A publication of the Maricopa County Medical Society
A Human Connection pg. 16
The Hospice Conversation pg. 20
Spring 2020
Thank You TO
OUR
H E A LT H C A R E
WORKERS for your diligence and personal sacrifice. We owe you everything!
When helping your patients see clearly,
make each moment matter.
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Reading Recommended
Because a little additional
perspective and a healthy sense of humor can lend a little strength to our struggles, compassion to our care, and light in our lives.
Being Mortal: Medicine and What Matters in the End
The Art of Aging: A Doctor’s Prescription for Well-Being
By Atul Gawande, M.D. This non-fiction narrative by American surgeon Atul Gawande addresses end-of-life care, hospice care, and also contains Gawande’s reflections and personal stories. Gawande chronicles the work of a hospice nurse on her rounds, a geriatrician in his clinic, and individuals reforming nursing homes.
By Sherwin Nuland, M.D. Exploring the consequences of aging on the mind, body, work, and relationships, Dr. Nuland masterfully melds a scientist’s passion for truth with a humanist’s understanding of the heart. The result is a frank, wise, and inspirational read about the final stages of life’s incredible journey.
Another Country: Navigating the Emotional Terrain of Our Elders By Mary Pipher, Ph.D. A New York Times Bestseller, Another Country is a field guide to the rough terrain for a generation of baby boomers who are finding themselves unprepared to care for those who have always cared for them. The older generation is living longer and occupies a larger percentage of the population than ever before. However, they find themselves isolated in a culture that has come to worship youth--a culture in which families have dispersed, and communities have broken down. 2
ARIZONA PHYSICIAN | Spring 2020
You’re Only Old Once! By Dr. Seuss (not a physician) Though perhaps not a volume for academic reference, this illustrated “Book for Obsolete Children” is sure to garner a smile, a laugh, and knowing nod. Released in 1986 on Theodor Geisel’s eighty-second birthday, Dr. Seuss’ historic wit and imagination guide the story of a senior patient through his medical appointments at the, “Golden Years Clinic on Century Square for Spleen Readjustment and Muffler Repair.”
VOLUME 2, ISSUE 2 EDITOR-IN-CHIEF JOHN MCELLIGOTT, MPH, CPH
Contents
MANAGING EDITOR EDWARD ARAUJO ASSOCIATE MANAGING EDITOR DOMINIQUE PERKINS LAYOUT & PRINTING PRISMA ADVERTISING
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MARICOPA COUNTY MEDICAL SOCIETY BOARD MEMBERS: LEE ANN KELLEY, MD MAY MOHTY, MD, FAAP RICARDO CORREA, MD, ESD, FACP SHANE DALEY, MD JOHN PRATER, DO DARREN WETHERS, MD, CPE, FACP GERALD GOLNER, MD, FAAP KARYNE LIMA VINALES, MD
The Hospice Conversation
20
Features
But What About the Empowering Women 8 23 Snowbirds? A Breakdown Through Caregiver
10
of the Senior Population in Maricopa County
Making Your Patients More Comfortable
arizonaphysician.com Twitter: AZPhysician Facebook: ArizonaPhysician Instagram: AZ_Physician
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TGen’s Online
Mindcrowd Research
Training
The Wilderness of Medical 26 School
Health Policy in the 28 Valley 2020
Human Connection: 20 AServing Patients at Their Most Vulnerable
In This Issue 2 Recommended Reading 4 MCMS in 2020: Executive Director’s Update Saba Radhi, MD, MS Medical Oncologist
6 Protecting Physicians: Letter from the President Spring 2020 | arizonaphysician.com
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MCMS in 2020
E X E C U T I V E D I R E C T O R ’ S U P D AT E
S
tephen M. R. Covey, son of the late author and speaker Stephen R. Covey, wrote The Speed of Trust: The One Thing That Changes Everything. Personal and professional relationships, Covey argues, move at the speed of trust. So does a membership organization like the Maricopa County Medical Society. The Board of Directors of MCMS and I are dedicated to building upon the trust members have continued to place in the society since its founding in 1892. Members must trust we have their best interests at heart and non-member physicians need to trust MCMS before they join.
John McElligott, MPH, CPH
Communication Overload
To build trust with physicians, we will share information relevant to medicine today and help members to prepare for the future of medicine in Maricopa County. But we won’t overshare. You may already be inundated with emails and push notifications from smartphone apps. MCMS will limit the amount of information we share, so you don’t get overloaded and can focus on being a doctor. I’ve heard from many physicians who are thrilled to have Arizona Physician in their hands again. With so much media shifting to digital, doctors have said they like having something they can dog-ear, mark up, and throw Moving at the Speed of Trust on the coffee table. MCMS will balance emails and social The Maricopa County Medical Society has always been media posts with the old-fashioned in-person events at the crossroads of medical care in the Valley of the Sun. you’ve come to love. We will continue to play that role for the next century. MCMS is a community of physicians in a county with MCMS will take the side over 12,000 doctors. While we may of physicians and we’ll not be able to shake hands with all The Maricopa County Medical physicians in Maricopa County and support whatever you connect every doctor from Mesa do, whether it is caring Society has always been at the to Surprise, we’ll certainly try by for patients, conducting using a mix of seasonal events and crossroads of medical care in research, educating medical modern communication. students, or volunteering in the Valley of the Sun. We will the community. COVID-19 Support for Doctors MCMS will be an continue to play that role for the Scores of members have been organization to which next century. rattled by the pandemic caused by physicians can turn for the SARS-CoV-2 novel coronavirus support. Doctors often ask and rightly so. MCMS appreciates us for referrals to the best how much the spread of disease has impacted your work lawyers who specialize in contracts or compliance, the best as a physician. The lack of personal protective equipment staffing agencies to fill vacancies, or the best investment or (PPE) and policies to “flatten the curve” led to massive accounting firms. MCMS can help you. patient cancellations, fear of transmission to medical staff Physicians value having a community of fellow and patients, and questions about the economic impact of physicians in an organization which looks out for their best the virus. interests. MCMS is on your side.
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ARIZONA PHYSICIAN | Spring 2020
Throughout the local pandemic response, MCMS has shared timely information about PPE availability, COVID-19 test kits, and guidelines from federal, state, and county governments. MCMS has hosted teleconference and video chats about telehealth policies and considerations when selecting a platform. We solicited volunteer physicians to assist with response efforts by the state. We represented your perspective with county and state officials, arguing for more supplies, emergency loans, and urging patients to stay at home to slow the spread. You can find some details online at www.mcmsonline.com/page/coronavirus.
Refer-a-Physician For MCMS to do more for physicians, we need more members. Annual dues are low at $250. Attend just a couple of our CME events and you’ll recoup those costs. Plus, we are launching a Refer-a-Physician program for existing members. When fellow physicians you refer become dues-paying members of MCMS, then you’ll receive a $50 discount on next year’s dues. So, don’t delay. Please sign up today and join MCMS. Encourage your colleagues to join. With your help, we will build on the Society’s long and positive legacy of supporting medicine in Maricopa County. As an organization that physicians can trust, MCMS will promote excellence in the quality of care and the health of the community. We will represent and serve members by acting as a strong, collective physician voice.
COVID-19 Support Throughout the local pandemic response, MCMS has shared timely information about PPE availability, COVID-19 test kits, and guidelines from federal, state, and county governments. Visit: https://www.mcmsonline.com/ page/Coronavirus for more information.
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Protecting Physicians LETTER FROM THE PRESIDENT
I
n this Spring 2020 edition of Arizona Physician we are focusing on geriatrics, a theme which was chosen long before the COVID-19 global pandemic was born. Our focus happens to coincide with current events in several ways that are pertinent to our Maricopa County Medical Society physician members, including concern about our aging patients who are disproportionately affected by the SARS-CoV-2 virus, as well as the role in this crisis of older and/or retired physicians, and their inherent vulnerability which is worsened by the lack of adequate PPE. Although COVID-19 infection is mild or even asymptomatic in the majority of cases, Centers for Disease Control and Prevention (CDC) has confirmed that older people, particularly those with serious medical conditions or living in long-term care facilities, seem to be at higher risk for developing more serious complications from COVID-19 illness. In China, 80% of the deaths occurred in patients ages 60 and older, and we are seeing similar statistics in this country. Recent CDC estimates show that hospitalizations, ICU admissions, and deaths due to COVID-19 are higher after age 45, significantly escalating in patients ages 65 and over, with the highest percentage of severe outcomes in the 85-and-older age group. As our baby-boomer patient population has gotten older, so too have many of the physicians who care for them: 20% of our working physicians are aged 55 to 64 years old and 9% are aged 65 or older. Most of these older physicians are still reporting to work each day, despite lack of institutional protection for them via adequate PPE. Whether these physicians should be serving on the frontlines of patient care during this pandemic is a complex issue, deserving careful consideration of the risks and benefits to the physician and their families, including the risk of taking the virus home and infecting spouses who may be aging and infirm, as well as the obvious risk to their own lives. These risks must be weighed against the benefits our seasoned clinician leaders bring to the battle against COVID-19. This is the time when they are needed more than ever, contributing their decades of experience, knowledge, wisdom, leadership, decisionmaking skills-- and possibly experience with disasters and conserving scarce resources. Healthcare systems should
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ARIZONA PHYSICIAN | Spring 2020
Lee Ann Kelley, MD
be giving deliberate consideration to protection of their older workforce by ensuring that they have proper PPE and possibly shifting their responsibilities to areas with less chance of exposure, such as teaching, consulting to younger staff, decision-making, problem-solving, advising, and serving as liaisons to the community. These issues are even more important now that retired physicians across the country are being asked to re-enlist and join the healthcare force as reinforcements in the battle against this global pandemic. Physicians with active licenses may volunteer to join the Maricopa County Medical Reserves Corps or other groups through the Department of Public Health. Per Governor Doug Ducey’s Executive Order, retired physicians with inactive licenses may be able to obtain a temporary re-activation of their license if they have been out of practice for 4 years or less, and the Orders include temporary emergency provisions for professional liability coverage. New opportunities for practicing medicine without risk of viral exposure include telemedicine, which will have insurance coverage equivalent to an in-person visit until the termination of the declared public health emergency, per Executive Order by Governor Ducey in Arizona. More controversial Executive Orders have included the order halting all elective surgeries, for various reasons including helping to keep PPE available to front-line providers. This has significantly impacted the livelihood of many physicians. The Governor also exempted Arizona from the regulation requiring CRNAs to be supervised by a physician, which ostensibly frees up physicians for other needed medical services but creates concern among physicians about ongoing scope of practice issues, particularly if this change is maintained after the crisis is over. These and other risks abound in this “Brave New World” of global pandemic, not the least of which is flawed information. Thousands of fast-tracked publications using the new concept of “preprint” have been published, with data made available without the scientific scrutiny of the peer-review process. By far the greatest risk to physicians and patients in this crisis has been the dangerous shortage of PPE. According to the AMA Code of Medical Ethics, physicians’
well-recognized duty to provide medical care during a public health emergency – even in the face of greater than usual risks to physicians’ own safety, health, or life -- creates a corresponding duty on the part of health care institutions to support and protect staff. In the context of a pandemic, this duty includes making every effort to provide adequate PPE. Physicians have an ethical obligation to address conditions that undermine their ability to fulfill their responsibilities to provide safe, high quality patient care. This may require them to argue in the public sphere, asking for action to address critical shortage of essential resources and for expedited distribution or manufacture of these resources. Physicians have a further responsibility to protect their own health to ensure that they remain able to provide care, which includes speaking out about lack of appropriate PPE or policies that prohibit individuals from securing their own PPE. To assist with procuring PPE, Maricopa County Medical Society is partnering with Arizona Medical Association to help Arizona physicians collectively purchase PPE. Millions of physicians have spoken out about PPE problems by signing petitions and tens of thousands have sought peer support via social media. Clearly there is a significant degree of physician stress resulting from this pandemic. Our duty to protect includes providing counseling for frontline staff grappling with the moral and psychological stresses of trying to provide quality care under crisis conditions. Maricopa County Medical Society is helping meet this need by offering weekly support group sessions via teleconference for our members. There have been many changes in our world during this uncertain time. While we hope some of them are temporary, some may be lasting, and time will tell whether that is for the best. As physicians, let us learn from the negatives and sustain the positives from this pandemic, including the recognition that in order to survive, we need to band together as a profession and protect ourselves, which in turn protects our patients. Stay safe!
Resources: To collectively purchase bulk PPE via MCMS and ArMA: http://actionppe. com/az/ AMA resources to provide guidance to senior and retired physicians who may wish to return to work or are called upon to do so during the coronavirus (COVID-19) outbreak: https://www.ama-assn.org/delivering-care/ public-health/senior-physician-covid-19-resource-guide Arizona Disaster Healthcare Volunteers: https://esar-vhp.health.azdhs.gov/ https://azmd.gov/Misc/MiscInfo/COVID-19 AMA Code of Ethics, Opinion 8.3 - https:// www.ama-assn.org/delivering-care/ethics/ physicians-responsibilities-disaster-response-preparedness AMA Code of Ethics, Opinion 8.4, “Ethical Use of Quarantine and Isolation” - https://www.ama-assn.org/delivering-care/ethics/ ethical-use-quarantine-isolation The Disaster Distress Helpline: this federal crisis hotline has seen a huge spike in calls of people seeking help recently. In March, the helpline saw a 338% increase in call volume compared with February 2020, and compared to the month of March 2019, they had an 891% increase of calls. The national helpline, run by the Substance Abuse and Mental Health Services Administration (SAMHSA), provides counseling for people facing emotional MICA_AZphysician0420quarters.qxp_Layout 1 4/8/20 8:05 AM Page 1 distress during times of natural and human-caused disasters. https://www. samhsa.gov/find-help/disaster-distress-helpline
Merci
Lee Ann Kelley, MD
President, Maricopa County Medical Society Our mission is to promote excellence in the quality of care and the health of the community, and to represent and serve members by acting as a strong, collective physician voice. -- Maricopa County Medical Society
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Spring 2020 | arizonaphysician.com
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Making Your Patients More C
comfortable
ommunication is the keystone to a trusting doctor-patient relationship and effective healthcare. However, human communication is no easy thing. What we often feel should be a simple and straight-forward exchange can be complicated and bogged down by mood, tone, perspective, background, strong emotions, and a hundred other factors at any given time. As a healthcare provider, it could be argued that you are at a disadvantage before you even walk into an exam room. Patients aren’t often at their best when coming in for a doctor’s visit, and are likely to be stressed, confused, scared, sick, in pain, irritated, and impatient. As patients grow older, their difficulties and frustrations often increase, and communication can become more and more challenging. There are a few strategies you can employ in your interactions with elderly patients that will help them feel more comfortable, enable you to obtain the information you need, and encourage compliance with instructions and treatments.
1. Start with a quality interaction Patients need to feel seen and heard, and want to feel that their time with you was well-spent. While you may still need to juggle the demands of record-keeping during your patient conversations, make an effort to show them that this is their time, and that you are committed to 10
ARIZONA PHYSICIAN | Spring 2020
making their visit meaningful and helpful. First impressions matter. The more quality attention you can give your patients at the start of the conversation the better they will feel about their visit. Minimize as many distractions as possible and sit facing your patient. Patients struggling with loss of hearing may rely on reading your lips to fully understand what you are saying. Strong eye contact remains one of the most powerful forms of nonverbal communication, and plays a vital role in communicating engagement, building trust, and encouraging honesty.
2. Slower, shorter, louder You’ll want to communicate information, answers, and instructions as clearly as possible. It may help to use shorter words and sentences, so that you can zero in on the most important elements. Another helpful practice may be to practice speaking just a little bit slower, and a little bit louder, to make it easier for older patients to hear and understand. However, this advice comes with a caution: the line between “speaking louder” and “patronizing” is astonishingly thin. Always speak to your patients as if they are intelligent adults, no matter the other adjustments needed.
First impressions matter. The more quality attention you can give your patients at the start of the conversation the better they will feel about their visit. 3. One thing at a time Older patients are likely to be struggling with many different concerns and conditions, and your visits will naturally cover a variety of areas. Make sure you focus on one topic at a time, and have clear transitions when moving on to a new area. This will help your patients focus, which helps them give you clearer answers to your questions. It also helps them to more clearly associate instructions and treatments with each issue, instead of blurring them together and missing important elements, or a sense of urgency.
4. Teach them how to talk to you, and then listen carefully As a physician, it can occasionally seem as though your patients expect you to be able to read their minds. Providing the best care and treatment plans can hinge on the quantity and quality of information your patients provide. Help them give you the answers you need by taking a little extra time to teach them how to talk to you about what they are experiencing. It would be beautifully simple if every patient could march into the exam room and calmly recite a list of their symptoms as clearly and concisely as a medial textbook, but individual experience is rarely that straightforward. It is difficult for a patient to identify the source of pain and discomfort when it is so exhausting that it seems to be coming from everywhere. Or to distinguish between the “normal” weariness and discomfort of aging and symptoms of a more serious condition that should be addressed immediately. Patients may feel embarrassed to speak up and share too many details. Help them find the words to describe what they are feeling, and give them the time they need to express their questions and concerns.
Visual aids such as charts and illustrations are also valuable tools for helping patients comprehend and retain information – especially regarding complex procedures and issues. Give them something they can take home when they leave, so they don’t have to rely on memory alone. This will also help some patients to find more information later if they were too timid or overwhelmed to ask enough questions during the visit.
6. Plan on a little extra time Recognize that the steps you take to improve communication with your older patients will help, but they will add a few extra minutes to your appointment time. Schedule exams for elderly patients with just a little extra time to ensure you can get through all of the necessary information without having to rush – this will help both you and your patient feel more calm and focused, and the conversation will be more productive. While it does add a little time to your day, it will benefit your work in the long run. Good communication builds trusting relationships. Patients of any age are more likely to tell you what is going on in their lives when they are comfortable and feel confident that you are listening to them and taking them seriously. By Dominique Perkins, Maricopa County Medical Society (MCMS), dperkins@mcmsonline.com
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Thank you
5. Review key takeaways, and write them down Speaking of instructions, take a moment between topics to repeat the most important items. Older patients need more information than younger generations, but too easily that needed information can become an overwhelming flood. By reviewing key items and takeaways, you will help your patients feel that they are getting the information they need – and that they know where to go from here.
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TGEN’S ONLINE MINDCROWD RESEARCH PROJECT AIMS TO PROVIDE A PERSONALIZED GUIDE FOR SUCCESSFUL BRAIN AGING
“WE WANT ALL OF US TO AGE AS BEST AS WE CAN, AND WHAT THAT PROBABLY MEANS FOR EACH OF US IS THERE’S A SPECIFIC ‘PRESCRIPTION’ FOR HOW WE SHOULD AGE BY IDENTIFYING THE RIGHT BALANCE BASED ON YOUR PERSONAL RISK FACTORS AND PERSONAL LIFESTYLE CHOICES HOW TO BEST AGE YOUR BRAIN.”
A
10-minute online memory test is gathering data from around the world with the hope that one day physicians will be able to recommend a personalized way for their patients to improve brain performance as they age. The MindCrowd research project, developed by the Phoenix-based Translational Genomics Research Institute, an affiliate of City of Hope, in partnership with the University of Arizona and Alzheimer’s Prevention Initiative, has been aided by more than 135,000 participants over the past seven years from all 50 states and more than 150 countries. Matt Huentelman, Ph.D., MindCrowd director and a professor in TGen’s Neurogenomics Division, said the ongoing project’s goal is to better understand how the brain ages and develop guidelines for individualized precision aging, a concept similar to precision medicine, which is used to fight cancer and other diseases. Precision aging targets could include diet, exercise,
stress reduction, improved sleep or even therapeutics for patients through their senior years to match brain performance with life span. “We want all of us to age as best as we can, and what that probably means for each of us is there’s a specific ‘prescription’ for how we should age by identifying the right balance based on your personal risk factors and personal lifestyle choices how to best age your brain,” Huentelman said. “We do think understanding how the brain ages can also play a significant role in helping us avoid or better understand Alzheimer’s disease.”
The MindCrowd Test The MindCrowd web-based test, which remains open, starts by measuring reaction-time response to a red circle that appears, disappears, and randomly reappears multiple times. The second portion is the word-pair memory test. Twelve pairs of words are shown in quick succession. After Spring 2020 | arizonaphysician.com
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one word appears, the participant is asked to fill in the second word within three seconds. Then the process repeats two more times. The results are provided immediately, including a comparison to the overall testing average and others in the same age bracket. A follow-up survey asks questions that help us understand the risk factors that might predict a participant’s performance on the memory test, said Lee Ryan, Ph.D., professor and head of the University of Arizona Psychology Department in Tucson, who helped develop MindCrowd. The test is not intended to, nor is it able to, diagnose Alzheimer’s disease or determine individual risk for developing Alzheimer’s disease in the future, according to a statement provided to MindCrowd participants, and does not make clinical recommendations. Over the past year, MindCrowd has added versions in Spanish and Mandarin Chinese and revamped the test to be more culturally sensitive to the Latino population. Huentelman said there’s a strong push to attract a more diverse population, including more
“[THE TEST] IS SHORT, IT’S SWEET, WE HAVE FUN, IT’S UNDER 10 MINUTES AND YOU GET TO SEE YOUR RESULTS. AT THE END YOU CAN PLAY WITH THE DATA, AND YOU CAN REMAIN ANONYMOUS.”
African-Americans, Native Americans, and Latino participants, all of whom are understudied. Huentelman said this type of study is much easier for underserved groups to join than many investigations because people can participate from home and can remain anonymous if they choose too. For those willing to provide contact information, the survey is provided shortly after the test, and further contact is possible in the future for individuals who meet the criteria for additional study. The goal is to reach 1 million participants. “It’s short, it’s sweet, we have fun, it’s under 10 minutes and you get to see your results,” Huentelman said. “At the end you can play with the data, and you can remain anonymous.” Huentelman, who joined the Phoenix-based nonprofit medical research institute in 2004, focuses on diseases of the nervous system in his research. In addition to aging, Huentelman’s lab studies Alzheimer’s disease, cognition, and rare neurological diseases. Ryan, a clinical neuropsychologist and associate director of the Evelyn F. McKnight Brain Institute at
UArizona, studies how the brain changes with age utilizing magnetic resonance imaging, and how those brain changes result in problems for older adults with memory and problem solving. She also studies the risk factors for age-related cognitive problems.
Emerging Trends A major finding from MindCrowd released last year is that participants with a family history of dementia or Alzheimer’s disease performed worse on the test than those without family history across all age groups up to 65, even as early as their 20s. This was especially true among men, and people with diabetes and lower educational attainment. Huentelman said that doesn’t mean that young people are suffering from dementia or guaranteed to suffer from a brain disease later in life, but it’s known those with a family history do have a greater risk. Ryan added, “These individuals do more poorly on memory testing, but we don’t know why at this point.” MindCrowd has also revealed that increasing age correlates with lower memory performance. There is also a difference between the biological sexes, with women outperforming men on the memory test across the entire adult lifespan, not just among older age groups. Yet Huentelman points out that just because you are aging doesn’t mean you have to decline at the exact same slope. “There are plenty of 70-year-old people, for example, who perform on this test as if they were in their 20s and those folks are very interesting to us,” Huentelman said. “Is it their lifestyle, choices they’ve made, or is it their genetics that led to them being high performers for their age?” Huentelman said he is excited to find these rare folks who beat the odds among the more than 20,000 participants so far over the age of 60. “They might give us clues on how to best take care of your brain as you age, and might help us identify new biological targets so that we might be able to design drugs to prevent diseases of the brain like Alzheimer’s disease,” he said.
their cognitive function across the entire adult lifespan,” Ryan said. Huentelman encourages everyone, ages 18 and up, to take the MindCrowd test, with an emphasis on participants ages 40 and above, including the elderly. To take the test, visit MindCrowd.org. To learn more about TGen, visit tgen.org. To learn more about the Evelyn F. McKnight Brain Institute at UArizona, visit https://www.embi.arizona.edu/. By Brian Powell, Flinn Foundation, BPowell@flinn.org
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Looking Ahead Huentelman and Ryan are working on a large federal grant proposal to launch precision aging, including the expansion of MindCrowd and its demographic reach that will enable them to collect additional information about people’s cognitive function and predictors of their function. And by following the participants over time, researchers can see who remains stable and who declines. “That is critical information in understanding the trajectory of normal aging, and we hope will lead to new insights about how to intervene to help people maintain
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A Human connection:
SERVING PATIENTS AT THEIR MOST VULNERABLE
S
aba Radhi, MD, knew she wanted to be a physician when she was still in high school. While her parents thought perhaps she should chose a career as a lawyer, Radhi considered ways that she could give back to the world and to her community, while also pursuing something that interested her. Medicine was a very clear choice. “The human body is the most fascinating thing to study,” she said. So combining her love of science and desire to serve, she attended the Sultan Qaboos University, College of Medicine & Health Sciences, in Oman. After graduating she moved to the United States and pursued a Masters of Science in Clinical and Biomedical Investigations at The University of Southern California Keck School of Medicine. She completed her residency in
Internal Medicine in Lubbock, Texas, at the Texas Tech University Health Science Center, where she also went on to complete a fellowship in Medical Oncology and in Geriatric Medicine. After moving to Arizona with her family, Radhi began working for Cancer Treatment Centers of America (CTCA) in Phoenix, Arizona, in 2017.
Daily Reward Radhi was fascinated by the incredible advancements in oncology, and felt it was uniquely situated to provide her with the ideal combination she had been looking for – the challenge of scientific research and application, combined with an incredibly close patient-physician relationship.
Many of her former patients keep in touch. Radhi every aspect, involved them in every decision, and described one patient in particular, a woman in her 30s supported them through the end. Their best-case scenario she treated during her fellowship in Texas, who is now was realized, and her family member was able to live a full approaching 5 years free from her cancer. She still sends 18 months before passing. Rahdi a text whenever she has a follow-up appointment, It is that level of care and compassion that Radhi communicating updates, asking questions, and sharing strives to bring to all of her patients, to always be able to photos of her beautiful daughter. deliver the best-case scenario. “I think it is one of the most rewarding careers,” Rahdi In the complex and often convoluted landscape of said. “It is a really humbling experience.” healthcare, physicians encounter many obstacles as they As an oncologist, Radhi helps patients during what try to deliver the best solutions and care for their patients. is perhaps the most frightening and vulnerable time of Radhi feels that one of the biggest stumbling bocks in their lives. Treatment methods in the field have come an healthcare today is insurance, and the need to appeal for incredibly long way, and whether she is able to see her approval on every treatment plan and step. patient through to remission and a long, cancer-free life, Rahdi recalled one instance where she and her team or to hold their hand until they reach the end of the road, of physicians wanted to treat their patient with a certain she is awed and inspired by each of her patients, and cites medication. While it had been approved by national them as her constant motivation. and federal authorities in trustworthy studies, insurance “You learn strength and resilience just from what declined to cover the treatment. you see every day,” she said. “I still can’t believe this “I think everyone is touched happened,” Radhi said. “I think “You learn strength and by cancer one time or another we as physicians should decide in their lives, or in their what is best for our patients, resilience just from what you see families.” not insurance.” Her philosophies on every day. I think everyone is Perspectives on Aging caring for her patients may in part be motivated by touched by cancer one time or While the textbook her own experience. Early definition of geriatric medicine another in their lives, or in their in her medical training, includes anyone over the age one of Radhi’s close family of 65, Radhi does not see aging families.” members was diagnosed with in such black and white terms. a particularly aggressive form “Sometimes you see of brain cancer. In even the a 65-year-old with more best-case scenario, his life expectancy was little more comorbidities than a strong, healthy 85-year old,” she said. than a year. Triple-certified in internal medicine, clinical oncology, His physicians made every effort and he received and geriatric medicine, Radhi’s background makes her a cutting-edge treatments and care. The battle with cancer clear expert in caring for the elderly. Among the many is lengthy and exhausting, and takes its toll on an entire health challenges patients face at the end of life, cancers family. Radhi remembers that for every step of the fight are certainly one of the more frightening, and geriatric there was someone there for their family. They explained oncology is a growing field.
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Across all possible stages of growing older, there are unique challenges and circumstances to take into consideration. Geriatric oncology requires carefully considering these unique challenges, and incorporating them into care. Hearing and vison loss for example, or limited mobility, are factors that will heavily affect patient care. The typical oncology consultation might not include hearing and vision tests, but since each patient is facing such a different set of circumstances, careful and thorough assessments are key. “Most of them feel like they are a burden,” Radhi said of geriatric patients. “They might not tell you they can’t hear.” Radhi says it is important to pay attention. She and her team members employ a comprehensive geriatric assessment as a part of their treatment plan. Typical questions are supplemented with hearing and vision tests, as well as queries about emotional health, home life, who will be driving them to and from their treatments and assisting with their recovery. She also asks all patients whether they have experienced a fall in the last 6 months, so that she can arrange for physical therapy. “There is this balance of functioning in the elderly,” Radhi said. “You want to strengthen anything you can strengthen, and reverse anything you can reverse.” In that regard Radhi considers herself extremely fortunate to be working with CTCA – whose care model strives to make every aspect of care available under one roof. In fact, this was something she long dreamed of when she thought of how she would form her own clinic.
ON THE PERSONAL SIDE with Saba Radhi
1. Describe yourself in one word: Passionate, or dedicated. 2. Family? I’m blessed with a Supportive husband and two beautiful girls, and I love to spend time with them and teach them everything I‘ve learned from my life experiences. 3. What is a talent you have that most would not know about? I love yoga. I’m not there yet, but my goal would be to be an instructor – I don’t know if I would have time, time would be a limitation always. 4. What career would you most likely have if you had not entered medicine? I don’t know what I would have done – maybe a researcher and teacher.
5. What is the last book you read? “Quiet: the Power of Introverts in a World that Can’t Stop Talking” by Susan Cain 6. Favorite movie? I enjoyed Forrest Gump; I really love that movie. 7. Favorite food or restaurant in the Valley? I just like different cuisines, I love to try everything. I like to try weird things; something I am not used to – combinations that you would not think to put together. 8. Favorite sports teams? I’m not big on sports, I like my kids’ schools teams – Mustangs. 9. Favorite pastime outside of medicine? I like to spend time in nature, I like to walk – walk and just listen to everything around me; no headphones, I hate those.
“Everything my patients need is here,” she said. “It’s very convenient.” For physicians and healthcare professionals treating the elderly who do not work in the all-under-one-roof atmosphere of a medical center like CTCA, Radhi said time and communication are vital. Understanding that practicing healthcare is already incredibly busy, geriatric appointments simply take longer, and require more frequent visits. There are so many screening tests and assessments, so much information to get through. And because most geriatric patients will face diverse health challenges that require coordinated care across
multiple specialties, good communication is essential. Even more so with Arizona’s famous “Snowbird” population – the wave of seasonal long-term visitors who flood the sunny Valley area from October to mid-April each year, and need to coordinate care between states, in addition to specialties. “I wish we had an ideal electronic medical record, that would be perfect,” Radhi said. Working within existing systems is possible, but not easy. By Dominique Perkins, Maricopa County Medical Society (MCMS), dperkins@mcmsonline.com Photography by CTCA.
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Spring 2020 | arizonaphysician.com
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THE
HOSPICE CONVERSATION
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ARIZONA PHYSICIAN | Winter 2020
T
he purpose of hospice care is to maximize quality of life for patients in the last phases of a disease that cannot be cured. Hospice care provides collaborative and comprehensive care for the patient and the family at a most difficult time. Introducing the concept of a hospice referral to patients and their families can be a challenging and difficult conversation for us as physicians. We may not be comfortable with shifting from a curative perspective. Feelings of patient abandonment can arise, and both patient and family may feel they are just being told to give up. A hospice referral, however, more appropriately represents a broader and more inclusive level of care, focusing on patient comfort, dignity and symptom management. Hospice care can remove some of the burden of care for struggling patients and their families by providing a network of support, symptom management and security that we, as physicians, alone cannot always provide. Symptom management, after-hours clinical support, in-depth social worker involvement, help with daily living activities and spiritual assistance all come into play with a hospice referral. Hospice organizations welcome the continued involvement of the primary physician, as patients transition to a comfort-based philosophy of care. The hospice medical director seamlessly partners with the patient’s doctor to provide oversight, treatment and guidance. While some hospice referrals occur at the hospitalist level, following a hospitalization and subsequent decline,
Hospice care can remove some of the burden of care for struggling patients and their families by providing a network of support, symptom management and security that we, as physicians, alone cannot always provide. all hospice referrals require thoughtful conversation and guidance. Here are four scenarios that may trigger a hospice conversation.
1. The patient is burdened by the impact of aggressive treatments and desires comfort care. This notion can be more difficult for the family or physician than for the patient. Yet the desire for comfort and dignity can be a decision that actually empowers patients and brings an inner peace. It also provides a time for them to share reflections on their lives and accomplishments, and even to mend fences. In some cases, discontinuing curative treatments can allow patients to temporarily improve and even extend their lives. Spring 2020 | arizonaphysician.com
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2. There are no further aggressive or effective treatment options available for the patient’s illness. In such cases, guidance toward hospice services provides for active symptom management, in-home care, medical equipment, pharmacy needs and supplies — all covered under hospice care. Working together to meet physical, emotional and spiritual needs, the hospice care team includes a physician or nurse practitioner; nursing and social worker support; aides who provide assistance with personal hygiene; and chaplains who comfort both patient and family. Volunteers provide companionship visits to ease loneliness — often with soothing music or cheerful pet therapy.
The hospice discussion can be a challenging and anxious one. But in keeping with the purpose of hospice, it strives to maximize quality of life for patients and help them enjoy every moment.
3. A patient faces continued decline despite frequent hospitalizations or escalating intensity of interventions. In-home hospice care can provide welcome stabilization with home treatment options for pain, other symptoms such as shortness of breath and recurring infections. It can also reduce anxiety because patients and families have 24/7/365 access to one of our healthcare professionals, as well as a nurse who can visit, should they have an issue in the middle of the night or on weekends.
For more information on hospice and palliative care programs at Hospice of the Valley, visit hov.org or call (602) 530-6900 anytime day or night.
4. A patient’s condition presents difficult or challenging symptom management. As patients near end of life, a team approach can be beneficial when treating challenging conditions like dementia behaviors or severe respiratory distress. Hospice care teams are experienced at connecting caregivers to community resources and providing comfort to family members who may be feeling vulnerable and overwhelmed. The use of an inpatient unit can be beneficial in developing an effective treatment plan to manage behaviors or symptoms and can also provide caregiver respite. In summary, the hospice discussion can be a challenging and anxious one. But in keeping with the purpose of hospice, it strives to maximize quality of life for patients and help them enjoy every moment. It represents a promise of improved comfort and dignity at a time when families may struggle with feelings of relative hopelessness. It can provide the opportunity for physician collaboration to achieve desired goals of care. It extends the trusted patientfamily-physician relationship with a conversation that can bring peace of mind. And it helps families receive the kind of compassionate care we would want our own loved ones to have. Finally, from the patient perspective, there is no better source of opinion or advice than a trusted physician.
By Dr. John Williams, Hospice of the Valley Medical Director, jwilliams@hov.org
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ARIZONA PHYSICIAN | Spring 2020
PRIMARY CARE PRACTICES WANTED FOR ACQUISITION Matrix Associates LLC represents a Large, Local, Physician-led and Physician-run, Multi-specialty Practice seeking to acquire Primary Care Practices in the Metropolitan Phoenix Market (All fees paid for by our Client) For Further Information, Please Contact:
Jeff Heinemann Matrix Associates, LLC (602) 370-7764 cell jeff@matrixphoenix.com
EMPOWERING THROUGH
WOMEN T
he United States has a higher immigrant population than any other country in the world. And though political debates in recent years have laid emphasis on Hispanic immigration, it is in fact Asian Americans, Native Hawaiians and Pacific Islanders (AANHPI) that have become the fastest-growing minority group in the United States. According to New American Economy and the 2017 American Community Survey, the AANHPI population jumped from 7 million in 1990 to 17 million in 2010. And by 2017 that number has grown to over 22 million – an increase
CAREGIVER TRAINING
of over 25 percent. For comparison, between 2010 and 2017 the overall US population only increased by 5.3 percent. Many families in the AANHPI community have lived here for multiple generations, in addition to the significant number of newcomers who have come for work, opportunity, and to be closer to family members already living in the United States. While AANHPI represent the fastest-growing minority group in the US, there is another segment of the population that is growing even faster – the old. According to the Spring 2020 | arizonaphysician.com
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National Institute on Aging, the number of Americans aged 65 and over is expected to double in the next 25 years, and those ages 85 and older represent the fastestgrowing segment of the US population – fully expected to grow from 4 million to nearly 19 million by 2050. When considered side-by-side, these statistics paint a clear picture of a rapidly growing group of individuals aged 65 and older who speak many languages, come from many cultures, and may not be entirely comfortable in their new homes as they face their final, and sometimes most difficult years of life. Life-expectancy may have significantly increased, but the diseases and conditions that effect the oldest members of our society have hardly disappeared. Many of this generation will need at-home care – a task that will often fall to the women in their families, at the sacrifice of their own comforts and career opportunities. According to the National Center on Caregiving, 65 percent of seniors with long-term care needs rely exclusively on family and friends for assistance – and 66 percent of caregivers nationally are female. In 2015, over 34 million Americans said they had provided unpaid care to an adult age 50 or over in the previous 12-month period, and the economic value of the service provided by unpaid, informal caregivers in the United States is estimated in the hundreds of billions each year. In fact, in 2013, the estimated value of unpaid caregiving was $470 billion – more than the value of paid home care and total Medicaid spending combined. Family support and at-home care allows individuals to stay in the comfort of their homes for as long as possible. When family members seek additional help for their aging family members, finding a day-time caregiver who can speak and understand their regional language and respond to their cultural environment can be extremely difficult.
In Arizona, inquiries to local caregiver institutions have confirmed a high demand for caregivers with regional language skills, and the inability to meet that demand. The Asian Pacific Community in Action organization (APCA) sees an opportunity to empower women within the AANHPI community to leverage their language skills and train and qualify as paid caregivers.
Prisma would like to thank all of our healthcare workers and first responders for keeping us safe. 602 243 5777 prismagraphic.com
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ARIZONA PHYSICIAN | Spring 2020
“Many of this generation will need at-home care – a task that will often fall to the women in their families, at the sacrifice of their own comforts and career opportunities.”
Communication is key in any relationship, and a strong language barrier can make senior care more frustrating and difficult for both parties. Additionally, seniors in need of care, and their families who love and support them, are more likely to accept and respond to a caregiver who speaks their language and understands the values and traditions of their culture. Caring for patients in their native language gives women an opportunity to leverage their language skills as a distinct advantage over other care providers, and such a foundation for trust can greatly increase the comfort, enjoyment, and quality of life for their patients. For all its challenges, caregiving can be a fulfilling and enjoyable career, and provide a great sense of personal accomplishment and satisfaction. By providing women in immigrant and minority populations with additional training, they are able to provide financial support for themselves and their families, as well as a much-needed service to the fastest-growing group in the nation. By Prakash V. Kotecha, MD, MSc, Asian Pacific Community in Action (APCA), pvkotecha@apcaaz.org , and Dominique Perkins, Maricopa County Medical Society (MCMS), dperkins@mcmsonline.com
APCA is a non-profit organization headquartered in Phoenix, who serves Asian American, Native Hawaiian, Pacific Islander and emerging communities in Arizona. By providing services and training, their mission is to empower individuals and families to build a brighter future through seeking better physical health. Professional caregiving provides many advantages to women looking for employment opportunities – especially women in minority populations with excellent regional language skills but a low proficiency in English, which may make finding other employment more difficult. Caregiving roles can often be part-time and flexible in hours and scheduling, making it ideal for women looking to earn additional income while balancing multiple other roles and needs – whether caring for young children and other family members at home or supplementing an existing job. Work as a caregiver can require minimal additional training and education, making it an accessible, lessexpensive career path for families who lack the time and resources to commit to more extensive programs. Many are also drawn to caregiving roles due to a compassionate nature, and find it rewarding to provide such a needed service for individuals and families. Caregiving, after all, is a vocation as well as means of making a living. Rather than a simple list of tasks, caregivers are also companions, story-tellers, listeners, chefs, drivers, personal stylists, and so much more. Spring 2020 | arizonaphysician.com
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the WILDERNESS OF A
a rollercoaster: exciting, mildly terrifying at times, with s the Phoenix area continues to explode in unexpected twists and turns, and suddenly it is nearly over population, its medical programs are growing to before I realized. match it. For medical students, the metropolitan area At this point, faced with arranging audition rotations is an attractive place to live, but we are also drawn here for and residency applications that will pave the way for our the wide variety of specialties and medical institutions the futures, the funny thing is that there are many students region has to offer. After the first two years of laser-focused still unsure of what kind of physician they want to be. studying via didactics, self-study, and preparations for board Medicine has grown at an incredible rate and there are more exams, be it USMLE or COMLEX, clinical rotations in the specialties than ever before, all with their own challenges latter half of our schooling are a whole new world. The both professional and personal, and it is impossible for board study blinders finally come off and we can stretch students to explore them all before being faced with the big out a bit, remembering what it is like to function in the real decisions. And now the waters seem muddier than ever for world again. It is finally a chance to apply our hard-earned those of us wading through this process with the imminent book knowledge to real patients. The clinical years are ACGME merger looming our time to not just get our ahead. The unified ACGME feet wet but to jump into the Match will apply to both deep end, explore the many Personally, I can attest to the students from MD and DO avenues of medicine, and see schools. where we fit into the medical fact that my third year has been And this, Dear Physician world. Unfortunately, these like a rollercoaster: exciting, Reader, is where you come two years can just fly by and in. Nothing in this article so suddenly decisions must be mildly terrifying at times, with far is news to you. In fact, made regarding specialty and the story may seem quite residency, sometimes before unexpected twists and turns, familiar. The experience and all options of interest have wisdom practicing physicians been explored. Personally, and suddenly it is nearly over have gained throughout their I can attest to the fact that before I realized. medical journey, all the way my third year has been like
medical scHool from school to residency and beyond, is an invaluable resource to students who are finding the start to their own path. We, the students of the Phoenix region, ask you to lend us a helping hand. Please welcome students into your practice. Give them the opportunity to learn by doing and solidify all that book knowledge with action. Become a mentor, a trusted voice and friendly ear to aspiring physicians who are excited about the future but perhaps a little lost on what comes next. Sometimes the early years of medicine feel a bit like cutting your own path through the wilderness, and who would say no to a guide who has cut their way through it before? By Morgan Reeve, OMS III, A.T. Still University, sa195201@atsu.edu
Do you have
an idea to
improve health or the delivery of healthcare?
If you have a health-related idea and entrepreneurial aspirations but don’t know where to start, the Health Entrepreneurship and Innovation Lab (HEALab) at Arizona State University, along with our partners at Coplex and Maricopa County Medical Society, can help. This two-day, interactive workshop will teach you how to identify health-related problems, ideate potential solutions, develop a business model, navigate legal issues, find paths to revenue, and pitch your idea to investors.
Healthcare Innovation and Entrepreneurship Workshop Presented by HEALab @ ASU
A Two-day Workshop at ASU, Downtown Phoenix Campus Friday, August 7 2pm - 6pm
Saturday, August 8 8am - 5pm
RSVP at: https://www.eiseverywhere.com/hie-workshop This event will be eligible for continuing medical education (CME and CPE) credits. Entrepreneurship + Innovation
@ HEALab
Spring 2020 | arizonaphysician.com
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M
aricopa County Medical Society (MCMS) brought physicians, healthcare leaders, and business professionals together for its first event of 2020, Health Policy in the Valley. The cozy evening event highlighted by keynote speaker Tom Dorn of Dorn Policy Group, Inc gave attendees updates on healthcare legislation in Arizona and policy issues the Arizona legislature might take up in 2020. Mr Dorn also spoke to a variety of health care legislative issues that will be affecting Arizona physicians beyond 2020. Attendees enjoyed time with Mr. Dorn, other healthcare business professionals and spoke to attending physicians in ways in which they could help their businesses. Photography: Ben Scolaro, scolarodesign.com
WHY BECOME A
Maricopa County Medical Society member?
Networking Opportunities Physician oriented events
Patient Referrals Helping patients reach you
Professional Referrals From legal, financial, etc.
We create an environment that serves physicians’ best interests
Join Today!
Arizona Physician Magazine Keeping you informed
CME Continuing medical education
Business Services Medical collections to credentialing
A strong collective physician voice! Join at www.mcmsonline.com
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