Vol. 107, Issue 3, 2018
The latest on colon cancer screening
GCMB’s focus on physician burnout Free & sliding-scale clinics in Georgia A legal take on prescription pad security Dr. Joe Craver’s remembrance of Lamar Dodd’s medical artistry Digital stethoscopes
More options. Better outcomes.
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TABLE OF CONTENTS VOLUME 107, ISSUE 3
12
14
24
IN EVERY ISSUE
30 Perspective
3 President’s Message
32 Prescription for Life
4 Editor’s Message 6 Executive Director’s Message
FEATURES
10 Medical Ethics
8 Colon cancer screening guidelines
13 Georgia Composite Medical Board: Why physician burnout 12 An introduction to digital stethoscopes matters 14 Dr. Joe Craver’s remembrance 16 Legal: Prescribing pitfalls– of Lamar Dodd’s medical prescription pad security 20 Patient Safety: Telemedicine artistry key to combatting opioid misuse
22 Georgia free & sliding-scale clinics
26 County, Member & Specialty News
24 The opioid misuse epidemic: A national crisis hits home
PRESIDENT’S MESSAGE
Magic or medicine? Frank McDonald, M.D., M.B.A.
fmcdonald@icloud.com
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n the 19th century, the medical profession in the U. S. was a mess – something that Paul Starr pointed out in his book The Social Transformation of American Medicine. Most physicians had little formal education, and they learned their trade by serving as apprentices to other physicians or by attending two-term private medical schools that were more focused on enriching their founders than teaching their students. Most doctors were in the middle-to-lower class in earnings, and medicine was considered an inferior profession.
speaker who has a Ph.D. in nutrition. The talk was organized by a local Parkinson’s support group, and the sponsors included national Parkinson organizations and major drug companies. I expected to get information that I could use to help my Parkinson patients. But it turns out the speaker was first and foremost a naturopath. She explained how she diagnosed and treated Parkinson disease, and not just with herbs and supplements, but with prescription medications. While both surprised and troubled, I discovered that naturopaths in her state can be fully licensed to practice medicine and prescribe drugs.
The American Medical Association (AMA) struggled to “raise and standardize the requirements for a medical degree.” It created a code of professional ethics that excluded untrained and unorthodox physicians. But its efforts, being voluntary, had little effect. Because orthodox physicians had few effective treatments at their disposal, unorthodox sects arose – including homeopaths, chiropractors, and herbalists.
The July 5, 2018 edition of Neurology Today included an article that advocated the incorporation of CAM therapies into the practice of neurology. The rationale is that CAM is a useful way to treat a patient’s pain without opioids. The neurologists who were featured in the article use acupuncture to treat migraine headaches, chronic pain, musculoskeletal conditions, small fiber neuropathy, and cervical radiculopathy. One telling line in the article was that many patients see acupuncture as “life-changing,” even though there has been no demonstrable change in their pain scales.
Finally, in 1904, AMA formed a Council on Medical Education that invited the Carnegie Foundation for the Advancement of Teaching to evaluate medical education. Carnegie chose Abraham Flexner, an educator who was trained at Johns Hopkins, to conduct the study. His 1910 report proved to be a watershed in medical education. He recommended that the better medical schools adopt the Johns Hopkins model and that the for-profit schools should be eliminated. By 1915, the number of medical schools in the U.S. had dropped by nearly 30 percent – while the number of medical school graduates had declined by 45 percent. Science-based medicine was on its way to revolutionizing patient care, while unorthodox sects were marginalized. The 20th century proved to be a remarkable period for the advancement of science-based medicine. Physicians had effective, evidence-based therapies in their armamentarium – and new treatments were coming online at a rapid pace. Nevertheless, unorthodox practitioners continued to ply their trade. Toward the end of the century, they were amalgamated and labeled as Complimentary and Alternative Medicine (CAM) – giving them an air of legitimacy. Despite the lack of any scientific basis, a lot of prestigious academic medical centers offered CAM therapy, pandering to patient demand. A few months ago, I attended a lecture on nutrition and exercise for patients who have Parkinson disease that was given by a
Richard Bedlack, M.D. – who is a professor of neurology with the Department of Neurology at the Duke University School of Medicine and the director of the Duke ALS Clinic – has enlisted unbiased ALS experts from all over the world to investigate the plethora of “miracle” ALS cures that are available on the Internet today. Their first criterion is determining whether a treatment is scientifically plausible. If it is, they look for evidence of efficacy. What they have concluded is that the only thing that these alternative therapies achieve is separating desperate and dying patients from their money. The question isn’t conventional medicine versus alternative medicine or western medicine versus oriental medicine. No, this comes down to science-based medicine versus pseudoscience. When a treatment is built on scientific evidence, our profession embraces it as conventional. But until then, it has no place in medicine. Physicians’ attitudes toward CAM run the gamut from complete skeptics, like me, to unabashed enthusiasts like the neurologists who were featured in the Neurology Today article. I believe that when one tolerates or recommends or practices CAM, they are being dishonest with their patients. They are relying on magic rather than medicine. www.mag.org 3
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 Mark Murphy, M.D., Savannah Barry D. Silverman, M.D., Atlanta Joseph S. Wilson Jr., M.D., Atlanta Michael Zoller, M.D., Savannah MAG Executive Committee Frank McDonald, M.D., President Rutledge Forney, M.D., President-elect Steven M. Walsh, M.D., Immediate Past President Lisa Perry-Gilkes, M.D., First Vice President Despina D. Dalton, M.D., Second Vice President Frederick C. Flandry, M.D., Chair, Board of Directors Steven M. Huffman, M.D., Vice Chair, Board of Directors Edmund R. Donoghue Jr., M.D., Speaker James 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.
4 MAG Journal
Highlights from MAG’s Legislative Seminar
Stanley W. Sherman, M.D.
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hat was probably our best attended Medical Association of Georgia (MAG) Legislative Education Seminar in recent years took place on June 1-2 at the Brasstown Valley Resort. Since it is not possible for everyone to attend, I thought sharing a few highlights would let you know what was discussed and hopefully inspire you to attend in the future. The Friday night reception and dinner included remarks by Sen. David Shafer, who was a candidate for lieutenant governor. On Saturday morning, MAG President Frank McDonald, M.D., welcomed everyone and discussed the importance of MAG and our legislators working together to continuously improve health care in Georgia. MAG Director of Government Relations Derek Norton recognized and thanked our sponsors. Past president and the chair of MAG’s Council of Legislation, Scott Bohlke, M.D., introduced the legislators and began the first session on insurance reform issues. Our legislative panelists discussed some of these insurance issues. Sen. Chuck Hufstetler sponsored a bill to deal with narrow networks that passed in the Senate but not the House. Sen. Kay Kirkpatririck, M.D., felt the lack of a doctor presence on the Senate Committee on Insurance & Labor has not been helpful. She feels we need to get data on how harmful retrospective ER claims reviews policies can be. Speaker Pro Tem Jan Jones spoke of the legislature’s responsibility to Georgia’s 300,000 state employees to keep insurance rates stable, while recognizing that narrow networks strive for the lowest cost providers to accomplish this. Speaker Pro Tem Jones felt MAG’s input was helpful the past few years in dealing with these issues. Rep. Bob Trammell felt that there is bipartisan dislike for the retrospective ER billing insurance issue. He said that 25 percent of Georgians will be uninsured in the coming years. His plan to expand Medicaid did not pass. Rep. Lee Hawkins, DDS, felt claims downcoding and payment delays allowed insurance companies to pay too little. He felt that the proposed surprise billing solutions have not been comprehensive enough. In his opinion, it is best to fix problems the right way, but this takes time. The panelists for our second session, facilitated by GAMPAC Vice Chair James L. Smith, M.D., dealt with emerging legislative issues. Sen. Dean Burke, M.D., spoke on the problem that rural hospitals have – they are losing money, which has to be taken into consideration of our CON goals. Georgia Sen. John Kennedy, J.D., recounted that his father was a doctor who “did it all.” He noted that there are three doctors currently in the Georgia Senate, and he felt that the issues legislators deal with need to come from those of us who deal with patient care. Unfortunately, opioid misuse is increasing and continues to be an issue. He felt CON issues continue, and that it does not represent a traditional economic model. Rep. Sharon Cooper, RN, MSN, felt the Georgia CME requirement for opioid prescribing was putting us ahead of other states but that we need fewer illegal drugs and more therapy programs. There has been a 33 percent rise in addiction in those younger than 18 years of age.
She reviewed the exceptions to check the PDMP, such as only prescribing a three-day supply of narcotics. Scope of practice issues are being pushed for solving health care needs in rural counties, but this is not where most of the nurse practitioners and physician’s assistants practice, and a major problem is that more in-patients are needed for a rural hospital to stay open. Rep. Betty Price, M.D., addressed the opioid misuse crisis with a need for stopping pill mills and securing our borders from illegal drugs. She lamented that bills dealing with our issues get stuck in the legislature, with too many adversarial – rather than collaborative – efforts to obtain solutions. Rep. Debra Silcox, J.D., the wife of an orthopedic surgeon and a cancer survivor, said that half of states have gotten rid of CON. She felt “microhospitals” with less than seven beds to stabilize patients may help improve rural health and may be economically viable. Georgia has a high infant and maternal mortality rate, so she introduced a bill that passed tasking the Georgia Department of Public Health to create a state designation system for perinatal facilities – like our trauma designation system. Rep. Matt Hatchett focused on the need for more incentives for primary care, telemedicine for rural care, more insurance product options and choices, and Medicaid waivers to expand health care in our state. A lively Q & A session, led by Jim Barber, M.D., vicespeaker of MAG’s House of Delegates, was followed by lunch. There were remarks from Georgia Speaker David Ralston, then from the Insurance Commissioner nominee Jim Beck, and then a keynote speech by Lt. Gov. Casey Cagle. Special thanks to all our bipartisan legislators, all of our members who attended, and all of our MAG staff who made this event possible. I believe all attendees, like me, thoroughly enjoyed this seminar. I hope this review will stimulate even more MAG members to attend next year! The feature article in this issue of the Journal, written by MAG member Charles Duckworth, M.D., deals with colon cancer screening guidelines. Hopefully, this will be the first of future articles from our specialty society members that deal with guidelines that are applicable to general and other practices and to ourselves as patients. Please let us know when you have such guidelines published to review for us. Our other articles dealing with patient care include an article by Barry Silverman, M.D., on utilizing digital stethoscopes. We have articles on dealing with the opioid misuse crisis from Mark Murphy, M.D., and MagMutual. A fourth-year Mercer medical student addresses health disparities among LGBTQ patients. The Georgia clinics that may help you obtain care for economically disadvantaged patients are also highlighted. To find a clinic near you, click the links located under “statewide clinics.” MAG CEO Donald Palmisano Jr. reviews MAG’s latest efforts to stand up on our behalf to help us and our patients. John Antalis, M.D., reviews the Federation of State Medical Board’s efforts to curb physician burnout, and our legal article
deals with prescription pad security. Dr. McDonald lets us know that alternative medicine is still aggressively seeking our patient’s health care dollar. Thomas Gore, M.D., interviews Joseph Craver, M.D., about his relationship with artist Lamar Dodd that led to many fabulous paintings depicting heart surgery. Dr. Murphy wrote an article that reminds us that we still need “old school” medicine. Finally, Jay Coffsky, M.D., will convince you that most of life’s “boulders” are really only “pebbles” that can be dealt with. Hope you enjoyed your summer and made some great family memories!
MAG YPS hosts social event
The Medical Association of Georgia’s Young Physicians Section (YPS) hosted a social event at the Punch Bowl Social in Atlanta in July. From the left are MAG Executive Director Donald J. Palmisano Jr., Tolulope Adebanjo, M.D., Rachel Adams, M.D., Nitasha Ricks, M.D., YPS Chair Zachary Lopater, M.D., YPS Secretary/Treasurer Amin Yehya, M.D., YPS Vice Chair Tracey Henry, M.D. (in the green shirt and black pants), Corrie Burke, M.D. (in the white shirt), MAG President Frank McDonald, M.D., M.B.A., Yolanda Scott, M.D., Rashad Smith, M.D., YPS AMA Delegate Shamie Das, M.D., Britton Crigler, M.D., Lauren Crigler, and Joseph Christenbury, M.D.
MAG & ACEP file lawsuit against Anthem over ER policy The Medical Association of Georgia and the American College of Emergency Physicians (ACEP) recently filed a federal lawsuit against Anthem/Blue Cross and Blue Shield of Georgia to compel the company to rescind its policy to review claims for ER service on a retroactive basis. MAG and ACEP contend that the policy violates the “prudent layperson” standard. Go to www.mag.org for additional information. www.mag.org 5
EXECUTIVE DIRECTOR’S MESSAGE
Creating value and peace of mind for you and your patients Donald J. Palmisano Jr. dpalmisano@mag.org
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s the Medical Association of Georgia’s executive director, I get to speak to physicians who represent every specialty and practice setting on a regular basis – including those who are MAG members and those who are not.
The members obviously see the value associated with MAG’s advocacy efforts, but a few of the non-members have told me that they believe MAG is too focused on health insurance issues and that it should place a greater emphasis on patient care and safety. I would like to think that we can do both on parallel tracks, and I genuinely believe that MAG is creating value and peace of mind for both patients and physicians in Georgia. One example of this is the approach that MAG is taking with Anthem’s Blue Cross and Blue Shield of Georgia subsidiary, which has instituted a policy whereby it can retroactively deny a patient’s coverage for emergency care. Not only is Anthem using criteria it hasn’t made public, it has refused MAG’s multiple requests to release the diagnostic codes that it uses to identify the diseases, disorders, symptoms, etc. for billing and claims purposes that are no longer covered as result of this policy. Physicians know that the average patient isn’t qualified, nor should they be asked, to avoid potentially life-saving emergency care because they are worried about getting a big bill. One of MAG’s former presidents recently, and rhetorically, asked me how a patient is supposed to know the difference between a sore throat and epiglottitis. Of course, they shouldn’t have to – which is why MAG and the American College of Emergency Physicians (ACEP) recently filed a lawsuit in federal court to compel Anthem/Blue Cross to rescind its ER policy. Anthem’s ER policy violates the “prudent layperson” standard, which is a federal law that requires insurers to cover the costs associated with emergency care based on the patient’s symptoms – not their final diagnosis. It is also illegal because it contravenes the ‘Civil Rights Act’ because it disproportionally affects protected classes of people (i.e., it limits their access to care). MAG is also standing up for patients and physicians in the state legislative arena, as it was instrumental in the formation of a 6 MAG Journal
Georgia House study that will look at Anthem’s ER policy and other health insurer practices in the coming months, including prior authorization and step therapy – which routinely deny your patients access to the medication you have prescribed. MAG deserves much of the credit for bringing these key issues to the forefront at the State Capitol. MAG has been a leader in other patient key safety areas as well, including prescription drug misuse and distracted driving. In fact, MAG deserves much of the credit for seeing the ‘HandsFree Georgia Act’ signed into law by Georgia Gov. Nathan Deal in 2018. MAG found the right sponsor in Rep. John Carson for this legislation, which is reducing injuries and saving lives by making it illegal for drivers to hold their cell phones while they are driving. This was one of MAG’s priorities for the 2018 General Assembly. I would be remiss if I also did not applaud three of MAG’s closest allies – the MAG Foundation, the MAG Alliance, and the Medical Association of Atlanta – for funding the ‘Make Georgia Hands-Free’ campaign to warn Georgians about the dangers associated with distracted driving. Individual patients or physicians don’t have the resources or wherewithal to go toe-to-toe with giant companies like Anthem, but MAG and its allies do. And I can’t make any promises about how the Anthem ER policy will turn out, but I can assure you that we will exhaust every option to see it rescinded. There is just too much on the line for patients and physicians. Editor’s note: Patients who have concerns or who would like to lodge complaints about the Anthem ER policy can send an email to MAG at anthemerpolicy@mag.org. In addition, they can share any stories about having ER claims rejected at www.FairCoverage. org. MAG is also encouraging Anthem’s customers to contact the company to determine what services it will and will not cover and how much money they will owe if it determines the care they receive in an ER was not an emergency. Finally, MAG is encouraging patients to contact the Georgia Insurance Commissioner’s office at 404.656.2070 or 800.656.2298 to voice any concerns they have that are related to this or any other health insurance issues.
www.mag.org 7
Colon cancer screening guidelines in 2018 By Charles Duckworth, M.D., clinical associate professor of medicine, Mercer University School of Medicine
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olon cancer is the second leading cause of cancer deaths in the U.S., with an estimated 140,000 new cases and 50,000 predicted deaths in 2018. The good news is that the incidence and death rates associated with colorectal cancer have been steadily declining over the last 10 years largely due to better and more screening – which leads to prevention and earlier stage diagnosis. There are some ongoing areas of concern, however. Colon cancer rates in patients younger than age 50 are actively rising, while some groups – such as Hispanic women – have not seen the incidence and mortality declines of other groups. Current screening guidelines According to the U.S. Multi-Society Task Force (MSTF) on Colorectal Cancer current colon cancer screening guidelines call for screening average risk individuals beginning at the age of 50. Meanwhile, the American Cancer Society (ACS) recently changed its guideline and is now recommending screening the average risk individual beginning at age 45. This was not based on any new data that suggested earlier screening would have a significant impact on death rates from colon cancer in younger individuals, although extending screening to nearly 22 million patients between the ages of 45 and 50 would be expected to have some impact on the incidence and death rates. The MSTF is considering the new ACS guideline. And the consensus for African-Americans continues to be screening at the age of 45 given multiple studies showing advanced adenomas and colon cancer in this group at an earlier age. If the average patient has a first degree relative with colon cancer or an advanced adenoma (polyp >1cm or with villous components or high grade dysplasia) over the age of 60, they 8 MAG Journal
should begin screening at the age of 40 and follow the average risk guidelines thereafter, according to the MSTF. This recommendation is somewhat controversial as it is clear that these patients are at a modestly increased risk for colon cancer compared to the general population. Many physicians continue to call for screening every five years in this population, even though it is not called for in the current guideline. If the first degree relative is under the age of 60 when the patient is diagnosed with colon cancer or an advanced adenoma, screening should begin at the age of 40 or 10 years younger than the onset of cancer or advanced adenoma in that individual, whichever is earlier. Screening should continue every five years after the initial exam. Physicians should review the most recent MSTF recommendations for other high risk populations, such as Lynch syndrome, and surveillance guidelines (e.g., patients who have a polyp or polyps at the time of their exam).1 When to stop screening The MSTF recommends that patients should continue to be screened until the age of 75. Between the ages of 75 and 85, physicians should consider discontinuing screening if the patient remains in excellent health and has a life expectancy of 10 or more years. After the age of 85, colon cancer screening tests are no longer recommended. What are our screening options? Today, patients and their primary care physicians in the U.S. have access to a wide variety of screening tools, including colonoscopies, fecal immunochemical tests (FIT), FITfecal DNA (Cologuard), virtual colonoscopies, and flexible sigmoidoscopies.
A colonoscopy is recommended every 10 years for average risk patients. Studies have found an 80 percent to 95 percent risk reduction in colon cancer mortality when a colonoscopy is performed every 10 years. These rates are based on the patient receiving a high-quality endoscopic exam. While colonoscopies do have impressive results in mortality reduction, it is an invasive sedated procedure that requires a difficult bowel preparation. When referring a patient to an endoscopist, it is important to know if a high-quality exam is being performed. Without it, you may see very little mortality benefit while exposing the patient to some procedural risk. What qualifies as a high-quality exam? Cecal intubation and adenoma detection rates are the primary indicators of high-quality exams. An endoscopist should be able to report the data to the referring physician or the patient. Cecal intubation of more than 95 percent and an overall adenoma detection rate of more than 25 percent are considered adequate, and most experienced endoscopists exceed those numbers. In addition, the endoscopist should be using splitdose bowel preparation regimens to maximize visualization. Yearly FIT testing is recommended for those patients who do not undergo a colonoscopy. It leads to a 60 percent to 70 percent risk reduction in colon cancer mortality. It is simple, non-invasive and inexpensive. If the result is positive, the patient will need to undergo a colonoscopy and continue with yearly testing. Conducting a Cologuard every three years has also led to a 60 percent to 70 percent risk reduction in dying from colon cancer. Like FIT testing, Cologuard is simple and noninvasive – though its’ cost is significantly higher. Once a patient has had a positive test result and they have had a colonoscopy, they should follow the colonoscopy screening and surveillance guidelines. I have often been faced with the dilemma of caring for a patient who has had a negative colonoscopy who also had a positive FIT or Cologuard test. There are no guidelines to assist the endoscopist in how to proceed in these cases, as these tests do have significant false positive rates, and in rare occasions can indicate upper gastrointestinal tract lesions. Colonoscopies that are done in response to a positive FIT or Cologuard are considered diagnostic and are therefore subject to copays and/ or deductibles. Conducting a CT colonography (virtual colonoscopy) or flexible sigmoidoscopy every five years also provides significant (>50 percent) risk reduction for colon cancer death, but they are both somewhat invasive – requiring substantial preparation that is usually quite uncomfortable. They are, therefore, rarely used for screening purposes today. Most insurance companies do not cover a virtual colonoscopy unless the patient has failed more conventional screening methods. A virtual colonoscopy is primarily ordered when the endoscopist cannot reach the cecum, and they complete the evaluation of the colon with a CT colonography. While these studies reduce the risk of perforation, they do not eliminate it.
death. Even with high-quality exams, polyps are missed. Even small cancers can escape detection. Some malignancies bypass the polyp stage altogether. We still have a long way to go to prevent all colon cancers. There are practical considerations in choosing a colon cancer screening plan. Can the patient safely undergo a colonoscopy? For instance, do they have a clotting disorder that makes coming off anticoagulation risky? Do they have anatomic issues that might preclude endoscopic examination? Do they have other practical concerns such as immobility with lack of home assistance? Other issues can be related to finances. While some insurance plans wave the deductible for screening studies, they may apply it to colonoscopies that are being performed because of a a positive FIT or Cologuard result – even if the patient has never undergone a colonoscopy. Some insurers view colonoscopies as a diagnostic study. Before deciding on a screening course of action, patients – in conjunction with their primary care physician – may want to consult with their insurance company to find out what is covered. Other practical concerns might be the availability of good endoscopists in a given area. In rural areas, FIT or Cologuard may be a better option due to the distance the patient needs to travel to have a colonoscopy. Does one’s endoscopist send significant numbers of patients to surgery to remove “large polyps?” Today, most polyps – even quite large ones – can be removed with endoscopic techniques. Not all endoscopists are comfortable with these endoscopic resection techniques, but they should develop a network of physicians that they can refer their patients to for endoscopic resection of large colonic polyps. Ultimately, a physician should choose the screening exam that fits the needs and desires of their patient after reviewing the options with them. If a colonoscopy is chosen, the physician should make sure that the endoscopist provides high-quality exams and can provide data on cecal intubation, adenoma detection, and complication rates. Remember that a poor exam is tantamount to the patient receiving no exam at all. If stool testing is chosen, make sure that the patient understands that they must get a FIT every year or a Cologuard every three years. If the patient has significant health issues that suggest that they have a life expectancy of less than 10 years, the physician should strongly consider discontinuing colon cancer screening programs in that patient. Just 67 percent of eligible adults undergo some form of colon cancer screening. With today’s tools, used properly, colon cancer deaths in most people can be prevented. Dr. Duckworth is a gastroenterologist in Savannah. He is a member of MAG, the American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, the American Gastroenterological Association, and the Georgia Gastroenterologic and Endoscopic Society.
What is the best exam for your patient?
References
The test your patient is willing to undergo is definitely the right one. Unfortunately, no test can prevent every colon cancer
1
Rex et al. Colorectal Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2017
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MEDICAL ETHICS
Health disparities in the LGBTQ population By Lauren Middleton, MS-4, Mercer University School of Medicine
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e are particularly interested in what future They are less likely to have health insurance coverage, and they are more likely to delay or not seek medical care. physicians have to say about cutting edge LGBTQ youth are more likely to be threatened or injured issues in 21st Century medical ethics. The with a weapon in school, transgender adults are more likely following is our first submission, which was have suicidal ideation, and LGB youth are more likely to written by a medical student at Mercer attempt suicide. Furthermore, LGBTQ people who are also a University School of Medicine (MUSM). Lauren Middleton racial or ethnic minority face even poorer health outcomes.1 describes a new component of the curriculum at the medical school, which had the support of MUSM Dean Jean R. Sumner, These well-documented disparities are especially relevant and M.D. We agreed to take this module on and we asked Middleton important in our state. In 2016, Georgia ranked fourth in the country in percentage of adults who identify as transgender to be a part of the process. The following is her report of how this – and it was 18th in the country in the percentage of adults curricular innovation was planned and executed and how the who identify as LGBT.3 This equates to an estimated 55,000 medical students responded to it. Middleton deserves our thanks transgender and 400,000 LGB individuals in the state.4 These and gratitude. – Brian H. Childs, Ph.D., professor of bioethics numbers are believed to be even higher due to underreporting. and professionalism, and J. David Baxter, M.D., FACP, associate professor and Year 3 Every health care provider will ultimately provide care to an program director, MUSM. LGBTQ individual. Georgia’s The demand for equality I especially feel like it is important to unique demographics and justice has never been further compound the quite this loud. The Women’s have this curriculum since we are a aforementioned data as March, Black Lives Matter, African-Americans make up medical school that is based in the part of and #MeToo are all current 31.5 percent of Georgia’s and active social movements the country where this community faces a population, the fourth that have been galvanized highest percentage in the in response to decades lot of discrimination. country.5 African-Americans of structural inequality, have dramatically worse resulting in grave and health outcomes than whites objective disparities between – with more deaths due to specific populations. As these movements progress and the heart disease, hypertension, and diabetes.6 This matters individuals behind them recount their experiences, patterns because identities overlap, amplifying independently existing are exposed and the systemic sources of inequity are revealed. outcomes. These numbers mean that we should pay more attention to our minority populations and how they intersect Undergraduate medical education plays a critical role in with other identities. Ignoring these outcomes leads to higher alleviating health inequity by cultivating future physicians health care costs, unproductive constituents, and a society who are capable and willing to care for a diverse patient that cannot thrive. population. This type of competence begins by acknowledging that specific populations face higher rates of certain diseases In April, MUSM successfully introduced its first LGBTQ+ and burdens that are a result of social, economic, and Module for pre-clinical medical students at its Savannah environmental disadvantages. and Macon campuses. The purpose of the module is to enhance students’ knowledge and understanding of the The lesbian, gay, bisexual, transgender and queer (LGBTQ) health disparities that are facing LGBTQ individuals. The population has categorically worse outcomes in mental and four-hour module consists of three components, including 1 physical health than the rest of the population. LGBTQ an introductory lecture on LGBTQ terminology and people are at an increased risk for cancer, mental illnesses, epidemiology, a patient panel, and four case studies. The 1,2 drug and alcohol abuse, and sexually transmitted infections. 10 MAG Journal
panel consisted of four to five members of the local LGBTQ population, and it was moderated by a faculty member. The panelists narrated their experiences as an LGBTQ person as they interacted with health care providers and the health care system at large. Following the patient panel, students were separated into groups of six to eight and were presented with four cases to review. They evaluated key and prevalent health issues specific to the LGBTQ population. Patient panel members walked through the groups and offered their guidance and perspective. Pre- and post-module surveys were sent to the class to assess their attitudes about the LGBTQ population. The survey responses were quantified on a Likert scale, and a Wilcoxon Signed-Rank test was used to evaluate the difference between the mean. The pre- and post-module assessments found an overall significant improvement in attitudes towards LGBTQ patients (p<0.05) – with feedback on 10 of the 14 questions showing an improvement in acceptability. Questions with a negative mean difference in attitudes were related to comfort and preference in treating LGBTQ patients. This could be due to a better understanding of the complexity of care for these patients.
I think this is a patient population that is very different for me coming from mostly a heterosexual background and not having much experience with the LGBTQ population. Qualitative feedback was requested in a post-module questionnaire that was designed to identify how the module can be improved for future classes. Most saw the patient panel as the highlight of the module, as it seemed to have the most significant impact on one’s beliefs and perceptions. One student said that, “I was able to better understand the difficulties many LGBT individuals experience in their daily lifestyles and how different groups of people experience life.” Another said, “I think this is a patient population that is very different for me coming from mostly a heterosexual background and not having much experience with the LGBTQ population. That being said, this experience was invaluable and allowed me to see that I need to try and incorporate more learning about this patient population and specific guidelines that can help this community.” And one student noted that these kinds of effects “will allow me to be more empathetic towards the LGBTQ community...I will be more cognizant of asking open-ended questions without making any assumptions.”
It is also worth noting that the pre- and post-module surveys exposed differences in regional attitudes towards LGBTQ patients. One student wrote that, “I especially feel like it is important to have this curriculum since we are a medical school that is based in the part of the country where this community faces a lot of discrimination. Georgia is a place where LGBTQ is not widely accepted, and I feel like Mercer has a responsibility to help encourage acceptance in its medical students.” And when asked if regional attitudes can affect care for LGBTQ patients, both pre- and post-module surveys indicated a higher mean level of agreement than any other question. One student also said that, “I’m not sure how to rectify the negative perspective towards physicians once they are already formed...but hopefully moving forward with LGBT training, fewer negative experiences will be formed in the first place.” This response recognizes the inherent challenges in both acknowledging and addressing health disparities, yet it also acknowledges that focused and strategic efforts can improve health outcomes. The LGBTQ+ Module for future physicians was the first of its kind at MUSM, and it is a step forward for improving health outcomes for a population that has historically been left behind in medicine. This first step entailed looking inward and recognizing that the medical profession can and must address the disparities of the population it serves. Until this happens, these patients will not have the autonomy, justice, beneficence, and nonmaleficence that they deserve.¨ MAG members are encouraged to submit their articles and comments and questions to Dr. Baxter at baxter_jd@mercer.edu. Specific questions or comments about this article can be sent to Middleton at middleton.laurenm@gmail.com.
References 1
Krehely, Jeff (2009). How to Close the LGBT Health Disparities Gap. Center for American Progress. https://cdn.americanprogress.org/wp-content/uploads/issues/2009/12/pdf/lgbt_ health_disparities.pdf.
2
Nama N, MacPherson P, Sampson M, McMillan HJ. Medical students’ perception of lesbian, gay, bisexual, and transgender (LGBT) discrimination in their learning environment and their self-reported comfort level for caring for LGBT patients: a survey study. Medical Education Online. 2017;22(1):1368850. https://www-ncbi-nlm-nih-gov.medlib-proxy. mercer.edu/pmc/articles/PMC5653936/pdf/zmeo-22-1368850.pdf.
3
Flores, A.R., Herman, J.L., Gates, G.J., & Brown, T.N.T. (2016). How Many Adults Identify as Transgender in the United States? Los Angeles, CA: The Williams Institute. https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-asTransgender-in-the-United-States.pdf.
4
The Williams Institute. Same-sex Couple and LGBT Demographic Data Interactive. (2016). Los Angeles, CA: UCLA School of Law. https://williamsinstitute.law.ucla.edu/visualization/ lgbt-stats/?topic=LGBT&area=13#density.
5
U.S. Census Bureau (2010). The Black Population: 2010. Retrieved from https://www. census.gov/prod/cen2010/briefs/c2010br-06.pdf.
6
Mays VM, Cochran SD, Barnes NW. Race, Race-Based Discrimination, and Health Outcomes Among African Americans. Annual review of psychology. 2007; 58:201-225. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181672/.
www.mag.org 11
TECHNOLOGY
An introduction to digital stethoscopes By Barry Silverman, M.D.
B
edside auscultation was touted as a significant breakthrough – the ultimate diagnostic tool for pulmonary and cardiac diagnosis – when it was featured in René Laënnec’s De l’auscultation médiate in 1819. And as recently as the 1970s, auscultation was still seen as an important part of bedside teaching rounds. But the tide had changed by the turn of the century. In a 1996 American Heart Association journal article, Cardiac Auscultation: A Glorious Past – But Does it Have a Future?, Morton E. Tavel lamented the lost skill of the bedside exam. Bedside auscultation is now used mostly as a screening tool – to determine if the patient is alive – and as a symbol of the medical profession. This procedure is now largely perfunctory, an activity that is carried out to fulfill documentation requirements. Many patients, especially women, prefer not to completely undress during an exam. Perhaps a more important point is that our profession views the echocardiogram, and not the stethoscope, as the most effective and reliable way important tool to diagnose heart disease. Very little had changed in the basic stethoscope construct and technology for some 200 years until the introduction of the digital stethoscope (DS) in the last few years.
The DS can transmit sounds without complete contact with the patient. This as opposed to the diaphragm of the BS, which must be in good contact with the body for good sound transmission – something that can be difficult on a patient’s neck or a bony chest. I have also found that a DS records clearer sounds through a patient’s clothes, and I can hear clearer Korotoff sounds when I use a DS when I’m measuring manual blood pressures. A BS can be awkward to use. It requires the physician to stretch and lean over large patients or maneuver around a hospital bed, which can place physicians in uncomfortably close proximity to the patient and which often displaces the ear piece. Meanwhile, the DS enables physicians to have unencumbered movement during an exam. This includes maneuvering the microphone around the patient’s body and under their clothes. As an educator, I appreciate the fact that DS have teaching and recording values. The sounds can be recorded and played on a cell phone or a tablet. In addition, the sounds can be converted into a visual form as a phonocardiogram. This eliminates the need for every individual physician to listen to the patient on rounds, and the recording can be shared with others.
DS are generally small and affordable (less than $500) and can be used on a wired or wireless (Bluetooth) basis. The volume can be adjusted, and one can select different frequencies for lower-pitched cardiac tones and higherpitched breath sounds.
In the event you acquire a DS, I have found that the best way to clean it using an alcohol wipe.
When a physician uses an “old-fashioned” binaural stethoscope (BS), the ear piece needs to be firmly situated in the physician’s ear canal. The DS is more forgiving in that regard – especially when one uses headphones – and it permits superior sound transmission.
Auscultation is still important an important way to diagnose cardiovascular disease and care for our patients, but digital stethoscopes do represent a significant advance – a development that may alter what was been an icon of our profession.
For the majority of my career, the first rule of auscultation was to conduct the procedure in a quiet room. This has traditionally been next to impossible in the hospital or an office, but today’s noise-canceling DS headphones provide a nearly silent environment – even when people are talking in the room. And based on my experience, the sound quality of a DS is consistently equal to or better than a BS.
Dr. Silverman is a cardiologist at Northside Hospital, he teaches cardiac care at Grady Memorial Hospital, and he is a long-time member of the Journal of the Medical Association of Georgia’s editorial board.
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Finally, my DS has proven to be durable – as I have dropped it several times and it still works.
GEORGIA COMPOSITE MEDICAL BOARD
Why physician burnout matters By John S. Antalis, M.D., immediate past chair, Georgia Composite Medical Board John S. Antalis, M.D.
A
n increasingly important issue for individual physicians and the Georgia Composite Medical Board (GCMB) is burnout.
We are all keenly aware of the factors that wear us down in our roles as physicians on a daily basis. I am also sure that a lot of us regularly ask ourselves, “Why I am still doing this?” or “How much more of this can I take?” or “How much longer can I do this?” At the same time, we know that physicians cannot unilaterally afford to “have a bad day” without significant repercussions to their patients or employers. An untold number of physicians are consequently suffering in silence – masking their pain, blaming others, and often unknowingly or unwittingly taking it out on their family and friends. Feelings of frustration can evolve in “disruptive” behavior at the hospital or the practice, which can result in complaints to GCMB. Of course, physician burnout isn’t limited to Georgia. It’s something that myriad state medical boards and the Federation of State Medical Boards (FSMB) are wrestling with. It is also worth noting that the American Medical Association has “urged state medical boards to evaluate physicians’ mental and physical health and to study identifying risk factors in medical students.” It is troubling that several studies suggest that the problem is getting worse. One recent Mayo Clinic Proceedings article noted that a survey of nearly 7,000 physicians found that 55 percent of physicians reported experiencing symptoms of burnout – and more than six percent have contemplated suicide. The National Institute of Health also reports that a lot of today’s “preventable errors” are related to physician burnout. In 2014, FSMB’s Ethics and Professionalism Committee determined that there is a clear link between “physician burnout” and “disruptive physicians,” something that has the potential to undermine patient safety in significant ways. FSMB then formed a work group in 2016 to devise the best ways to address physician burnout. The following is a summary of that FSMB work group’s key recommendations, which were released in April of this year… • State medical boards should consider asking probative questions concerning a physician’s mental health, addiction, or substance abuse in the initial and renewal licensure application process. (I agree, though I believe that we also need to find a way to ask those questions in ways that protect patient safety
without discouraging physicians from seeking help without the fear of losing their license.) • State medical boards should focus on a physician’s current impairments – and not their distant past. • State medical boards should place an equal value on an applicant’s mental and physical health. • If it is applicable and needed, a state medical board should advocate for expanding (including securing additional funds) the professional health program (PHP) in its state to include mental illness services in addition to addiction and substance abuse. (Go to gaphp.org or email webinquiry@gaphp.org or call 678.825.3764 for information on the Georgia PHP.) • State medical boards should work with state lawmakers to ensure that a physician’s personal health information is not publicly disclosed. (I believe that this is something that needs to be debated in the context of patient safety in full.) • State medical boards should authorize quality programs that emphasize the need for licensees to address their health and well-being and to seek treatment without any fear of retribution. • State medical boards should take steps to streamline and eliminate redundant regulations, including the introduction of legislation, to reduce the administrative burden that is placed on physicians. • State medical boards should make sure that it is clear that an investigation of a complaint is not tantamount to disciplinary action – and should be done in concert with the PHP. I agree with FSMB that our efforts to curb burnout must include a multifactorial solution, and GCMB must play a key leadership role in Georgia. With that in mind, you have my assurance that GCMB will consider the FSMB recommendations in great depth and detail. I further hope and believe that we will do so in concert with the Medical Association of Georgia, the Georgia Hospital Association, and other key stakeholder groups. There is no doubt that physician burnout is a problem in Georgia. GCMB’s challenge is to find a reasonable balance of policies that both help physicians and protect patients. Dr. Antalis is a member of the Whitfield-Murray County Medical Society, and he was MAG’s president in 2004-2005.
www.mag.org 13
ONE- ON- ONE
An interview with Joseph M. Craver, M.D. By Thomas Gore, M.D. Joseph Craver, M.D.
J
oseph Malcolm Craver, M.D., retired as a well-known cardiothoracic surgeon at Emory University Hospital in 2010 after a distinguished career comprising more than 10,000 operations. Less well-known is Dr. Craver’s role in the Lamar Dodd series of medical art work. Dr. Gore had the opportunity to discuss this with Dr. Craver. Dr. Gore: Joe, we worked together for many years as you operated so successfully on our patients. I will always appreciate what you did for all of them.
Thomas Gore, M.D.
were able to continue with raising their daughter. Dr. Gore: That was Irene Dodd? Dr. Craver: Yes. She is an artist in her own right. She became chair of the art department at Valdosta State University. Dr. Gore: And Lamar was at UGA [the University of Georgia]? Dr. Craver: Yes. He was the chair for many years of the art department at UGA, but I think he had retired by then.
Dr. Craver: Thank you. It was my pleasure.
Dr. Gore: Mary had the operation. What happened then?
Dr. Gore: What are you doing now in your retirement?
Dr. Craver: Lamar came back with her on the follow-up visits and expressed an interest in knowing more about heart surgery. We discussed this many times. He would come back with questions, and he would make sure he understood our answers. He went to the UGA library and others to read more. I would then confirm or correct his understanding. It became a very deep and spiritual understanding of the procedures.
Dr. Craver: I’m focusing on growing older gracefully. And down-sizing. Dr. Gore: I hope I can do that, too. Can we jump into this? I know that you were very involved with the medical art work of Lamar Dodd. Do you know why I am so interested in this? Dr. Craver: Not really. Dr. Gore: Lamar grew up in LaGrange. I met him through his physician, Dr. Bob Copeland. And we have many pieces of the Dodd art work at our hospital. Can you tell us how this really began? Dr. Craver: Spencer King was at Emory Cardiology, and he asked me to help in the treatment of Mary Dodd, Lamar’s wife. She had a weakened heart at that time, coronary artery disease and a left ventricular aneurysm. She was considered at high risk but had enough viable myocardium that we felt we could help her with surgery. We recommended bypass and repair of the aneurysm. I met with Lamar and Mary and told them we had a reasonable chance to improve her outcome with surgery. They took some time to think this over. That was typical of Lamar. He was a very intellectual person. And a religious person. And they thought it over, and my understanding was that they prayed about it. Since the quality of her life was poor, they came back and decided to accept our recommendation and go forward with the surgery. Fortunately, she Lamar Dodd did improve – and they 14 MAG Journal
Dr. Gore: Sounds like he would have made a good medical student. Dr. Craver: Yes, I think so. I suggested he write down his impressions. He then said that he could express his ideas better through painting. And eventually we discussed [the possibility of him] actually watching an open-heart operation itself. We obtained proper consent and discussed this with the patients and families and he actually came into the OR [the operating room] and observed and sketched [drawings]. He did not participate in the procedure, but observed very closely. He became very knowledgeable about it. Dr. Gore: How often did that take place? Dr. Craver: He came in about 10 to 15 times. He would stand behind the screen where he could directly observe the operation up close. This occurred over about six months. And he would come back with more questions and we had many discussions. Dr. Gore: Amazing. What else do you remember about that? Dr. Craver: His intensity of interest in the subject. And he had a great deal of empathy for the patients and their families. He knew that life was in the balance. He knew how critical this was for them. He was a kind and wonderful person. A very spiritual person. Dr. Gore: I read somewhere that he said he found you to be a very sensitive person.
Dr. Craver: Not sure where he came up with that.
course Lamar was very well known in Georgia and throughout the Southeast.
Dr. Gore: Yes, I kind of questioned that too from what I know about you. Just kidding…but back to Lamar, I think there must be about 60 or 70 of these paintings altogether. Do you see a timeless element or a theme to these pieces of art? Dr. Craver: Yes, I do. He depicted scenes that we see every day. Many of them had patients stretched out on their hospital beds, awaiting who knows what. Life or death. I think he saw that they were often at death’s door and could be revived. Medical equipment hooked up to them. Tubes everywhere. He was usually depicting the person. It was a very personal type of image most of the time. Dr. Gore: Any other themes that you see in them? Dr. Craver: He often had a crucifix theme in the painting. Brings to mind crucifixion and resurrection. Dr. Gore: One is called “Dr. Craver and his Team.” Do you remember that one? Dr. Craver: Yes. I believe it showed that many, many people were involved in the operation. Not just the surgeon. Dr. Gore: I really like the ones showing several sets of hands in the operative field. Dr. Craver: I know that one. There were several like it. Again, many people required to perform the operations. Dr. Gore: In these scenes the operative team members were very close together, often hands and bodies leaning together as a unit. Dr. Craver: Same idea. Dr. Gore: It is my understanding that some of the pieces have been used in exhibitions in places such as San Diego and Augusta and Emory University. Were you at any of those?
Dr. Gore: This is just me, but I wonder if we are experiencing some de-personalization in medical training. More and more a physician is becoming commoditized. We sometimes feel we are a number and that our production seems to be priority one. I wonder if we have lost some of the traditional focus of medicine. Do you see any value in this art bringing more of a sense of meaning or value to the medical treatment experience? May it be one way of combating burn out, leading to discussions of the real meaning of our daily work? Dr. Craver: I might not have come up with that, but I can see that as a possibility. Maybe to stimulate further thought or insight. Dr. Gore: How could we get more appreciation for this incredible series? We have about 50 of [the paintings] here in LaGrange – on the walls of WellStar West Georgia Medical Center that we pass by every day. There are also many Dodd paintings in a private collection of C. L. Moorhead in Athens. LaGrange College has many of his works at the Lamar Dodd Art Center on display. And the Georgia Museum of Art in Athens has many pieces of his art work. Lamar had many different styles of painting during his prolific career. Dr. Craver: Yes, he traveled the world and painted many scenes from Europe and other locations overseas. Many scenes also were from Monhegan Island, Maine. I think someone just needs to bring it to the attention of the public. This has been done through the exhibitions, but not in a while as far as I know. Dr. Gore: Do you personally own any of the medical series?
Dr. Craver: All of them. They were very popular exhibits, well-attended, and there were many questions.
Dr. Craver: Yes, I do. I have several that I purchased. And I have given some to family members.
Dr. Gore: Did you come to LaGrange when the collection was obtained by Dr. Copeland on behalf of the Georgia Heart Clinic in 1984?
Dr. Craver: No. I think I’ll hold onto these. They mean a lot to me.
Dr. Gore: Any of yours for sale?
Dr. Craver: Yes, I made several visits.
Dr. Gore: Any final comments or ideas you want our readers to think about?
Dr. Gore: What value do you see in this series of medical art work? What do you think a lay-person or a medical person gets out of viewing this?
Dr. Craver: I would just emphasize that this was a very spiritual experience for Lamar. It held deep meaning for him and he expressed his emotional feelings though his art. I had the incredibly fortunate opportunity to get to know him personally.¨
Dr. Craver: Stimulation of thought. You might need to have a knowledge base in art to appreciate some of its aspects. Of
If you are interested in learning more about Dodd’s paintings, contact Dr. Gore at tbgore@gmail.com. A comprehensive book about Dodd’s life and art, ‘The Truth in Things’ by Bill Eiland, is available on Amazon.com. Dr. Gore is a cardiologist in LaGrange.
www.mag.org 15
LEGAL
Prescribing pitfalls: Prescription pad security By Daniel J. Huff, Esq., partner, and Cody M. Allen, Esq., associate, Huff, Powell, & Bailey, LLC
I
n light of the growing concern over prescription drug abuse in Georgia, the state legislature has taken action by imposing duties upon practitioners who issue prescriptions for controlled substances. In order to satisfy these duties, each individual practitioner should ensure that they are implementing best practices in their prescription protocols to protect themselves from potential civil and criminal liability.
requirements of subparagraph (A) of paragraph (38.5) of Code Section 26-4-5 or security paper that meets the requirements of subparagraph (B) of paragraph (38.5) of Code Section 26-4-5.” 9 Security paper is defined in the Georgia Code as…
Prescription pad security requires not only that practitioners satisfy the duties required of them by Georgia law, but it also requires them to take action to reduce the risk of the unauthorized use of prescription pads by others in their practice.
1. One or more industry recognized features that are designed to prevent unauthorized copying of a completed or blank prescription form and
Georgia’s prescription pad law Despite the growing number of electronic methods that are available to order prescriptions, many physicians still use paper prescription pads. The Georgia legislature has adopted a number of statutes regulating the use of prescription pads that a physician should always consider to ensure that they are taking the proper steps so they do not subject themselves or other members of their practice to potential civil or criminal liability. As a preliminary matter, the Georgia legislature has placed certain limits on the use of prescription pads by practitioners. First, a practitioner may not authorize anyone to use his or her DEA registration number to issue controlled substances.1 Second, a practitioner may not post-date any prescription.2 Third, a practitioner may not issue any prescription upon which his or her signature is affixed by stamp.3 And fourth, a practitioner may not issue any pre-signed blank prescription.4 Importantly, the issuance of a pre-signed blank prescription will be prima-facie evidence of a conspiracy to violate Code Section 16-13-41.5 A physician who violates any of these provisions may be subject to criminal liability.6 Rules governing prescription pads for Schedule II drugs In 2011, Georgia Gov. Nathan Deal signed S.B. 36 into law. The ‘Prescription Drug Monitoring Program’ created a new section of the Georgia Code requiring the use of security paper in hard-copy prescription drug orders for Schedule II substances.7 Specifically, Code Section 26-4-80.1 requires practitioners to “employ reasonable safeguards to assure against theft or unauthorized use of security paper and shall promptly report to appropriate authorities any theft or unauthorized use [of security paper].”8 Where a hard copy of an electronic data prescription drug order for any Schedule II controlled substance is given directly to the patient, the “manually signed hard-copy prescription drug order must be on security paper approved by the board that meets the
16 MAG Journal
• A prescription pad or paper that has been approved by the board for use and contains the following characteristics…
2. One or more industry recognized features that are designed to prevent the erasure or modification of information written on the prescription form by the practitioner and 3. One or more industry recognized features that are designed to prevent the use of counterfeit prescription forms or • A prescription pad or paper that was approved by the Centers for Medicare and Medicaid Services on or after January 1, 2013.10 In order to prevent the unauthorized use of security paper, S.B. 36 also authorized the Georgia Board of Pharmacy to create “a seal of approval that confirms that security paper contains all three industry recognized characteristics required by paragraph 38.5 of Code Section 26-4-5.”11 Again, failure to meet the requirements of this code section subjects physicians to potential criminal liability.12 Allied staff and prescribing controlled substances Many practitioners utilize physician assistants (PAs) or advanced practice registered nurses (APRNs) who have been given the authority to issue prescriptions for certain controlled substances. Those PAs and APRNs are permitted to prescribe Schedule III, Schedule IV, and Schedule V controlled substances when a physician has delegated this authority to them.13 Neither of these allied providers, however, are permitted to issue a written prescription for a Schedule I or Schedule II controlled substance.14 So what best practices should I implement? By understanding the limits that are placed on practitioners concerning the issuance of hard-copy prescriptions in general, you can begin to take steps to ensure that your practice is meeting the duties that are imposed by law. In order to avoid liability, you should establish a process to review and fill out prescriptions one at a time – affixing your signature at that time. Moreover, if you have prescription pads that include your DEA registration number, you should limit access to these and keep them on your person as often as possible. (continued on page 18)
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www.mag.org 17
(continued from page 16)
Not only does Code Section 26-4-80.1 require physicians to use security paper that satisfies the requirements set forth in Code Section 26-4-5, but it also requires physicians to 1) take reasonable precautions to protect against theft of security paper and 2) take reasonable precautions to protect against the unauthorized use of security paper and 3) report the theft or unauthorized use of security paper. Practices frequently utilize software that prints a prescription on security paper. The physician will then sign this printed prescription before they send the patient on his or her way with the prescription in hand. This is a permissible use of security paper, but there are a series of links in this chain that could subject the physician to liability. If your practice uses this approach, we recommend that you take the following steps to reduce potential liability. First, never place more than one sheet of security paper in the printer at a time. When printing a prescription, take a single sheet of security paper and place it in the printer. Second, always limit access to security paper. We recommend locking security paper in a desk or cabinet that only you and other practitioners who are allowed to issue prescriptions for Schedule II controlled substances have access to.
Third, always follow the general rules that are set forth at the beginning of this section regarding the issuance of prescriptions. You should also take appropriate steps to ensure that PAs and APRNs do not have access to security paper or prescription pads that would permit them to prescribe controlled substances in violation of these rules. This can be easily accomplished by ensuring that security paper is locked away and by reviewing any prescriptions that are issued by PAs and APRNs. Of course, good hiring practices will always reduce the risk of fraudulent prescriptions. Finally, if you or anyone else suspects that a member of your practice is violating any of these regulations, you have a duty to report that to the appropriate authorities, including – but not limited to – your local police, the Georgia Composite Medical Board, the Georgia Board of Nursing, and the Georgia Board of Pharmacy. ¨ Huff and Allen are with the law firm of Huff, Powell & Bailey, LLC, which has locations in Atlanta, Gainesville and Columbus. Huff and the members of his firm defend civil lawsuits on behalf of hospitals, physicians, product manufacturers, businesses, corporations, and other professionals. Huff and his firm try several jury trials each year. Contact Huff at dhuff@huffpowellbailey.com. Paid editorial submission.
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PATIENT SAFETY
Telemedicine key to combatting opioid misuse By Emma Cecil, J.D., senior regulatory counsel, MagMutual
T
he statistics are nothing short of grim. With more than two million Americans addicted to or dependent on opioids and an estimated 66,000 overdose deaths in 2017 – up from 64,000 in 2016 – there is no dispute that the nation is in the midst of an opioid misuse epidemic, one that shows little sign of abating any time soon. While no part of the country is immune to the effects of this crisis, rural communities have been disproportionately affected by opioid addiction and abuse, with drug overdose death rates in rural areas having far eclipsed those in urban and suburban areas. Not surprisingly, these same communities suffer the greatest lack of access to medical professionals who can safely prescribe and administer anti-addiction medications like buprenorphine and methadone, which have been highly effective in reducing opioid dependence and overdoses. Many experts agree that telemedicine is one of the keys to solving this dilemma, though obstacles remain for providers and patients. Telemedicine, which allows health care professionals to provide services via telecommunications technologies such as live video conferencing, makes it possible to treat patients regardless of their physical location. Although telemedicine is a critical component in curbing rampant opioid abuse in rural areas – where treatment centers and qualified mental health professionals are in short supply – existing barriers to electronic prescribing of controlled substances and anti-addiction medications have frustrated the expansion of access to care in these areas. Chief among those barriers is the ‘Ryan Haight Online Pharmacy Consumer Protection Act of 2008,’ federal legislation that prohibits physicians from prescribing controlled substances – including the drugs that are used to treat addiction via telemedicine unless 1) they examine the patient in-person or 2) the patient is treated by, and physically located in, a hospital or clinic that has a valid Drug Enforcement Agency (DEA) registration. While this legislation gave the DEA the authority to create a “special registration” that would exempt telemedicine providers from the in-person medical evaluation requirement, it has thus far taken no action to promulgate any rules that would allow it to issue such special registrations. The DEA’s inaction, even in the wake of President Donald Trump’s October 2017 declaration of the opioid misuse epidemic as a national public health emergency – which promised to allow for expanded access to telemedicine, including services involving remote prescribing of medicine commonly used for substance abuse or mental health treatment – has prompted a bipartisan group of senators to 20 MAG Journal
send a letter to the DEA urging it to expedite the rulemaking process to allow providers to use telemedicine to prescribe opioid-based medication-assisted addiction therapies. This letter notes that without a special registration process for prescribing controlled substances via telemedicine, the bar on remote prescribing of anti-addiction medication “will continue to impact rural Americans, who often live far from dedicated treatment centers and mental health professionals.” In making their plea, the senators clarified that the special registration would “not allow for the prescribing of controlled substances generally or the prescribing of opioids for pain management, pain treatment, or any other pain-related purpose that is not part of a medication-assisted treatment for opioid addiction.” Other initiatives at the federal level to eliminate barriers to access and expand the use of telemedicine to combat the opioid misuse crisis include efforts by one of Georgia’s members of the House of Representatives. Rep. Earl L. “Buddy” Carter has introduced legislation that would force the government to promulgate rules allowing providers to prescribe controlled substances even without a faceto-face meeting with the patient. This bill, the ‘Special Registration for Telemedicine Clarification Act,’ would give the Attorney General and the Secretary of the Department of Health and Human Services 30 days to develop interim final regulations. The House passed this bill unanimously on June 12, 2018. Another bill, the ‘Improving Access to Remote Behavioral Health Treatment Act of 2018,’ would allow certain addiction treatment centers to register with the DEA as clinics – allowing the centers to prescribe controlled substances without an in-person examination. The goal of these bills is to ease the burden on doctors who wish to use telemedicine to combat the opioid misuse epidemic. To reduce the number of deaths from opioid misuse, we will need to employ new technologies like telemedicine. The more barriers we can remove from telemedicine’s use, the more likely physicians will be to use this nascent technology. At MagMutual, we will continue to monitor the political climate in both Atlanta and Washington, and we will promote legislation that is in the best interest of physicians and their patients. 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 as an offer to insure such conditions or exposures or to indicate that MagMutual 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 21
PATIENT RESOURCES
Georgia Free & Sliding-Scale Clinics The following is a list of some of the free and sliding-scale clinics in Georgia that offer health care services to economically disadvantaged individuals. Some of these clinics charge a fee that is based on the patient’s income, household size and/or other factors. This informal list was developed with input from county medical societies and state specialty societies. It is not a comprehensive list. Albany
Phoebe Hospitals Not-for-profit organization that offers free or discounted health care and catastrophic discounts to eligible patients who are unable to pay their bills regardless of insurance status. Patients can apply for free or reduced-cost care before medically necessary services are rendered. Free care is available to qualified patients whose family income is at or below 125 percent of the Federal Poverty Level (FPL). Charity or discounted fees are available to qualified patients whose family income is between 126 and 200 percent of the FPL. Catastrophic discount is available to qualified patients whose bill exceeds 25 percent of their gross annual income. Discount varies between 25 percent and 100 percent of patient’s portion of the bill. phoebehealth.com / 229.312.4220 or 866.514.0015 (toll-free) Athens
AU/UGA Mobile Health Clinic Free mobile health clinic that provides care for uninsured and underinsured patients. Staffed by volunteers who “travel to neighborhoods around town, setting up tables and tents in the heart of the communities.” Focused on patients who “have trouble accessing health care through the traditional outlets because of transportation issues, untraditional work schedules, or other barriers.” Contact Mary Kathryn Rogers at mk.rogers@uga.edu with questions. news.uga.edu/mobile-health-clinic Mercy Health Center Provides “quality, whole-person health care in a Christcentered environment. Medical clinics scheduled throughout the week during regular administrative hours and TuesdayThursday evenings…also have pharmacy refill clinic on Wednesday mornings and Tuesday, Wednesday and Thursday evenings. Dental clinics are held on Fridays.” Patients must be “completely uninsured, at or below 150 percent of the federal poverty level, and a resident in one of the following counties: Clarke, Barrow, Jackson, Madison, Oconee or Oglethorpe.” 22 MAG Journal
New patients should call 706.425.4044 on Tuesdays from 4 p.m. to 5 p.m. to schedule an appointment. The center does not accept walk-ins. Services are “provided free of charge, although every patient is given the opportunity to contribute to their care either through financial donations or volunteering.” www.mercyhealthcenter.net / 706.425.4044 Augusta
Christ Community Health Services Offers “affordable, quality primary health and dental care to the uninsured and underserved.” Uses a sliding-fee-scale that is based on the patient’s household’s size and income. Services include adult health, children’s health, and dental care. cchsaugusta.org / 706.922.0600 Medical Associates Plus Partnership that includes University Hospital, the Richmond County Health Department, and the Richmond County Commission. Provides care for low-income patients, including children. Includes seven hospitals and three health departments. mapbt.com / 877.205.5006 or 706.790.4440 Druid Park Community Health Center Faith-based organization that “provides high-quality care and services to indigent and underserved populations.” Services include care for diabetes, asthma, allergy, hypertension, colds/flu, infectious diseases, physicals, preventive care, immunizations, flu shots, chronic disease, health education, and nutrition education. mirmakmin.com / 706.738.0455 or 706.738.0448 Columbus
MercyMed Faith-based health care center. “Individuals without insurance will be placed on a sliding scale that will go down to as little as $30 a visit.” Services include family and internal medicine, GYN, vision, cardio, dermatology, ultrasounds, pediatric care, prescription assistance, and health education and disease management classes. Registration and appointments required. mercymedcolumbus.com/about-mercymed / 706.507.4687 Hall County
Good News Clinics Christian non-profit that provides “medical and dental care at no cost to the patient for uninsured residents of Hall County who cannot afford to purchase health care services.”
Has nearly 50 primary care physicians, nine allied health care providers, and more than 40 dentists. Also has access to more than 300 volunteer specialists through a referral program. goodnewsclinics.org / 770.503.1369 Macon
Macon Volunteer Clinic “Provides free primary medical and dental care, as well as nonnarcotic medication assistance, to uninsured/working adults who live in Bibb County and whose income is equal to or less than 200 percent of the federal poverty level.” Offers primary medical care, dental services, eye exams and prescription eyeglasses, non-narcotic prescription medication assistance, GYN services, dermatology services, cancer screening, lab analyses, x-rays, diagnostic services, nutrition counseling, mental health counseling, and outpatient surgery. MaconVolunteerClinic.com / 478.755.1110 Metro Atlanta
Good Samaritan Health Center Serves patients who “have the least access to health care and are at the highest risk of having serious health issues remain undiagnosed and untreated.” Provides medical, dental, health education, mental health, and social services. Patients are charged on a sliding-fee-scale that is based on income and household size. Had nearly 40,000 patient encounters in 2017. goodsamatlanta.org / 404.523.6571 Physicians’ Care Clinic Free clinic that provides non-emergency medical care for lowincome and uninsured adults. Located at the T.O. Vinson Health Center in Decatur. All appointments are scheduled in advance. Does not accept walk-in patients. Eligibility is based on a “review and approval of the patient’s clinic application.” The clinic was founded in 1992 as an initiative of the DeKalb Medical Society. physicianscareclinic.org / 404.501.7940 Clarkston Community Health Center “State-of-the-art, culturally and linguistically competent primary and preventive health care facility” that provides “quality, affordable, accessible and comprehensive health care services to the residents of DeKalb and surrounding counties.” Services include medical, dental, vision, mental health, and women’s health. clarkstonhealth.org / 678.383-1383 Northwest Georgia (Floyd, Polk & Chattooga counties)
Faith & Deeds Community Health/Free Clinic of Rome “Faith-based, community supported non-profit organization whose mission is to serve the Northwest Georgia counties of Floyd, Polk and Chattooga by providing quality health care services to uninsured residents who have no access to basic health care.” Patients “receive treatment and care for the management of their chronic medical conditions.”
Savannah/Chatham County
Curtis V. Cooper Primary Health Care, Inc. Federally-funded, non-profit community health center. Includes seven sites and about 150 staff, including 30 health care providers serving over 1,900 patients. Services include primary care, prenatal, podiatry, radiology, pharmacy, dentistry, behavioral health, patient assistance, and outreach and health insurance enrollment assistance. “No one will be denied access to services due to inability to pay, race, color, sex, national origin, disability, religion, age, or sexual orientation.” Offers discounts based on family size and income. cvcphc.net / 912.527.1000 St. Mary’s Health Center (St. Joseph’s/Candler) Provides care for “people who fall into the uncomfortable space between not having insurance and not qualifying for Medicaid.” Services include primary and non-emergency and women’s care for uninsured adults between the ages of 19 and 64. Patients are asked to schedule appointments in advance. sjchs.org/in-the-community/st-marys-health-center/ 912.443.9409 Valdosta/Lowndes County
South Georgia Partnership for Health Offers free primary health care services. Staffed by volunteer physicians, physician extenders and nurses who “offer their time without compensation to serve the health care needs of the working uninsured in Lowndes County.” www.sgmc.org / 229.245.0020 Statewide
FreeClinics.com Online directory for free and affordable health clinics. Most of the clinics that are in its database receive federal grants, state subsidies, or are owned and operated by nonprofit organizations and provide services that are either free or offered at a reduced rate. Includes nearly 400 clinics – and medical practices are encouraged to register with the FreeClinics.com database. freeclinics.com/sta/georgia Georgia Charitable Care Network “Unites more than 90 independent, non-profit clinics across Georgia, and includes hundreds of physicians, dentists and other health care professionals who provide care in their own offices.” Provide services for uninsured, underserved and vulnerable populations. Patients may pay a flat rate or a fee that is based on a sliding scale. Care is provided by volunteers and paid providers regardless of patient’s ability to pay. Offers medical, dental, pharmacy, vision and/or behavioral health services. Clinics are funded primarily by private donations and foundations. Patients can go to charitablecarenetwork. com/resources/find-a-clinic to find a GCCN clinic. charitablecarenetwork.org / 678.389.3333
faithanddeedshealthcare.org / 706-234-1331
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OPIOID MISUSE
The opioid misuse epidemic: A national crisis hits home By Mark Murphy, M.D.
W
hen rocker Tom Petty died in late 2017, the cause of death was initially listed as “cardiac arrest.” Ultimately, the real etiology of Petty’s demise was an unintentional overdose of the opioid fentanyl and several other drugs. Prolific rock and roll performer Prince and rapper L’il Peep were also tragic victims of this nation’s burgeoning opioid misuse epidemic in the last several years. The number of overdose deaths in the U.S. has quadrupled since 1999. The Centers for Disease Control (CDC) estimates that half a million people died of drug overdoses between 2000 and 2015 – and the overwhelming majority of these deaths were related to opioids.
Collectively, opioids include drugs like morphine, heroin, codeine, oxycodone, meperidine, fentanyl, carfentanyl, hydromorphone and methadone – and they are most often used in the control of pain. Opiates are among the most heavily regulated medications under the auspices of the Controlled Substances Act of 1970, with prescribers requiring a medical degree and a license number from the DEA. While opiates certainly have medical value as pain relievers, they also have very dangerous side effects. Chief among those is the tendency to make people stop breathing. That, obviously, is a significant problem – especially for a class of drugs that has also been shown to cause addiction.
The modern opioid misuse epidemic can be traced to a single letter that was published in the New England Journal More than 64,000 people died of drug overdoses in this of Medicine in 1980. In that letter, Hershel Jick, M.D., country during 2016 alone. a physician at Boston That’s 175 drug overdose University Medical Center, deaths per day – more than reviewed his hospital’s patient automobile crashes, AIDS The CDC recently issued strict narcotic records and concluded or gun-related deaths ever that “despite widespread caused in a single year in prescribing guidelines for physicians, use of narcotic drugs in this country, and it is more and multiple states – including Georgia hospitals the development of deaths than the total from addiction is rare in medical the Vietnam and Iraq wars – have tightened their regulatory patients with no history of combined. Drug overdose is addiction.” Since its initial now the number one cause requirements for narcotic prescriptions. publication, Dr. Jick’s letter of death among people in has been used repetitively by the U.S. under the age of pharmaceutical companies to 50. promote the use of narcotics as pain relievers. “Pain control” became a trendy medical Opiates, derived from the opium poppy, have been around watchword during the 1990s. In 1999, the VA medical system for thousands of years. Poppy seed capsules have been even began advocating the measurement of pain control as found at 6,000-year-old European Bronze Age burial sites, the “fifth vital sign.” and trade in opium poppy seed pods dates back to the time of the ancient Egyptians. Recreational opium use was Spurred by misleading pharmaceutical industry marketing widespread in the Middle East as far back as the 1400s. and industry-funded “research” that emphasized the advantages and downplayed the risks of narcotics, doctors Use of opium as the medicine “laudanum” was touted as a began prescribing more narcotic pain relievers in the late remedy for everything from menstrual cramps to diarrhea 1990s. Five drug manufacturers were particularly active in beginning in the 1500s. Many in the Victorian era became promoting increased narcotic prescriptions for pain control: addicted to it. Heinrich Emanuel Merck, who owned a Purdue, Endo, Teva, Johnson and Johnson, and Allergan. family pharmacy in Darmstadt, Germany, first began the commercial sale of morphine in 1827. Merck’s family In 2009, an Endo-sponsored website, PainKnowledge. business, still based in Darmstadt, is now a multinational com, claimed that “people who take opioids as prescribed pharmaceutical corporation with more than $15 billion in usually do not become addicted.” That same year, Janssen annual sales. (a subsidiary of Johnson and Johnson) approved and 24 MAG Journal
distributed a patient education guide that attempted to counter the “myth” that opioids are addictive – claiming that “many studies show that opioids are rarely addictive when used properly for the management of chronic pain.” Purdue sponsored a publication by the American Pain Foundation, an organization that is funded by opioid companies, suggesting that pain was undertreated, and it even advocated the use of chronic narcotic pain medications for children. Today, the U.S. is by far the world’s leader in narcotic prescriptions. American physicians annually write five times more narcotic prescriptions per capita than their British counterparts. The proliferation of narcotic use has caused a skyrocketing demand for the illicit sale of synthetic opioidtype drugs such as fentanyl and heroin – drugs far more potent than morphine. Increasing demand for opiates also resulted in the propagation of so-called “pill mills,” where unscrupulous doctors write narcotic prescriptions in exchange for cash. The end result? A huge burden of narcotic addiction, which the CDC estimates has ensnared more than two million Americans. So what can be done about it? The CDC recently issued strict narcotic prescribing guidelines for physicians, and multiple states – including Georgia – have tightened their regulatory requirements for narcotic prescriptions. As a result of these sorts of measures, the number of new opioid prescriptions has been falling steadily since 2010. But this only addresses part of the problem. Narcotic-addicted individuals will find their drugs wherever they can get them – and since narcotics are less readily available from their doctors these days, addicted patients will often procure the more lethal street versions of these drugs. These street drugs are, of course, illegal – and the criminalization of narcotic addiction keeps addicts from seeking the help they need. Here are a couple of specific suggestions for combatting the opioid misuse epidemic… • Limit new cases of addiction by restricting the use of narcotic prescriptions by physicians. As noted, the CDC has issued guidelines limiting the use of narcotics for chronic pain. And the FDA recently placed narcotics on a tighter regulatory schedule. In 2011, the state of Georgia passed a law making it illegal for anyone to own a pain clinic in the state if they are not licensed to practice medicine in the state – closing a loophole that allowed out-of-state doctors to operate “pill mills.” The Georgia legislature also recently made the state’s prescription drug monitoring program (PDMP) more robust, allowing for the ready identification of doctors who are overprescribing narcotics and patients who are “doctor-shopping” to get multiple narcotic prescriptions. • Focus on the treatment of narcotic addiction, not its criminality. The best way to get rid of an addiction is treatment. Medication-assisted treatments with drugs like
methadone can help addicts break their addictions safely. A 2017 study that was published in the British Medical Journal showed that medication-assisted narcotic addiction treatment cuts opioid mortality rates in half. Unfortunately, treatment for narcotic addiction does not come cheap. Many narcotic addicts are young people (ages 18-25) without health insurance. As a result, just 10 percent of people who have narcotic addiction ever undergo formal medication-based therapy to kick the habit for good. Success in combatting the epidemic will, therefore, only come when significant public funds are used to provide treatment. The 2016 ‘Federal Comprehensive Addiction and Recovery Act’ allocated $181 million a year to this effort, and the bipartisan ‘21st Century Cures Act’ allocated another $1 billion over two years (FY 2017 and FY 2018) to combat the opioid misuse epidemic.
The state of Georgia recently funded the Georgia Opioid State Targeted Response Program at about $12 million per year – but these measures are a mere drop in the proverbial opioid addiction bucket. Andrew Kolodny, M.D., the codirector of Opioid Policy Research at Brandeis University’s Heller School for Social Policy and Management, has estimated that fully addressing the opioid crisis in this country could cost upwards of $60 billion over the next 10 years. If that sounds like a lot of money, consider this: The White House Council of Economic Advisors estimated in a November 2017 report that the opioid misuse epidemic costs the country over $500 billion a year. Fear of criminal prosecution leads many people to shy away from treatment for narcotic addiction. The situation is made worse by the fact that street versions of narcotics are often cheaper and more accessible than addiction treatment would be. Georgia’s Good Samaritan Law, signed in 2014, prevents criminal prosecution for anyone seeking medical attention for a person experiencing a drug or alcohol-related overdose. The law also provides better access to the narcotic reversal agent naloxone (Narcan). Many Georgia officers now carry a nasal spray version of Narcan with them at all times, and the narcotic overdosereversal agent is available in Georgia and 40 other states without the need for a prescription. Narcotic addiction needs to be universally treated less like a criminal act and more like the disease it is. The opioid misuse epidemic is all around us, in every community in Georgia. As physicians, ignoring its vast scope is simply not an option. In fact, such ignorance would be a tragedy of epic proportions – and an inexcusable one, primarily because it is eminently preventable.¨ This article has been modified from its original form, which originally ran in the ‘Savannah Morning News’ on January 27, 2018. Dr. Murphy is a gastroenterologist in Savannah, a longtime MAG member, and the former president of the Georgia Medical Society.
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COUNTY, MEMBER & SPECIALTY NEWS
COUNTY MEDICAL SOCIETY NEWS DeKalb Medical Society
by Melissa Connor, Executive Director The DeKalb Medical Society (DMS) will host an ‘All Politics are Local’ legislative open house event at Café Lily in Decatur from 6:30 p.m. to 8:30 p.m. on Tuesday, December 4. DMS President Don Siegel, M.D., says that, “After the November 6 election, we can expect to host many newly-elected legislators, and we hope that we can use this event to begin forging relationships to promote the initiatives of the house of medicine.” Contact Melissa Connor at mconnor@ pami.org or 770.271.0453 or go to www.dekmedsoc.org for details on this event or for more information on DMS. Georgia Medical Society
by Ca Rita Connor, Executive Director In July, the Georgia Medical Society (GMS) attended a dinner that the Medical College of Georgia (MCG) Alumni Association hosted to welcome the third-year medical students who are conducting a rotation at MCG/Augusta University’s Southeast Campus in Savannah. GMS member Dan DeLoach, M.D., encouraged them to join GMS. And in August, GMS President Luke J. Curtsinger, M.D., attended an orientation for incoming students at the Mercer University Medical School of Medicine’s campus in Savannah. Dr. Curtsinger 26 MAG Journal
also encouraged the Mercer students to join GMS. 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 night in conjunction with a Columbus Lions professional indoor football game in July, an event that featured a catered meal. Go to www.muscogeemedical. org or call 706.322.1254 for details or to join MCMS. Richmond County Medical Society
by Dan Walton, Executive Secretary In May, the Richmond County Medical Society (RCMS) held a meeting that featured a ‘Your Life of Professional Liability: How to Thrive and Survive Without Getting ‘All Tore Up’ presentation that was given by William “Bill” James, M.D., that was sponsored by MagMutual. The meeting also featured an ‘Implementing Precision Medicine in a Clinical Setting’ talk that was given by Hani El-Shawa, Ph.D., which was sponsored by AlphaGenomix Laboratories. Go to www.rcmsga.org or call 706.733.1561 for additional information or to join RCMS.
MEMBER NEWS The Albany Herald ran an article announcing that Charles B. Gillespie, M.D., and his wife, Carolyn Gillespie, made a $10,000 donation to The Albany Tech Foundation.
The check presentation took place at the Charles B. Gillespie, M.D., Center for Emergency Responders at Albany Technical College. The funds will be used to support the school’s Emergency Medical Service Professions and Paramedicine Program. A press release noted that, “This donation is made in honor of [Albany Tech President] Dr. Anthony Parker, a true visionary for Albany Tech and our community.” Dr. Gillespie is seen as the ‘father of emergency medical services’ in Georgia.
SPECIALTY SOCIETY NEWS Georgia Academy of Family Physicians
by Tenesha Wallace, Manager of Communications and Public Health The Georgia Academy of Family Physicians (GAFP) is encouraging physicians and practice staff to attend its 2018 Annual Scientific Assembly, which will take place at the Atlanta Evergreen Marriott Conference Resort in Stone Mountain on November 7-10. Family physicians can earn up to 48 AAFP-prescribed credits. AMA: The Georgia Academy of Family Physicians is accredited by the Medical Association of Georgia to provide continuing medical education for physicians. The Georgia Academy of Family Physicians designates this live activity for a maximum of 24 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The meeting will focus on providing family physicians
and other primary care clinicians with information that will strengthen their knowledge base and introduce them to new concepts and clinical practice skills through an evidence-based and diverse educational program. Go to www.gafp. org for more information and to register. Call Tenesha Wallace or Megan Neuffer at 800.392.3841 with questions. Georgia Chapter of the American Academy of Pediatrics
by Kasha Askew, Director of Membership & Education The Georgia Chapter of the American Academy of Pediatrics (Georgia AAP) held its Summer CME meeting, ‘Pediatrics by the Sea,’ on Amelia Island in June. Terri McFadden-Garden, M.D., of Atlanta was installed as the Chapter’s president, while Hugo Scornik, M.D., of Conyers was installed as its vice president. The Chapter also held its Fall CME meeting, ‘Pediatrics on the Parkway,’ at the Cobb Galleria Centre in September. Judson Miller, M.D., of Atlanta served as the program chair. The event included pre-conference seminars on advocacy, coding and practice management, hospital medicine, pediatric nutrition, and a MOC Part II Seminar on ‘Building Mental Health Wellness.’ The meeting also featured the Chapter’s annual awards luncheon. The Pediatric Foundation of Georgia – the Chapter’s philanthropic arm – celebrated its 20th anniversary with a gala event at the Renaissance Waverly Hotel on September
15 that featured a reception, dinner, a high school jazz ensemble, and a silent auction. All net proceeds benefitted the Foundation and the organizations it supports. The Chapter is encouraging its members to mark their calendar for the 2019 ‘Pediatrics by the Sea’ meeting, which will take place on June 12-15. Go to www. gaaap.org to register for the event or call 404.881.5091 for additional information. Georgia Chapter of the American College of Physicians
The Georgia Chapter of the American College of Physicians (ACP) will hold its annual meeting at Callaway Gardens in Pine Mountain on October 12-14. Go to www.gaacp.org or contact Mary Daniels at mdaniels@ gaacp.org for additional information on the Chapter. Georgia Chapter of the American College of Cardiology
by Melissa Connor, Executive Director The Georgia Chapter of the American College of Cardiology (GAACC) will hold its 2018 annual meeting and scientific program at The Ritz-Carlton Reynolds, Lake Oconee in Greensboro on November 16-18. It will feature a number of keynote speakers, case studies, and panel discussions. This year’s focal points will include cardiogenic shock, diabetes and cardiovascular disease, stroke/neuro cardiology, and imaging/worried wellpatients. ACC President Mike Valentine, M.D., will give a national update, while
GAACC’s program directors will give reports on what is taking place in the cardiology world in Georgia. The event will wrap up with a ‘Women in Cardiology’ session, the always-popular case study presentations and a game of ‘Cardiology Jeopardy.’ This meeting drew nearly 50 exhibitors and sponsors in 2017. Finally, GAACC will be honoring John D. Cantwell, M.D., MACP, FACC, with its 2018 Lifetime Achievement Award. The third-generation physician is a cardiologist with the Piedmont Heart Institute in Atlanta. Dr. Cantwell is a Fellow in the American College of Cardiology, a Fellow in the American College of Sports Medicine, and a Master in the American College of Physicians. Go to www.accga. org or contact Melissa Connor at mconnor@pami.org with any questions related to the meeting or GAACC. Georgia Society of Dermatology and Dermatologic Surgery
The Georgia Society of Dermatology and Dermatologic Surgery (GSDDS) was honored with the American Academy of Dermatology (AAD) Model State with Honors Award at AAD’s annual meeting in San Diego in February. It is the eighth year in a row that GSDDS has received the prestigious award. GSDDS’s 63rd annual meeting will take place at The Ritz-Carlton, Amelia Island on November 30-December 2. Visit www. gaderm.org for additional information on the meeting and GSDDS.
Georgia College of Emergency Physicians
The Georgia College of Emergency Physicians (GCEP) will host its ‘Georgia Emergency Medicine Leadership & Advocacy Conference’ at The Ritz-Carlton Reynolds, Lake Oconee in Greensboro on November 29-30. Go to www.gcep.org for more details. Contact Karrie Kirwan at karrie@ theassociationcompany.com for information on GCEP. Georgia Gastroenterologic and Endoscopic Society
by Dan Walton, Executive Director The Georgia Gastroenterologic and Endoscopic Society (GGES) held its annual meeting at the Atlanta Marriott Buckhead on September 15. It addressed a number of important issues, including Hepatitis C, fecal transplant, pancreatic cysts, IBD, EMR, MIPS, pancreatitis, esophageal motility – as well as abstract presentations. Go to www.georgiagi.org or contact Stacie McGahee at smcgahee@medicalbureau. net or 706.738.3119 with questions related to GGES. Georgia Neurosurgical Society
The Georgia Neurosurgical Society (GNS) will hold its ‘Annual Fall Meeting Scientific Assembly’ at The Ritz-Carlton Reynolds, Lake Oconee in Greensboro on November 30-December 2. Go to www.ganeurosurgical. org for details. Also contact Karrie Kirwan at karrie@ theassociationcompany.com for information on GNS.
Georgia Society of Interventional Pain Physicians
The Georgia Society of Interventional Pain Physicians (GSIPP) held its annual meeting at The Ritz-Carlton Reynolds, Lake Oconee in April. Go to www.gsipp.com or contact Karrie Kirwan at karrie@ theassociationcompany.com for information on GSIPP. Georgia Society of Otolaryngology/Head & Neck Surgery
The Georgia Society of Otolaryngology/Head & Neck Surgery will hold its Fall Meeting at The Ritz-Carlton Reynolds, Lake Oconee in Greensboro on November 30-December 2. Go to www. gsohns.org for details. Also contact Karrie Kirwan at karrie@theassociationcompany. com for information. Georgia Society of Rheumatology
The Georgia Society of Rheumatology (GSR) held its annual meeting at The Ritz-Carlton on Amelia Island in June. Go to www. garheumatology.org or contact Alyson Conley at alyson@ theassociationcompany.com for information on GSR. Please submit CMS, 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 27
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PERSPECTIVE
Going ‘old school’ By Mark Murphy, M.D.
Mark Murphy, M.D.
H
ere’s a confession that you won’t hear every day: I once boiled a cat. Okay, that sounds awful – so let me explain. When I was an undergraduate taking comparative vertebrate anatomy at the University of Georgia, one of our focal points was cat anatomy. As part of that exercise, we had to learn all of the bones in the feline skeleton. That required us to go into the anatomy lab, often during off hours, and acquire one of the 15 or so “bone boxes” that each contained a complete cat skeleton. Trying to corral one of the bone boxes was a tremendous inconvenience for an off-campus student like myself, so when opportunity knocked I took advantage. As I was driving back to my apartment one warm spring day, I spied the body of a recently deceased cat lying by the side of the road. Circling back, I saw that it was a stray with no collar, so I tossed it in the back of my Jeep and transported the unfortunate animal back to my apartment. I buried the cat’s body in a fire ant bed for the weekend, letting the insects do their work. Afterwards, I took the little bit that was left, boiled it in my biggest spaghetti pot and voila! With a little scrubbing and cleaning, I had my own independent cat skeleton. That skeleton became the stuff of legend, passed down from student-to-student for at least a decade before I finally lost track of it. When I recently told this story to a medical student, she was mortified. “Why didn’t you just look it up online?” the student asked. “There was no online back then,” I replied. “Well, couldn’t you have just taken pictures of the bones with your phone?” she inquired. “We didn’t have cameras with us. Heck, we didn’t even have cell phones!” The student stared intently at her iPhone for a moment, as though it were about to sprout wings and fly away. “What was it like?” she wondered. “What was what like?” “Practicing medicine back in the old days,” she said, managing a wan smile. I had a sudden glimpse of her image of me as a medical student – garbed in a white monastic habit, poring over a hand-lettered scroll in a darkened cave by candlelight before picking up my black leather bag of leeches, potions and archaic diagnostic tools 30 MAG Journal
to go to the wards and make rounds – which actually was not that far from the truth. “We didn’t have computers,” I said. “The lab did, of course, but the charts were all paper, kept in the nurses’ station, and the lab would print the labs up every day and put them in the lab section of the chart.” “How did you look things up?” she asked. “Well, if we couldn’t figure out what was going on, we used the Index Medicus. It was a series of books they kept in the library that indexed all of the medical literature as it came out each month. We’d search through that, month by month, and when we thought we had the list of articles we wanted, we’d give the librarian the list and they’d help us find them.” “That sounds like a pain.” “It was,” I said. I thought for a moment about my father, a surgeon who graduated from MCG in 1963. He started his career without the benefit of CT scans, MRIs, endoscopy, or the capacity for organ transplantation. The available spectrum of antihypertensive meds, antibiotics and blood thinners was limited. Biologic therapies were nonexistent. However, his histories were exceptional, his physical exam skills outstanding, and his clinical judgment impeccable. Even today, when I describe a case to him, he’s almost always diagnostically spot on. His patients loved him. In fact, they still do – and they tell me so every day. I glanced back up at my medical student, young enough to be my own child, and smiled. “I’m going to tell you something that is truly “old school,” something I learned from my father. You have a wonderful array of tools available to you these days. They make patient care so much easier. But be careful that you don’t rely on them too much. And always remember that the secret of caring for the patient is caring for the patient.” You see, in this technological age, a little “old school” medicine can sometimes go a long way. Dr. Murphy is a gastroenterologist in Savannah, a longtime MAG member, and the former president of the Georgia Medical Society.
The Dreaded Negative Online Review
A
negative review is one of the most frustrating experiences for any doctor. And unfortunately, it happens to everyone eventually. It could be from a patient who was unhappy with your front desk staff, the parking situation, the price of their prescription, the amount of 1:1 time with the doctor, having unrealistic treatment expectations, or just because they were having a bad day. In today’s world your online reputation is critical and can truly make or break a practice, especially if you have an aesthetic practice or out-of-network. So as much as you may wish to just ignore it, I highly recommend you devise a plan of attack to ensure your online reputation is an accurate representation of your practice. Where to Focus Your Efforts The most important review sites to focus on are Google and Yelp. Otherwise anything that ranks on page 1 of Google when you search your name or your practice name, which is generally HealthGrades, Vitals, and RateMD. And if you are in aesthetics, RealSelf should be high on your list. The goal is to have at least 50 reviews on Google and Yelp. The more reviews you have, the less impactful a future negative review will be, and the better you will rank in organic search results.
which makes it easy, and you can help patients using an iPad right from the office. All in all, I can promise you that nothing is better than the doctor/practitioner themselves verbally ASKING for the review. Plan of Attack #2: Remove and Prevent Negative Reviews Next, you need to deal with any current negative reviews and work to prevent future unhappy patients from going online to vent. For the current negative reviews, you can ‘flag’ them and argue your case on certain sites. You must be careful to only argue against something that conflicts with the site’s content or user guidelines. Just being untrue or not a real patient is unfortunately not an effective argument. Then you can respond to reviews privately and/or publically depending on the site. I recommend to take the high road, and not be argumentative. Thank the reviewer for their feedback and helping to make you better, perhaps explain something you have changed internally to help improve and that you encourage them to call to discuss or come back to visit and give you another chance. To help prevent unhappy reviews, you must give patients a safe place to vent. This can be done using something as simple as an anonymous patient satisfaction survey or followup customer service calls. Another perk of a follow up customer service call is, if the patient is happy, you can help direct them to leave a positive review!
Plan of Attack #1: Drive Positive Reviews First, you need to devise a strategy to drive happy patients to leave online reviews. Generally, a happy patient tells their friends or family about you. So how do you convince them to share their experience online? The absolute best way is for the doctor themselves to ask. Blame it on your marketing company, blame it on your practice manager, and do whatever it takes. I know it isn’t fun and can feel like a silly use of your time, but a verbal request direct from the doctor goes a long way. Then it should be followed up with something in writing. It could be a card to hand out or a text or email sent after the patient leaves the office. The most important thing to remember is the review must be left from outside of the office (i.e., a different IP address to avoid it from getting removed or filtered). If your patient is not a ‘Yelper’, their review on Yelp has a good chance of getting filtered (i.e., not showing on the main page or being a part of the overall star rating). Regardless, if they can ‘check-in’ on Yelp from your office, have a profile picture, have friends on Yelp, and have multiple reviews there is a higher likelihood of the review sticking. Google reviews are quite easy for anyone with an @gmail.com email address. RealSelf reviews can now be left from the office
In Conclusion Ultimately, Yelp and Google are both powerful platforms that cannot be avoided in today’s digital world. Everyone will get a bad review eventually, so the best idea is to get ahead of it with a comprehensive strategy. And please remember that your online reputation is just one piece of an effective overall marketing strategy. So your plan of attack should be developed in conjunction with your overarching marketing plan. Risa Goldman Luksa, Founder & President Goldman Marketing Group Full Service Marketing & Consulting Firm Exclusive in Healthcare Website Development • Graphic Design Lead Generation • Social 818.861.7092 info@goldman-marketing.com Goldman-Marketing.com Paid editorial/submission. www.mag.org 31
PRESCRIPTION FOR LIFE
The pebbles of life Jay Coffsky, M.D.
I
noticed that my son was limping as we left what has become an increasingly commonplace event at this stage of my life – a funeral. We stopped so that we could sit for a few seconds to retrieve a small pebble from his shoe.
It made me wonder how something so small can cause so much pain. And it reminded me (and probably others of my generation) of the story of The Princess and the Pea – which is about a princess whose royal identity was established by a test of her physical sensitivity – by Hans Christian Andersen. We all face obstacles in life. Of course, some are bigger than others. And like the princess who endured a sleepless night that was caused by a pea – despite being buried under 20 mattresses and 20 feather beds – I know that there are times when those pebbles seem more like boulders, which are capable of producing both physical and emotional pain. Of course, the odds of getting a pebble in your shoe is proportional to the path you take. The more difficult and challenging the road, the greater the risk. If you practice medicine in a busy community hospital radiology department like mine, you will evaluate tens of thousands of body parts in CT and MRI scans. You will eventually miss something, which means you will make a mistake. Most of these mistakes are pebbles, but they can turn into a boulder for your patient. You also cannot have relationships with the people in your life – including your friends, colleagues, better half or children – without advertently picking up a few pebbles along the way. I remember getting a pebble in my shoe on my first date with my wife, Sandy. We were holding hands on the couch at her house when her parents drove up. I panicked and jumped into a chair across the room – crushing Sandy’s glasses in the process. Then in my haste to leave, I backed my car into her parents’ car. It wasn’t exactly the first impression I had in mind – and that pebble seemed like a 10-ton boulder at the time – but I survived that experience and my relationship with Sandy (and, yes, eventually her parents) grew stronger.
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Some years later, my friend and I placed a “signal call” (i.e., making a long-distance telephone call, but only letting it ring once to avoid any charges) to our parents to let them know we had arrived safely in Athens after driving home from college in Augusta. MCG’s dean found about out our scheme. He said that signal calling was like stealing from the phone company. He even threatened to kick us both out of college (really!). Fortunately, we both had excellent GPAs – and he realized that if he kicked us out the fraternity wouldn’t have the minimum GPA (and terminating its charter would mean more work for him) – so he gave us small fines. What was a “Whew!” moment, and the story ended up being one about a boulder that turned into a pebble. I learned early on in life that just because someone else tries to put a pebble in your shoe, it doesn’t mean it really exists. Based on the results of the college placement test that I took in 10th grade, I was told that I was a borderline candidate for college – and certainly not smart enough for medical school. But you can’t measure one’s determination from a test. I finished college at age 19 and medical school at age 23. That pebble I got as a sophomore in high school served as a constant reminder, and it gave me the push I needed. The good news is that as an octogenarian – which is hard to pronounce, much less accept – the boulders in life a few and far between. I have a different perspective. I don’t let the little stuff turn into something bigger. This (and grandkids) is the silver lining of aging. We all have to contend with pebbles in life, but I have discovered that we have a choice: We can live with the pain or we can remove those pebbles as soon as we discover them to ensure they don’t turn into boulders. Dr. Coffsky and his wife, Sandy, have been married for 58 years. They have three children, eight grandchildren, and a greatgrandchild. Dr. Coffsky is in his 51st year at DeKalb Medical. You can contact Dr. Coffsky at jaycoffsky@gmail.com.
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