill of Rights, to manage the cost of prescription drugs, and to eliminate the EHR penalties until we have an AMA-certified EHR. Except for those related to the cost of drugs, these resolutions were either not approved by our House or I was told that they are already part of AMA policy. I wrote this article because medicine is under attack and it is time we wake up. No matter what type of practice model you employ, circumstances change and we need to have all options available – including solo practitioners. To quote Herman Cain, “Some things are stuck on stupid.” However, it is stupid to lie to ourselves and our beloved patients. My solution was to join a “super group” called the American Arthritis and Rheumatology Associates (AARA). This is composed of rheumatology practices from across the country. It allows small practices to come together for economy of scale to manage practice expenses, to have collective bargaining and negotiating power with payers, and to innovate ways to deliver optimal rheumatology care. This model includes a single tax ID, central billing, and central purchasing of medical and non-medical supplies, insurance coverage, and evidenced-based treatment pathways. It allows us to now lead as rheumatologists instead of “holding on to the status quo.” I have autonomy and control of my practice, my staff, and my hours while having the protection and leverage associated with scale. AARA is powered by Bendcare, its business innovation arm that provides me with new revenue opportunities such as specialty pharmacy, data mining and outcomes research, clinical trials, medical education, quality nutritional supplements, ancillary services, and various management tools. I am now more optimistic because the patient-first vision resonates with me, and with the scale and innovation associated with this super group I will keep my practice intact and agile enough to operate within the ever-changing medical marketplace. ¨ In addition to MAG, Drs. Goldman and Silverman are members of the Medical Association of Atlanta. MAG members who would like to share their practice model experience in the Journal should contact Dr. Silverman at mssbds@gmail.com. www.mag.org 29

GENERAL ASSEMBLY

2017: The ‘Open Season on Physicians’ in Georgia By Rep. Sharon Cooper, chair, Georgia House Health and Human Services Committee Rep. Sharon Cooper

onsidering all of the gun bills that passed, the constant legislative attacks on physicians, and the political posturing by both the House and Senate, I’m calling 2017 the “Open Season on Physicians” session.

it out of the House Regulated Industries Committee, and moved it to the floor for passage. Only a bold-faced lie perpetrated by the optometrists and relayed to the Senate by way of a naive freshman sponsor allowed the bill to pass by one vote during the session’s final hours.

The one ray of sunshine that broke through the chaos was that for the first time in my memory, physicians from all over Georgia stepped forward in droves to voice their concerns to legislators about bills: making phone calls, writing letters, and visiting the Capitol. Better yet, physicians spoke out even when a piece of legislation didn’t affect their individual specialties.

The surprise billing fight went on throughout the session. H.B. 71 failed to pass only because you and your lobbyists convinced enough legislators that it was the wrong position to take. While a much better solution was proposed by the Senate, the sponsors of the House bill would not even consider it.

For too long Georgia’s physicians fell victim to the age-old ‘divide and conquer’ strategy. Finally, our physicians have learned that there is strength in numbers, and speaking with a united voice is most effective. The legislature’s schizophrenic approach towards health care policy has never been more evident than during the last session. For 10 years, Georgia has spent millions of dollars to recruit and retain physicians – we upped enrollment at the Medical College of Georgia by 300 slots, reworked our loan forgiveness program for residents in rural areas, and facilitated new residency programs. The goal of these efforts is to broadcast that Georgia is a great place to live and practice medicine. But this year’s multi-faceted attack on medicine sends a very different message, showing little regard for physician’s years of education, personal sacrifice, and dedication – not to mention the commitment to quality patient care that Georgia doctors exhibit, especially those working in underserved areas of our state. The most flagrant legislative examples of this callous attitude were the passage of a bill authorizing optometrists to perform injections, the near-passage of a “surprise billing” measure, and the passage of new Prescription Drug Monitoring Program (PDMP) requirements. S.B. 153 grants optometrists the right to perform injections around and into the surface layer of the eye after only completing a 30-hour training course. Despite extreme pressure from the bill’s powerful author and co-author, my House Health and Human Services Committee killed the bill twice. On the last night of the session, the authors stripped a Senate bill, inserted their language, passed

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Unfortunately, H.B. 71 and S.B. 153 prompted high-ranking members in both chambers to publically bemoan the greed of the physician community and your supposed lack of concern for poor patients – an appalling position that I vigorously rejected, both publically and privately, at every opportunity. The third example of this year’s assault on medicine was the PDMP legislation. The original Senate version would have made it a criminal offense for not checking the PDMP before prescribing any Schedule II, III, IV or V drug. By working with the sponsor of the House bill (which is the version that passed) we made significant changes. H.B. 249 will not go into effect until July of 2018, and only Schedule II opiates and benzodiazepines will have to be checked. There are various other exceptions and no significant penalties. Sadly, physicians are bearing most of the blame for the opiate crisis. Yet this year the legislature gave physician assistants the permission to prescribe hydrocodone. If each of Georgia’s 3,500 PAs write just five prescriptions a week for hydrocodone, the result is almost 1 million more opiate prescriptions a year. The nurses, not wanting Medical Board oversight, removed themselves from this year’s bill; but they will be back in 2018, adding another 5,000 prescribers. Legislators repeatedly stated that the bill is not a problem because physicians have the right to say no to prescribing by their PAs. Regrettably, though, if our opiate crisis worsens YOU WILL GET THE BLAME and your right to prescribe Schedule IIs will be further regulated and restricted. In the face of these challenges, physicians formed a united front to be heard. Please take the lessons learned this year to heart and plan to become even more involved in the lawmaking process – starting now.

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www.mag.org 31

PATIENT SAFETY

Opioids: The pain that won’t go away By William Kanich M.D., J.D., MagMutual chief medical officer

he growing opioid epidemic has been well documented in both the press and medical journals. The epidemic’s toll in lives lost and resource consumption continues to grow. Opioids are now the number one cause of accidental death in the U.S. – as approximately 78 people per day die from opioid overdoses. Deaths from opioid overdoses increased by some 200 percent in the U.S. between 2000 and 2014. The epidemic has affected all areas of our country, and Georgia is certainly not immune from this crisis. Between 2009 and 2014, inpatient stays related to opioid use doubled in the state. Over the same time period, emergency department (ED) visits in Georgia related to opioid use increased by 85 percent. At MagMutual, we have seen several cases where opioid administration has played a prominent role in allegations of medical malpractice. The following two cases illustrate some of the dangers inherent in opioid use… Case #1

A 35-year-old male is brought to the ED by his brother after falling from a porch swing. According to the brother, the two men were drinking beer when the patient became dizzy, fell out of the swing, and struck his lower back. The patient’s only complaint is of severe low back pain. His past medical history is significant for morbid obesity and also included an incident of lower back injury three years prior to this, for which the patient now takes Klonopin regularly. The attending physician orders a CT scan of the patient’s lumbar spine, but the patient is unable to tolerate the procedure due to severe pain. The physician doses the patient with 2 mg of Dilaudid and 25 mg of Phenergan, both of which are administered intramuscularly.

transdermal Fentanyl 75 mcg and asks the patient to return in two weeks. Background

Archaeological evidence suggests that opium poppies have been used for thousands of years. Morphine, named for the Greek god of dreams, was first isolated from opium in the early 19th century. Opiates act on several receptors throughout the body, but the most profound effect is on the mu receptors in the central nervous system. They are commonly used for their analgesic effects. Opiates are drugs derived from the opium poppy plant, while opioids are compounds that bind opioid receptors in the central nervous system producing effects characteristic of naturally occurring opiates. While opioids have profound abilities to treat pain, they also have potentially serious side effects. Chief amongst these is the threat of respiratory depression. Other side effects may include constipation, nausea, euphoria, and altered mental status.

Case #2

Over the past several decades, development of extendedrelease formulations of opioids allowed for less frequent, more convenient dosing. These long-acting medications were also marketed as less addictive alternatives to opioids requiring more frequent dosing, despite scant evidence to support this claim. During this same timeframe, chronic pain patient advocacy groups and others were lobbying for a more aggressive treatment of pain, which they felt was under-appreciated and under-treated by the mainstream medical establishment. A movement was started and adopted by many medical institutions to adopt pain as the “fifth vital sign.” These and other factors contributed to a surge in the number of prescriptions that are written for opioid medications.

A family practitioner sees a 42-year-old male for an initial examination. The patient tells the doctor his medical conditions are COPD, a distant history of alcohol abuse, and chronic low back pain for which he has been treated at an out-of-state pain clinic for the past several years with oral opioids. The patient complained about the need for twice a day dosing and asked the physician if there is an alternative, such as a patch. The physician prescribes

The conditions for which opioids are prescribed has also expanded. Opioids were once reserved for treatment of the most severe sources of pain, such as cancer, end-of-life care, and acute and serious traumatic injuries. These indications remain appropriate. Opioid prescribing has expanded to include conditions such as chronic back pain, headaches, and other chronic pain conditions. However, there is little or no evidence that opioids help in these conditions.

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As the number of prescriptions written for opioids increased, so too did the number of deaths attributed to these medications. What can practitioners do to protect the safety of their patients when prescribing these medications? Several resources, including the recent CDC Guideline for Prescribing Opioids for Chronic Pain, give us some guidance… • Start an opioid at the lowest possible effective dose • Be aware of your patients’ co-morbidities and other medications when prescribing opioids; any medications or conditions that could affect respiratory status may be exacerbated by opioid administration • Calculate a “milligram morphine equivalent” for your patients on opioids. Any value over 90 should prompt a re-consideration of the medications or dosing • Discuss the risks, benefits and alternatives to opioid treatment with your patient • Consider and discuss a taper plan for your chronic opioid patients Case #1

After returning from the CT scanner, the patient was noted to have loud snoring. Thirty minutes later – when the doctor went into the room to deliver the normal CT results to the patient – he was found to be apneic. Despite the administration of ACLS protocol, he could not be revived. Case #2

The patient filled the prescription for the Fentanyl patches. Two days later he was found dead by his roommate in their apartment. Post-mortem toxicology demonstrated elevated levels of alcohol and opioids. Discussion

In the first case, the use of Dilaudid may have been appropriate, but the patient’s co-morbidities must be considered. His obesity, concurrent alcohol intake and regular use of a benzodiazepine, put him at high risk for respiratory depression. Use of an opioid in this situation increases that risk. If the attending physician believes that an opioid is the most appropriate class of medication to use in this situation, several tools could be used to mitigate the risk to the patient. Close respiratory monitoring could be employed, such as pulse oximetry and/or end-tidal CO2 (ETCO2) monitoring. If this technology was not available to the physician, the patient could be moved to an area of the department where he could be closely visually monitored. Alternatively, frequent, periodic checks could be made by the nursing staff of the patient’s respiratory status. Timely

documentation of these surveillance methods would aid the practitioners if there is an untoward outcome, as there was in this case. In the second case, the doctor started the patient on the highest dose of Fentanyl patch. The “milligram morphine equivalent” of this dose is 160 mg; this figure should prompt the doctor to consider the appropriateness of his dosing and possible alternatives. As in the first case, this patient also had co-morbidities (COPD and a history of alcohol abuse) that put him at higher risk for respiratory depression with opioid use. Alternative approaches to this patient’s chronic back pain could have included non-opioid medication or alternative therapies such as massage or acupuncture. Since this was a new patient to the practice, the physician also could have considered consulting the patient’s previous providers, checking his state’s Prescription Drug Monitoring Program or employing a screening tool, such as the SOAPP-R, to assess him for the risk of overdose. Conclusion

Opioids remain a powerful tool for the treatment of pain in the appropriate patient population. Their efficacy, however, has to be weighed against their possible serious side effects, such as respiratory depression. Practitioners can maximize their patients’ safety by judiciously prescribing these medications at the lowest starting dose possible. Consideration should be given to alternative treatment modalities, particularly for chronic, non-cancerous pain patients who are not in hospice. Patients who are already on chronic opioid therapy for noncancerous, non-hospice treatment should be considered for tapering. The goals and scheduling of tapering should be discussed with the patient. Documentation of recommendations for tapering programs and alternative courses of therapy will aid in the defense of a practitioner if there should be an adverse outcome. ¨ The information that is presented in this article is intended to serve as general information of interest for physicians and other health care professionals. The recommendations and advice that is published herein do not reflect or establish a standard of care and do not establish rules for the practice of medicine. The publication of this information is not intended to serve as an offer to insure such conditions or exposures or to indicate that MagMutual, LLC will underwrite such risks for the reader. Our liability is limited to the specific written terms and conditions of actual insurance policies issued.

www.mag.org 33

SPECIALTY NEWS

The doctors who have contributed to the cardiac physical exam By John Davis Cantwell, M.D., MACP, FACC

he following is the first of a three-part series that will appear in the Journal.

1768, Heberden reported “some disorder of the breast…” – the first description of angina pectoris.

In their fine book, Clinical Skills for Adult Primary Care, the late Mark Silverman, M.D., and J. Willis Hurst, M.D.1 noted that, “With the advent of highly sophisticated testing, physicians now devote less time to low technology data collection, and their interest and skills at bedside data collection have atrophied.”

Heberden took notes at the bedside of the sick for 50 years and shared them with his son, who subsequently published them in book form after his father’s death.

In an attempt to rekindle interest in the history of the cardiac physical examination, I would like to reflect upon the contribution of our illustrious predecessors – beginning in the 1600s, and carrying forward to present times. Time and space demands limited comments on each notable contributor to several paragraphs. 1600s

William Harvey (1578-1657), the son of a city mayor and a contemporary of Shakespeare who studied under the Italian Fabricius, who discovered venous valves. Settling into a general practice in London, Harvey wanted to study the circulatory system by personal inspection rather than relying on the writings of others. In the process, he disproved the erroneous teachings of Galen (which has persisted for over 14 centuries) that blood was formed in the liver from ingested food and passed via “invisible pores” in the ventricular septum to the left side of the heart. Harvey was subsequently appointed “physician extraordinaire” to King James I and then to his son, Charles I. Unfortunately, many of his papers and possessions were stolen by a mob in 1642 during the First English Civil War. But Harvey’s great book, De Motu Cordis, has endured. 1700s

William Heberden (1710-1801) was of the same era of William Withering, who discovered digitalis.2 A friend of Ben Franklin and physician to King George III, Heberden described the typical rash of chicken pox and the arthritic nodules in the hands. In a lecture to the Royal College of Physicians in London in 34 MAG Journal

Joseph Leopold Auenbrugger (1722-1809) was born in Vienna, the son of an innkeeper. He took time away from his medical practice to enjoy Viennese court life, including the music of Mozart and Salieri (the reigning court musicians). In fact, Auenbrugger wrote the lyrics for Salieri’s opera, The Chimney Sweep. Empress Maria Theresa requested that he write another, but he refused as he had more important things to do, such as caring for the poor. For his good medical deeds, Auenbrugger was ennobled by Emperor Franz Joseph in 1784. Auenbrugger got the idea for medical percussion by observing how wine merchants used the technique to assess the level of wine in a barrel. He first used percussion in 1754, but the chief of his service was unimpressed. Auenbrugger published his findings in 1761, but the technique did not catch on until Jean Corvisart (Napoleon’s physician) translated the paper into French. Physicians started carrying a percussion hammer. Once deep tendon reflexes were discovered (in 1875), the hammer evolved into the reflex hammer we use today. Born in Italy, Antonia Maria Valsalva (1666-1723) was the student of Malpighi, who discovered the capillary circulation, and the teacher of Morgagni, who wrote a masterpiece correlating clinical and autopsy data at the age of 79. In 1704, Valsalva wrote The Human Ear, subdividing the ear into external, middle, and inner categories. He also named the eustachian tube and described the sinuses behind the aortic valve. To help expel pus from the ear, he described a maneuver that now bears his name. During breath holding while straining, there are normally four phases, including… Phase 1 – The systolic blood pressure rises due to the straining

Phase 2 – The blood pressure falls as positive intrathoracic pressure is maintained. The heart rate increases due to stimulation of the carotid sinus nerve Phase 3 – Release of the strain results in a further dip in the blood pressure Phase 4 – An overshoot of the blood pressure and a decrease in heart rate occurs due to reflex sympathetic activity triggered by the fall in blood pressure and stimulation of circulatory baroreceptors In heart failure, the blood pressure does not fall in Phase 2 due to the volume overload. Failure of the systolic blood pressure to fall below the resting level during the strain phase suggests that the left ventricular end-diastolic pressure is at least 15 mmHg.

The maneuver can also be used to assess systolic heart murmurs. All tend to decrease during the maneuver except for hypertrophic cardiomyopathy and mitral valve prolapse, which usually – though not always – increase. An excellent physician, surgeon, and anatomist, Valsalva was one of the first to introduce humane treatment of the clinically insane. ¨ Dr. Cantwell is a cardiologist with the Piedmont Heart Institute in Atlanta, and he is a member of MAG and the Medical Association of Atlanta. References 1

Silverman ME, Hurst JW (eds). Clinical Skills for Adult Primary Care. Lippincott- Raven, New York, 1996.

Cantwell JD, Cantwell RV. William Heberden, M.D. His life, his times, and his book. Atl Med 1992; 66: 51-52.

MagMutual seeks to change company structure to benefit policyholders On May 17, Georgia Health News reported that MagMutual “aims to convert from a ‘mutual’ company to a stock company, according to filings with the state insurance department.” The article said that, “Atlanta-based MAG Mutual is a leading carrier in the Southeast for physician coverage, and has about half of the medical malpractice insurance market in Georgia. “Mutual companies are owned by policyholders. The proposed reorganization, if approved by policyholders and state Insurance Commissioner Ralph Hudgens, would create a new mutual holding company. That entity would then form an ‘intermediate’ holding company, which would own a converted stock insurance company.” According to the article, “Policyholders would own the mutual holding company but would not receive stock.”

MagMutual Executive Vice President Joe Cregan was quoted as saying that, “This really is a structural matter only, with 100 percent of the company being owned by our policyholders, both before and after the transaction. Their ownership, voting and policyholder rights all remain intact.” Cregan also stressed that “the stock would not be publicly traded.” In a letter that it sent to state regulators, MagMutual stated that, “The new structure provides greater flexibility – and we believe greater financial stability and competitiveness – for the long-term benefit of…current and future policyholders.’’ The article also noted that, “[MagMutual] recorded more than $915 million in policyholders’ surplus during 2016, according to the insurance department.”

Georgia Supreme Court rules in favor of MAG, physicians in key case The Georgia Supreme Court has ruled in favor of Resurgens Orthopaedics and Tapan K. Daftari, M.D., in a case that involved a patient who maintains that a lower court erred when it excluded the testimony of a nurse – a “surprise witness” – who worked at the hospital where he says he received negligent care that led to him to become paralyzed from the waist down. “If the Supreme Court had ruled in favor of this patient, it would have given future plaintiffs the ability to call surprise witnesses at will, without real fear of meaningful sanctions, thus tipping the balance of power in medical malpractice cases,” says Medical Association of Georgia (MAG) Legal Analyst Kimberly Ramseur. Ramseur adds that, “This would have essentially required defendants to identify and interview or depose each and every person who interacted with a plaintiff or patient throughout the course of their care and treatment, which would be

expensive, time-consuming, and unduly burdensome, and which would be in direct conflict with Georgia law.” In an amicus brief that it filed to support Resurgens and Dr. Daftari, MAG asserted that Georgia law gives courts the discretion to impose a wide range of sanctions for discovery violations, including the one that occurred in this case. MAG stressed that “the decision to allow plaintiffs to call surprise witnesses at will, without real fear of meaningful sanctions, grants them an unlimited amount of power… [which is a] major concern to physicians, as these claims are often brought by plaintiffs who have been seen by numerous other physicians and health care providers throughout the course of their treatment.” Contact Ramseur at kramseur@mag.org with any questions or to obtain a copy of the amicus brief. www.mag.org 35

COUNTY, MEMBER & SPECIALTY NEWS

COUNTY MEDICAL SOCIETY NEWS Bibb County Medical Society

by Dale Mathews, Executive Director The Bibb County Medical Society (BCMS) hosted a ‘Tasting of Wines of Spain’ social event at the lakeside home of Paul Dale, M.D., and his wife, Karen Dale, in Macon in April. BCMS members, spouses, and guests enjoyed a selection of appetizers paired with the appropriate wines, which were selected by Tammara Butler and her husband, William Butler, M.D. In addition to Mrs. Butler, the planning committee included J. Eric Roddenberry, M.D., Maria H. Bartlett, M.D., Rana K. Munna, M.D., Margaret C. Boltja, M.D., L. Arthur Schwartz Jr., M.D., Stephen D. Mallary, M.D., W. Robert Lane, M.D., and Christopher E. Minette, M.D., J. W. Griffin, M.D., and his wife, Alicia Griffin. They roasted a whole pig for the event. Go to www.bibbphysicians.org for information on BCMS.

BCMS members and guests enjoyed an array of wines and a roasted pig during the organization’s social event in April.

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Coffee County Medical Society

Hall County Medical Society

Go to www.coffeemedicalsociety. com or contact Charles Miller, M.D., at wcmiller@ windstream.net for information about the Coffee County Medical Society (CCMS) or contact Dawn Williams at 678.303.9261 or dwilliams@mag.org to join CCMS.

by Hank Holderfield, Executive Director The Hall County Medical Society (HCMS) hosted an ‘Equipping Physicians for the Shift to Quality Payment Programs’ program in Gainesville that was presented by the Medical Association of Georgia and KaMMCO Health Solutions in March. More than 30 HCMS members attended the event, which helped them prepare for the Medicare Access and CHIP Reauthorization Act (MACRA) – which has replaced the EHR ‘Meaningful Use,’ the Physician Quality Reporting System (PQRS), and the Value-Based Modifier programs. Event sponsors included MagMutual and Northside Gainesville Imaging. Contact Melissa Connor at mconnor@pami. org with questions related to HCMS.

DeKalb Medical Society

by Hank Holderfield, Executive Director More than 80 members and guests attended the DeKalb Medical Society’s (DMS) annual meeting in Decatur in April. Outgoing DMS President Kathryn Elmore, M.D., installed Don Siegel, M.D., as the organization’s president for 2017. The Physicians’ Care Clinic (PCC) Executive Director Carole Fortenberry presented Jane Perlman with PCC’s Volunteer of the Year Award. Meanwhile, Michael Baron, M.D., was honored with the DMS Judy and Bob McMahan Community Service Award for his “dedication to the Physicians’ Care Clinic and the community of DeKalb.” The event featured casino gambling and Bingo games. Gary Botstein, M.D., served as the master of ceremonies. The grand prize was a Big Green Egg grill. DMS also held an ‘Equipping Physicians for the Shift to Quality Payment Programs’ event at the Druid Hills Golf Club in May. Go to www.dekmedsoc.org or contact Melissa Connor at mconnor@pami.org for information on DMS.

Dr. Don Seigel presents Dr. Kathryn Elmore with a plaque for her service as DMS’ president in 2016.

Dougherty County Medical Society

Go to www.dc-ms.org or contact Susan Workman at 229.436.8191 or dcms. director@gmail.com for information on the Dougherty County Medical Society. Georgia Medical Society

by Ca Rita Connor, Executive Director The Georgia Medical Society (GMS) met in April. Savannah District 4 City Alderman and City Council Chair Julian Miller gave a talk on ‘The State of the City of Savannah.’ Neurologist Fremont P. Wirth Jr., M.D., received the GMS John B. Rabun Community Service Award, which honors a physician for their contributions to their community outside the practice of medicine. Dr. Wirth began his practice in Savannah in 1974, retiring in 2016. GMS is mourning the loss of two past presidents in the last several months, including Joe Nettles, M.D., and Robert Wynn, M.D. Dr. Nettles also served as MAG’s president. Contact Ca Rita Connor at gamedsoc@ bellsouth.net with questions related to GMS.

Muscogee County Medical Society

by Dan Walton, Executive Director The Muscogee County Medical Society (MCMS) held its annual family event at a Columbus Cottonmouths ice hockey game in March. Then in May, MCMS held a closed claim review CME event that featured Ben Cheek, M.D., that was sponsored by the MagMutual Patient Safety Institute. MCMS will host a beer tasting event at the RiverMill Event Centre in Columbus on September 28. Go to www. muscogeemedical.org or call 706.322.1254 for additional information or to join MCMS.

Ogeechee River Medical Society

Contact Michelle Zeanah, M.D., at doctor@zeanah. com with questions related to the Ogeechee River Medical Society. Richmond County Medical Society

MCMS member James Majors, M.D.’s wife Marcie Majors, ‘Boomer,’ and MCMS President Frank Willett, M.D., at Columbus Cottonmouths game in March.

North Georgia Mountains Medical Society

Physicians who would like information about the new North Georgia Mountains Medical Society (NGMMS), which was formed when the Stephens-Rabun and the Habersham county medical societies merged, should contact acting President Stephen Jarrard, M.D., at srcomedsoc@gmail. com. MAG President Steven M. Walsh, M.D., recently presented the new society – a “stronger, more viable organization” – with its charter. The society held a meeting at The Red Barn Cafe at Tiger Mountain Vineyards in May that featured a talk by former MAG president and the current Georgia Composite Medical Board Chair John Antalis, M.D. Contact Dawn Williams at dwilliams@mag. org or 678.303.9261 to join NGMMS.

by Dan Walton, Executive Secretary The Richmond County Medical Society (RCMS) celebrated Doctor’s Day in March. The RCMS Alliance hosted a luncheon to honor retired physicians, while it hosted a dinner to honor all practicing physicians. The meeting featured a CME program on skin cancer by Loretta Davis, M.D. And in April, RCMS held its annual James R. Lyle Resident Research Awards program. Three residents received awards for their abstracts, including first place winner Nischal Nadig, D.O., second place winner Aaron Shaw, D.O., and third place winner Smeet Patel, M.D. The selection committee chair was Donald Loebl Sr., M.D., who presented the awards along with RCMS President Donnie Dunagan, M.D. The society’s Drug Abuse and Addiction Task Force continues to explore ways

to combat opioid abuse in the community. RCMS offers free opioid abuse education CME programs on its website at www.rcmsga.org. Go to www.rcmsga.org or call 706.733.1561 for additional information or to join RCMS. Rome Area Medical Society

Physicians who would like information about the new Rome Area Medical Society (RAMS) should contact John A. Cowan, M.D., at jacowanjr@gmail.com. During its recent meeting, the society discussed the steps that physicians should take if they become aware of human trafficking. RAMS is also leading an initiative to address human trafficking in the area. Contact Dayna Jackson at djackson@mag. org or 678.303.9262 to join the society. Troup County Medical Society

Physicians who have questions about the Troup County Medical Society should contact Dayna Jackson at 678.303.9281 or djackson@mag.org. Walker-Catoosa-Dade County Medical Society

Physicians who have questions related to the Walker-Catoosa-Dade County Medical Society should contact Michael E. Wilson, M.D., at tenwilsons@gmail.com.

MEMBER NEWS Georgia Gov. Nathan Deal recently appointed Barby Simmons, D.O., to the Georgia Composite Medical Board. Dr. Simmons is a primary care physician with the Southeast Permanente Medical Group in McDonough.

Dr. Barby Simmons with Georgia Gov. Nathan Deal.

MAG’s ‘Top Docs Radio’ show passes 12,500 listeners

Between downloads and live listeners, the Medical Association of Georgia’s (MAG) ‘Top Docs Radio’ program on the Business Radio-X Network has now reached more than 12,500 listeners, including people in all 50 states and more than 80 countries. The program is available at www.topdocs.businessradiox. com at 12 p.m. on the second and fourth Tuesday of every month. Recordings of the show are also available at www.mag. org/resources/TopDocs. MAG’s ‘Top Docs Radio’ show is supported with a grant from Health Care Research, a subsidiary of Alliant Health Solutions.

From the left are RCMS ‘James R. Lyle Resident Research Award’ winners Drs. Smeet Patel, Aaron Shaw, and Nischal Nadig.

www.mag.org 37

Gwinnett Medical Center (GMC) resident Ben Hayes, M.D., won the ‘Quality Process Improvement’ category of the poster competition that took place in conjunction with the Association for Hospital Medical Education Academy’s annual meeting in Las Vegas in February. He addressed the prior authorization process from a physician’s perspective. Dr. Hayes’ mentor is John S. Harvey, M.D., MAG’s former president and the GMC’s Transitional Year Residency Program Director.

Dr. Ben Hayes, on the left, with Dr. John Harvey.

Robert Guyton, M.D., received the American College of Cardiology’s 2017 Presidential Citation during the organization’s 66th Annual Scientific Session in Washington, D.C. in March. The honor is given to a “person whose contributions to the field of cardiology have been truly extraordinary.” Dr. Guyton has been the chief of the Division of Cardiothoracic Surgery at Emory since 1990, and he is the chief of cardiac surgery at Emory University Hospital.

38 MAG Journal

The Augusta Chronicle reported that Augusta University Medical Center’s Kathryn Bollinger, M.D., has received a grant from the American Glaucoma Society to “continue her work on promoting inherent protections for the nerve cells in the eye that can become damaged by the disease and lead to blindness.” Kapil Sethi, M.D., a neurologist and the former director of the Movement Disorders Program at the Medical College of Georgia at Augusta University, is the recipient of the 2017 Association of Indian Neurologists in America’s Lifetime Achievement Award. Dr. Sethi is working on a study to “determine whether a constant subcutaneous infusion of apomorphine over 18 hours daily can help ‘rescue’ Parkinson’s patients from bouts of immobility and smooth out their movements.” J. Roy Rowland, M.D., has written a memoir – House Call: A Doctor’s Time in Medicine and Government – about his years as a family physician in middle Georgia and a member of the Georgia General Assembly and the U.S. House of Representatives, where he was a “principal figure in efforts to enact sweeping bipartisan health care reform during President Clinton’s first term.” The book is available on Amazon.com and other online outlets.

SPECIALTY SOCIETY NEWS Georgia Academy of Family Physicians

By Tenesha Wallace, Manager of Communications and Public Health The Georgia Healthy Family Alliance (GHFA) is the philanthropic arm of the Georgia Academy of Family Physicians (GAFP) and a networking member of the American Academy of Family Physicians Foundation. Since launching the Community Health Grant Award Program in 2012, GHFA has awarded $148,500 in grants to Georgia Academy members throughout Georgia. Grants are made to GAFP member affiliated charitable organizations that support GHFA program priorities, including underserved populations and outreach programs that promote healthy practices consistent with the principles of family medicine. So far in 2017, GHFA’s grant recipients have included Kevin Johnson, M.D., for ‘Truth’s Clinic 100 Mammograms for Women’ – which will fund 100 mammograms for women who are at risk for not receiving screening services, along with supporting a pharmacy program, and Mercer School of Medicine in Columbus for ‘Team Triumph Race for Disabled Georgians’ to purchase two ADA-approved Axiom Racing Wheelchairs – which will allow physically-limited children, adults and veterans to fully participate in endurance races throughout Georgia. Go to www.

georgiahealthyfamilyalliance. org or call 800.392.3841 to support the Georgia Healthy Family Alliance with a taxdeductible donation. Visit www.gafp.org for information on GAFP. Georgia Association of Pathologists

Contact Stacie McGahee at 706.738.3119 or smcgahee@medicalbureau. net or go to www. gapathology.org for information on the Georgia Association of Pathologists (GAP) or to join or renew your GAP membership. Georgia Chapter of the American College of Cardiology

by Hank Holderfield, Executive Director The Georgia Chapter of the American College of Cardiology is finalizing plans for its annual meeting, which will take place at The Ritz-Carlton Reynolds, Lake Oconee in Greensboro, Georgia on November 17-19. The organization expects more than 400 to attend the event, which will address every aspect of cardiovascular medicine. The program committee includes Chair Mani Vannan, M.D., and Arthur Reitman, M.D. Dr. Vannan says that, “Our format this year will include a keynote speaker who is followed by a moderated case presentation with responses from a reactor panel and the audience.” He also notes that the President’s Banquet will feature Commander Rorke T. Denver, who has run every phase of training for the

U.S. Navy SEALs and who led special forces missions in the Middle East, Africa, Latin America, and other hot spots. Rorke starred in the hit film ‘Act of Valor,’ which is based on The New York Times bestseller ‘Damn Few: Making the Modern SEAL Warrior.’ Contact Melissa Connor at mconnor@pami. org or go to www.accga.org for additional information. Georgia Chapter of the American Academy of Pediatrics

by Kasha Askew, Director of Membership & Education For the Georgia Chapter of the American Academy of Pediatrics, the 2017 state legislative session produced mixed results. This included the state’s FY 2018 budget, which will increase payment for certain Medicaid primary care and OB-GYN codes for the third year in a row, as well as a bill that will address Medicaid attestation issues. However, lawmakers also passed legislation that the Chapter opposed, including a “campus carry” hand gun bill, a PA hydrocodone prescribing bill, and a bill that expanded the state’s cannabis oil law to include autism as a covered condition. The Chapter hosted its ‘Pediatrics by the Sea’ summer CME meeting on Amelia Island, Florida in June. This year’s program chair was Susan Mazo, M.D., who is the chair of the Pediatrics Department at Memorial Health in Savannah. The event included preconference seminars on developmental pediatrics, coding and practice management, and

behavioral pediatrics. The Chapter recently began a Quality Network (CQN) Project that is designed to improve vaccination rates for children up to two years of age – which is a collaborative effort with the American Academy of Pediatrics – that is being led by Dixie Griffin, M.D., Flavia Rossi, M.D., and Harry Keyserling, M.D. It will provide QI training for 15 practices. The ‘Jim Soapes Charity Golf Classic,’ which raised funds for the Chapter’s foundation, was held at Lake Oconee in April. The Chapter will host a ‘Pediatrics on the Parkway’ meeting at the Cobb Galleria in Atlanta on November 2-4. It is also making plans to host webinars that will address a variety of issues, including sickle cell disease, congenital syphilis, infant/child nutrition, and mental health. Go to www.gaaap.org or call 404.881.5091 for additional information on the Chapter’s events and webinars.

net with any GGES questions.

Georgia Gastroenterologic and Endoscopic Society

Georgia Psychiatric Physicians Association

by Dan Walton, Executive Director The Georgia Gastroenterologic and Endoscopic Society (GGES) will host its annual meeting at the Atlanta Marriott Buckhead Hotel and Conference Center on Saturday, September 16. The meeting is free for GGES members. Go to www. georgiagi.org to join GGES. Also monitor that website for details on the annual meeting. Contact Stacie McGahee at 706.738.3119 or smcgahee@medicalbureau.

Georgia Chapter of the American College of Physicians

by Mary Daniels, Executive Director The American College of Physicians (ACP) held its annual convocation ceremony in San Diego in March. The Georgia Chapter’s new master is Edwin Grimsley, M.D. William Salazar, M.D., was honored with ACP’s W. Lester Henry Award Diversity & Access to Care Award. And ACP announced that it had conferred the award of Fellow on 21 physicians from Georgia. The Georgia Chapter will host a meeting at the Hyatt Regency Savannah on September 29-October 1 that will feature CME, SEP MOC, and internal medicine academic program competitions. Go to www. gaacp.org or contact Mary Daniels at mdaniels@gaacp. org with questions or for additional information.

Go to www.gapsychiatry. org or contact Sally Carter at sally@ associationstrategygroup. us for information on the Georgia Psychiatric Physicians Association. Georgia Society of Dermatology and Dermatologic Surgery

by Maryann McGrail, Executive Director The Georgia Society of Dermatology and Dermatologic Surgery’s (GSDDS) 62nd annual

meeting took place at The Cloister at Sea Island in June. The 41st annual Southeastern Consortium for Dermatology will be held at the Augusta Convention Center on November 3-5. Go to www. gaderm.org for information on these meetings and for other information on GSDDS. Georgia Society of Rheumatology

The Georgia Society of Rheumatology (GSR) held its annual meeting at The Ritz-Carlton Lodge, Reynolds Plantation in Greensboro in June. Go to www.garheumatology.org for information on how to join GSR. Correction

Donnie Dunagan, M.D.’s last name was misspelled in the second reference to him on page 31 of the last edition of the Journal. The Journal’s editorial staff regrets the error. Dr. Dunagan is a MAG member. Please submit your Georgia county medical society, member or specialty society news to Tom Kornegay at tkornegay@mag.org. Also contact Kornegay with any corrections, which will run in the next edition of the Journal. The Journal reserves the right to edit submissions for length and clarity. Bolding recognizes the physicians who are active MAG members at the time the Journal was prepared. Go to www.mag.org/membership to join MAG.

www.mag.org 39

MAG mourns loss of past president, Joe Nettles, M.D.

The Medical Association of Georgia (MAG) is mourning the loss of Joe L. Nettles, M.D., who served as MAG’s president in 1989-1990. He passed away on April 6. Dr. Nettles was an orthopedic surgeon in Savannah for more than 30 years. He graduated from Baylor University and the University of Alabama Medical School. It is also worth noting that Dr. Nettles was a veteran of the U.S. Air Force, as well as a Red Cross volunteer in Vietnam in 1968. After completing his residency at the Mayo Clinic in Rochester, Minnesota in 1969, Dr. Nettles moved to Savannah – where he practiced with his partners at Orthopedic Associates until he retired in 2001. Dr. Nettles completed nearly 100 marathons all over the world, and he carried the Olympic torch through Savannah in 1996. Dr. Nettles was born in Monroeville, Alabama. He was married to Sarah Katherine Quinn for 54 years. He is survived by a number siblings and children and grandchildren.

Protecting your patients, your profession & your future GAMPAC is your peace of mind. Joining MAG’s non-partisan political action committee is the best and easiest way to elect pro-physician candidates in Georgia. Go to mag.org/affiliates/gampac to join GAMPAC today.

Paid for by GAMPAC

40 MAG Journal

Thanks, applause for Dr. Jay Coffsky

The following letter was recently submitted to Jay Coffsky, M.D., who has written the Journal’s ‘Prescription for Life’ column since 2006. Dear Dr. Coffsky, I am a retired orthopaedic surgeon who practiced in Macon for 37 years. My wife and I recently moved to Atlanta to be closer to our grandchildren. I wanted you to know how very much I have enjoyed your articles that have appeared in the Journal for many years. It is what I most appreciate the most in the magazine, and your insights into quality patient care – and life in general – are always most profound. Every time I read your articles, I thought about sending you a simple note of appreciation – though, regretfully, I have always become fixed on something else and have never followed through. But today, after reading your latest article on the real importance of thanking folks who make your life better, I am finally taking the time to write to express my sincere thanks for taking time from your practice to share so many wonderful “pearls!” You are an excellent writer and I am most impressed by the content of your articles, including your recent one about “cleaning your plate.” I was truly amazed that your patient had such a good time during his barium enema. I must admit that in all my years of practice, I never had a patient tell me they enjoyed one of my knee injections! Keep up the good work and thanks again for all you do. Most gratefully, Frank Kelly, M.D. Atlanta AMA says opioid prescribing dropped by 17 percent between 2012 and 2016

The American Medical Association recently released a report that says that, “Between 2012 and 2016, the number of opioid prescriptions decreased by more than 43 million – a 16.9 percent decrease nationally.” According to the report, “Every state saw a decrease in opioid prescriptions during [the same] period.” It also notes that, “Physicians and other health care professionals used state [prescription drug monitoring programs] more than 136.1 million times in 2016 – a 121 percent increase from 2014.” And the report says that “nearly all 50 states now have naloxone access laws.” Go to https://tinyurl.com/mdeqjr6 to review the report.

MAG MEDICAL RESERVE CORPS

MAG MRC participates in high-profile training exercise By Ian McCullough, M.D., member, Medical Association of Georgia Medical Reserve Corps

ore than 20 members of the Medical Association of Georgia’s Medical Reserve Corps (MAG MRC) participated in ‘Vigilant Guard’ – a response training exercise that was designed to “simulate a realistic natural disaster to improve cooperation in preparing for emergencies and catastrophic events” that took place at multiple sites in 31 counties in the state on March 23-31.

“Forty ‘victims’ were transported from Tybee Island via UH-60 Blackhawk helicopters to a triage area, where they received care by the medical teams,” Dr. Harvey explained. “We then formulated a plan to transport these patients to a tertiary receiving hospital.”

The training that occurred in Georgia was part of a larger event that was sponsored by the U.S. Northern Command that involved 9,000 personnel in seven states. It was the first time the Vigilant Guard event took place in Georgia.

In addition to physicians, a number of professions were represented – including scientists, critical care and trauma nurses, registered respiratory therapists, medical students, and educators.

The training – which “simulated local and state emergency response to a category 3 or 4 hurricane making landfall on the Georgia coast” – was co-hosted by the Georgia Emergency Management Agency, the Department of Homeland Security, and the Georgia Department of Defense.

Importantly, there were no injuries reported during the training.

“This exercise gave us a realistic opportunity to train for a rapid deployment and response to emergencies and catastrophic events,” said MAG MRC Medical Director John S. Harvey, M.D. “There is no doubt that it enhanced our readiness and capabilities in significant ways.” Dr. Harvey added that, “Of course, getting an opportunity to fly in a C-130 Hercules plane and Blackhawk helicopters was also a great life experience – so our sincere thanks to the National Guard 165th Air Wing for that.”

The Georgia training scenarios included disease outbreaks, cyber-attacks, chemical spills, search and rescue, collapsed structures, and medical mass casualties.

In his post-exercise evaluation, Dr. Harvey said, “Kudos to the entire Georgia team, including our MAG MRC members, the Georgia National Guard, the Georgia State Defense Force, the Georgia Department of Health, the many first responders, the Medical College of Georgia faculty and residents, and the other volunteers and professionals who demonstrated great dedication and professionalism and who made this exercise a success.” With the approval of the U.S. Department of Health and Human Services, MAG formed the nation’s first medical society-sponsored statewide volunteer MRC in 2014.

The Georgia Department of Defense stressed that, “This is one of the largest disaster relief training exercises in the state… [it is] part of an ongoing effort to maintain a constant state of readiness and interagency efficiency.”

The MAG MRC supplements the official medical and public health and emergency services resources that are available in the state. It trains its members to respond to declared emergencies, including natural disasters (e.g., wildfires, hurricanes, tornados, blizzards, floods) and disease outbreaks.

Vigilant Guard is meant to “test and enhance the relationships between civilian, federal and military partners.”

MAG’s MRC is comprised of 50 deployable members with 30 additional personnel in the training pipeline.

Dr. Harvey pointed out that, “We all remember the effects of Hurricane Matthew in 2016, so we took a lot of lessons learned from that event and refined the processes we employed during this exercise.”

Health care providers who are interested in serving in the MAG MRC should contact Susan Moore at smoore@mag.org or 678.303.9275.

The Georgia State Defense Force and members of an “advance” MAG MRC team constructed and manned a mobile surge hospital at the Air Dominance Center in Savannah as part of the training exercise.

Go to www.mag.org/affiliates/mrc for additional information on the MAG MRC. Dr. McCullough is a resident physician at Gwinnett Medical Center. www.mag.org 41

PERSPECTIVE

The most fundamental question By Mark Murphy, M.D.

he old man sat on the edge of his hospital bed and raked his fingers through the unruly mass of white hair piled atop his head. He adjusted his wire-rimmed spectacles so his slate gray eyes could focus on me. “Well,” he said. “Here we are.” I sat down across from him and grasped his gnarled hands in mine. “The oncologist will be coming by to talk about chemo,” I said. He grinned at me, eyes crinkling up at the edges. His yellowing teeth were a jumbled mess, but the off-kilter smile was endearing. “I’m not taking chemo, doc. I’m ninety-one years old. Why the hell would I want to do that?” “We just want you to know what your options are,” I said. “Looks like I’m about out of options,” he said. We sat there for a moment in silence. The IV pump beeped insistently and I silenced it. “You need to straighten out your arm,” I said. He held out his arms and looked at them, clicking his tongue against his teeth. “That’s a sorry sight right there,” he said. The skin covering his wasted arms was bruised and parchment-thin. “I’m not really interested in talking with anyone about chemo, doc. But I do have one question.” “Sure.” “Is there a God?” Every day, doctors use scientific data to make life-or-death decisions. Questions about the meaning of life come up. It’s part of the job. But what he was asking me was something far more fundamental. The old man had fought the Nazis in the Battle of the Bulge, frozen ground crunching beneath his boots as he battled his way across the frozen French countryside. When the war ended, he went to Georgia Tech on the GI Bill. He got an engineering degree and married Nancy, his high school sweetheart. They had three children. His oldest boy had died in Vietnam. The old man had lived far longer than I had, had seen far more than I had seen, and had endured things I could scarcely imagine. So why would he ask me that question? “You see life and death every day, don’t you, doc?” he said, as if he were reading my mind. 42 MAG Journal

I nodded. Mark Murphy, M.D. “So tell me: Is there a God?” I gazed out of the hospital window and took a deep breath. “There is a God,” I said. “How can you be sure of that?” he said. The old engineer was used to dealing with things which could be measured, calibrated and catalogued. But how does a man of science deal with matters of faith? Indeed, how do any of us, in this data-driven age, deal with those things? I sat down on the edge of his bed and looked him in the eye. “First of all, life itself is a miracle. Each human being is a collection of atoms wound up into molecules that each have a specific purpose, working in concert to form the basis of a self-replicating, self-repairing sentient organism that can explore and build and shape the planet Earth to suit its own needs. And that planet orbits our sun in a manner that allows life, in all of its many forms, to be carved out of the sterile, airless void of space. How can that be random?” “It could be explained by science,” he said. “But there’s a tendency in all systems toward entropy, towards lesser organization. Why would cosmic dust coalesce into stars? Why would unicellular organisms organize themselves into something as complex and as formidable as us?” The old engineer sighed. “I don’t know,” he said. “My son died. Breast cancer took my Nancy away from me. And now look at me, eaten up with cancer myself.” “Well, what about love?” I asked. “I’ve heard folks say it’s just a biochemical reaction,” he said. “Did your love for Nancy seem like a biochemical reaction?” “No,” he said, wiping his eyes with his sleeve. “So here’s what I think: Love is God’s greatest gift to us – and yet it can’t be measured or quantified. The divine nature of love is something you simply have to take on faith. That’s why I believe there is a God. Because otherwise, the world would be devoid of love. And I believe in love,” I said. The old engineer passed away just a few short days later, surrounded by family and friends. At the very end, he wasn’t afraid. And when he died, he died smiling. Dr. Murphy is a gastroenterologist in Savannah, and he is a member of MAG and the Georgia Medical Society.

PRESCRIPTION FOR LIFE

The pseudo-Faustian negotiation Jay Coffsky, M.D.

aust was a legendary, 16th century scholar. He was successful, yet largely unfulfilled. He sold his soul to the devil for knowledge and wealth. The story has been told in countless ways in every form of communication known to man, from fairy tales to novels, to Broadway plays and musicals, including ‘Will Success Spoil Rock Hunter’ and ‘Damn Yankees,’ movies like ‘Nosferatu’ and ‘Mephisto,’ operas like Hector Berlioz’s ‘La Damnation de Faust’ and symphonies like Franz Liszt’s ‘Faust Symphony.’ It has also been told in the form of short stories, including the ‘The Devil and Daniel Webster,’ where a man who sold his soul to the devil hires Daniel Webster – who served as a U.S. Congressman, U.S. Senator, Secretary of State, and who was the leading defense attorney of his time – to represent him. With Webster at his side, the man wins his soul back from Mr. Scratch (aka the devil). The word Faustian means sacrificing or surrendering one’s spiritual values and morals or ethics for power or knowledge or material gain, including sex and money. The concept is like the kind of greed the is highlighted in the movie ‘A Christmas Carol’ or which was demonstrated by the notorious Wall Street fraudster Bernie Madoff. In the most primitive form, pseudoFaustian negotiations begin with just about every child on the planet when they are two to three years old. For example, we promise that they will receive toys from Santa if they are good – or they will get a lump of coal from him if they are bad. Some years ago, a patient who was complaining of chest pain and who had a noticeable cough came into my practice for a chest X-ray. He crossed his fingers and promised to give up smoking if we didn’t discover any serious illnesses. We determined that he had fractured a rib, probably as a result of the cough. Being a man of his word, he gave up smoking…for about two weeks. I am guessing that most of us have made a deal like this at least once in our life: “If the heartburn I’m experiencing isn’t a heart attack, I promise to get in shape and give up fatty foods and lose weight” or

“If I don’t flunk this class, I’ll party less and study more.” Just about every deal or contract that requires us to give up a vice or to change a less-than-desirable habit qualifies as a pseudo-Faustian negotiation – though we don’t generally need to hire Daniel Webster to get us out of a pseudo-Faustian deal. Heck, most of our New Year’s resolutions are pseudo-Faustian in nature. Over breakfast one morning some 15 years ago on a golf trip to Ireland, my three golf buddies and I – in our mid-60s at the time – got into a spiritual discussion about the existence of a supreme being. One thing led to another, and we ended up discussing the meaning of life. It turned into one of the most intense conversations in my life, especially when you consider that coffee was the only liquid stimulant that was involved. Someone finally asked, “Would you sign a contract to have 15 more good years of life?” (I hadn’t given Faust as second thought for 30 years, but we were, in retrospect, in the middle of cutting a classic pseudo-Faustian deal.) It seemed like a great contract at the time, so we all nodded in agreement that we would sign on the dotted line. The good news is we are all in reasonably good health today. We all exercise on a regular basis, we still play an occasional round of golf, and we all have our mental faculties. The bad news is that the contract ended in May of this year. What next? I, for one, would love to renegotiate the deal. And having called them, my three buddies have told me they would, too. In fact, they want me to handle the negotiation. This time, though, we are just asking for 10 more good years. The problem is where to begin. I thought I might start with Daniel Webster, but he died in 1857. The moral of this story is that there are no guarantees and we will all ultimately meet the same fate – so make every day count. Dr. Coffsky and his wife, Sandy, have been married for 57 years and have three children and eight grandchildren. He is in his 50th year at DeKalb Medical. His email is m3wejr@bellsouth.net.

www.mag.org 43

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The Journal of the Medical Association of Georgia A quarterly, four-color magazine from the leading voice for the medical profession in Georgia. MAG has more than 7,800 members. And the MAG Journal is focused on the issues that matter to physicians in the state, including state legislation, national health care reform, legal matters, practice management, and a lot more. Place an advertisement in the MAG Journal and expand your reach!

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Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. All third-party marks—® and ™—are the property of their respective owners. ©2017 Quest Diagnostics Incorporated. All rights reserved. Model used for illustrative purposes.